First published online April 26, 2006
British Journal of Radiology (2006) 79, 762-765
© 2006 British Institute of Radiology
doi: 10.1259/bjr/79794134
Nurse-led central venous catheter service: Christie experience
K Gopal, MRCP, FRCR
L Fitzsimmons, RGN
and
J A L Lawrance, MRCP, FRCR
Christie Hospital, Wilmslow Road, Manchester M20 4BX, UK
Correspondence: Dr J A L Lawrance
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Abstract
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The aim of this study was to evaluate the success and complication rate of Nurse-led subclavian central venous catheter (CVC) insertion using the landmark technique. A prospective study was performed on all subclavian CVC insertion between 13/01/03 to 01/07/03. Data recorded included indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction. A total of 348 subclavian cuffed tunnelled catheters were inserted over the study period. The age group ranged from 31 years to 84 years with a mean age of 53 years. This included 192 women and 156 men. The majority of CVC insertions were through the right subclavian (79%) and were single lumen (76%). In total, complications were encountered in 48 patients (14%). These included misplaced tip in 29 (8%), arterial puncture in 16 (4%), pneumothorax in 3 (1%) and the procedure failed in 3 (1%). Of these multiple complications were seen in 3 (1%). No interventions were required for the pneumothoraces or for the arterial punctures. In conclusion, nurse-led subclavian CVC placements using the landmark technique are both safe and effective.
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Introduction
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Venous access is a critical issue in the care and management of patients with a wide variety of malignancies. The insertion of tunnelled central venous catheters (CVC) for patients requiring long-term venous access is now common. In the NHS, approximately 200 000 CVC are inserted in adult patients per year [1]. This is partly due to increased usage in cancer patients. CVC are inserted by surgeons, anaesthetists, interventional radiologists, medical oncologists and nurses. The British Committee of Standards in Haematology (BCSH) guidelines [2] state that insertion should be performed by experienced operators, regardless of speciality. In our centre, these lines are inserted by a team of experienced nurses. Nurses undergo a supervised training programme for 5 weeks (discussed below) in which they not only observe but perform at least 50 CVC insertions. They are then formally assessed to determine whether they may perform the line insertions independently. Various studies have been published supporting the extension of nurse's roles in this area. One of the main advantages of nurse-led CVC insertion is that the procedure can be done at the bedside. Others include reduced waiting time for patients, stable workforce and successful outcome due to increased frequency of practice [3, 4]. Although central venous access devices are clearly advantageous with respect to delivery of therapy, their placement and maintenance is not without potential complications. McBride and colleagues [5] demonstrated that there is a steep operator learning curve and the complication rate improves notably with experience. In recent years, The National Institute of Clinical Excellence (NICE) has recommended the use of ultrasound guided placement of CVC [6]. However, this has been received with a mixed response form various specialities. At our institution, a large oncology centre in the UK, central venous access is performed by the landmark technique led by a team of nurse specialists. We undertook this study to evaluate the success and complication rate of nurse-led CVC insertion via the subclavian route.
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Materials and methods
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We perform approximately 950 nurse-led CVCs per year. These include both CVC and peripherally inserted central catheters (PICC). A prospective study was performed on all CVC insertion between 13/01/03 and 01/07/03. The following information was recorded, including: diagnosis and indication for catheter insertion, type and position of the catheter, complications during the procedure and patient satisfaction.
Insertion technique
Pre-procedure investigations include full blood count and coagulation profile. Local anaesthesia (5–10 ml 2% lidocaine) is used to anaesthetise the skin. Prophylactic intravenous antibiotics are not routinely administered [7]. Catheters are inserted blindly using the landmark technique. The right subclavian vein is used unless contraindicated, e.g. due to thrombosis, infection, left pulmonary compromise or right sided mastectomy and radiotherapy. The catheters are secured with ethilon sutures at the insertion site. The intended catheter tip position is the distal superior vena cava (SVC), SVC/right atrial junction or right atrium [8]. Following the insertion, a chest radiograph is performed to check catheter position and identify potential complications such as pneumothorax. As most of the patients received continuous infusion of chemotherapy as out-patients, they are taught to look carefully for signs of catheter infection, blockage or accidental removal. Written instructions are provided for reference. Patients were then asked to fill out an audit questionnaire regarding the procedure, which included patient satisfaction, waiting time, etc.
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Results
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348 CVC were inserted over this 6 month period. Similar numbers of PICC lines were also inserted, but these were excluded from the study group. Indications for catheter insertion include carcinomas such as breast, gastrointestinal, leukaemia, lymphoma, ovarian and multiple myeloma (Table 1
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The age group ranged from 31 years to 84 years, with a mean age of 53 years. This included 192 women and 156 men. The majority of the patients were of normal build except for 16% who were either obese or emaciated, which was calculated based on their body mass index (Table 2). The main indication for CVC insertion in patients was for chemotherapy. Others include bone marrow transplant, total parental nutrition, difficult venous access and combination of the above (Table 3). The right subclavian route was the preferred route of insertion unless contraindicated (Table 4). All insertions were done using the blind technique under local anaesthesia. Sedation was not routinely administered and in our study only 78 patients (22.4%) received sedation. Two patients had to have the procedure under general anaesthesia. Single, double or triple lumen catheters were used. Although multi-lumen catheters facilitate concurrent administration of different medications and fluids, we preferred the usage of single lumen catheters to reduce the rate of infection (Table 5). Nurse-led CVC insertions are usually performed at the bedside in the Day Case Unit (Table 6). The procedures are usually performed as day cases. CVC catheters were inserted with a single or double needle pass in the majority of patients (Table 7). Insertion related complications were noted in a total of 48 patients (14%). There were three pneumothoraces (1%), and 16 arterial punctures (4%). None of the former required chest drains and none of the latter caused significant haemodynamic problems, such as hypotension or tachycardia. In three patients there was failure of catheter insertion and an alternative approach, i.e. internal jugular vein was used. Chest radiographs confirmed tip malposition in 29 patients (8%). In cases where the tip is malpositioned, catheters are repositioned under fluoroscopy guidance by the nurse specialists themselves. This can usually be achieved by a technique developed by one of the authors (JALL) consisting of a combination of a forced saline injection and hyperventilation, the combination of which will usually reposition a contralateral line tip to the SVC. In cases where this fails, the tip of the CVC line is withdrawn and manipulated to lie within the distal SVC/right atrium fluoroscopically. In three patients (1%) multiple complications were seen (Tables 8 and 9). The latter patients were hospitalized, but all complications resolved conservatively. 327 patients (94%) tolerated the procedure very well. Minor problems, e.g. discomfort and pains were reported in 6%. Long term follow-up of these catheters, in relation to thrombosis, was not assessed in this study as this has been done in a previous publication from our institution [8].
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Discussion
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Initially implemented by Broviac et al [9] in 1973 and subsequently modified by Hickman et al [10] in 1979, indwelling central venous access devices have revolutionized the care and treatment of the oncology patient. Various studies have been published supporting the extension of the nurse's role in this area. Indeed, BCSH guidelines state that insertion should be performed by experienced operators regardless of speciality [2]. In our institution, all nurses undergo intensive training for 5 weeks. This is divided into Phase 1 and Phase 2, which last for 1 week and 4 weeks, respectively. During Phase 1, the nurses not only observe the insertion of CVC but also become familiar with all types of CVC access devices, their uses and the advantages and disadvantages associated with the various types of catheters. Later in Phase 2 they undertake at least 50 CVC insertions under direct supervision and with the assistance of a mentor. Concluding the training period, a formal documented assessment of competency is undertaken by an independent assessor and, once satisfactory, nurses are then allowed to perform independently. Nurse placements of CVC at the patient's bedside mean that insertions can take place at the optimal time in a patient's management as waiting lists for theatres or X-ray suites are no longer barriers to insertion, which helps to reduce the patients waiting time for CVC insertion. The nurse specialists are a stable workforce and the frequency of practice correlates with successful outcome [3, 4, 11]. In addition, the numbers of patients encountered are too great to be accommodated in the X-ray department with the limited resources available. Nurses are also being trained to use fluoroscopy, which they use to reposition CVC lines if blind insertions lead to misplaced catheter tips. In our centre, CVC are inserted by a team of experienced nurses under blind percutaneous placement. Image guidance is not used for venous puncture. One of the authors (JALL) has trained the team in the use of fluoroscopy and the team has free access to the interventional suite when uncertain about CVC placement or in patients in whom they suspect potential problems might arise. In rare cases, patients are referred for radiologically inserted internal jugular lines, using ultrasound and fluoroscopic guidance.
The right subclavian vein is punctured and the operator advances the catheter blindly to the lower part of the SVC/right atrium. Fluoroscopy is usually only used to reposition misplaced catheter tips. We have used the subclavian route historically and our CVC service was started before NICE guidelines and before the widespread use of ultrasound guidance for central line insertion. Due to the high success and acceptable complication rates over the years, this service has been continued. Given the high number of line insertions we perform and our limited resources, we have continued with this service. Some advantages of bedside CVC insertion are the fact that they can be inserted on the ward and patients may be less anxious of the ward environment compared with operating theatres or X-ray suites, as well as having cost implications. The main disadvantage is risk of catheter tip misplacement. As the use of tunnelled CVC is increasing, it is important to recognize that their use is not without complications. The experience of the operator is an important factor in keeping complications to a minimum. In our study, the total incidence of insertion related complications was 14%, which compares favourably with other reports [12, 13]. The majority of these complications was related to catheter tip malposition (8%) with data from other studies ranging between 12% and 32% [13, 14]. Early complications such as pneumothorax (1%) and arterial puncture (4%) are also similar to previous reports in the literature [15, 16]. It is said that the risk increases with blind punctures where the operator is solely reliant on anatomical landmarks for the venipuncture. However, in our case the risks were well within the limitations and all the pneumothoraces encountered were small and none required chest drain insertion. In our study, 1% of procedures failed and had to be abandoned [17] with multiple complications seen in a similar number [18], which are similar in number to those reported earlier.
Sedation is not routinely administered for this procedure and when used we perform this within the remit of The Safe Sedation Policy prescribed by the trust. The hospital policy on sedation is widely published in our department and intranet. As part of the training, the nurses undergo a formal training on sedation and, in addition, all nurse practitioners have a Post Graduate Diploma assessment on their ability to use drugs and side effects. All the procedures are performed under indirect supervision of a doctor in the outpatient or radiology department. To reduce the risk of infection, we prefer the insertion of single lumen catheters (76%) as it is apparent that the greater the number of catheter lumens, the greater the potential for sepsis [19]. The total life span of the catheters depends on need. For example, in haematology patients they can remain in situ for 12 months from diagnosis to post-transplantation and in solid tumour patients receiving chemotherapy, approximately 4 months. With respect to immediate complications involved in the placement of CVC, our results are comparable with those described previously by several investigators. Although the cost for nurse-led CVC was not within the remit of the study, we believe that the cost of the procedure as performed by nurses, including the complications, should be less than radiologically inserted lines. Given the European Working Time Directive and the move to roll redesign, this is an excellent example of the successful deployment of nurses to perform what was previously the doctors' role.
In 2002, NICE recommended the use of ultrasound for the insertion of CVC into the internal jugular vein in adults and children [6]. This has been received with a mixed response across various specialities. NICE had largely concentrated on the complication of inadvertent arterial puncture and had made the above recommendation. Ultrasound does reduce the risk, but it is usually small [20]. Two recent studies make clear that ultrasound guidance offered incomplete protection against arterial injury [21] and did not improve the result of right IJV cannulation, compared with a meticulous landmark based technique [22]. NICE had considered only one randomized control study that analysed the effect of ultrasound and landmark technique in the placement of subclavian CVC catheters. The operators in both groups were relatively inexperienced with failure rates as high as 55% in the landmark technique, which is far higher that reported in trials (9–19%) [6]. Muhm concluded that ultrasound guidance improved the number of attempts per cannulation and successful first attempts for catheterization of the internal jugular vein, but not the subclavian approach [23]. In addition, the Department of Health has suggested that the subclavian route was associated with less infection [24]. Furthermore, none of the trials quoted by NICE involved nurses [6]. NICE admits that the landmark method is safe in experienced hands and operators should maintain their ability to use the landmark method. The Royal College of Anaesthetists agrees and advises that utilization of the landmark method is still an acceptable alternative whether ultrasound is available or not [25].
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Conclusion
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The use of CVC is now well established in the treatment of cancer patients. With its increasing demand, manpower and facilities are its main limitation. Our study has indicated that complication rates are well within acceptable limits using a landmark technique for the subclavian route. Operator experience, irrespective of the speciality, is the key to limiting the complication rate and regular audits are necessary to prove their efficiency. Nurse-led CVC placements using the landmark technique are both safe and effective.
Received for publication July 11, 2005.
Revision received December 21, 2005.
Accepted for publication February 8, 2006.
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Abstract
Introduction
