Quality Improvement

Project: CVC Removal

Jessica Soltan, Kimberly Granados, Marty Sonke,
Andy Schwartz
March 16, 2017
CVC-associated air
embolism has an
incidence of
approximately 0.03% -
2.1% and mortality rates
from 23% to 50%.
Case Study Overview
27 yo male adm. to hospital for IV ABX course for tx of abscesses.

R. internal jugular (CVC) placed.

After completion of ABX course, CVC removed, patient discharged 30 min.

later.

Subsequently experienced acute onset SOB w/ "whistling sound" from neck.

Presented to ED w/ hypoxia and significant Alveolararterial gradient, requiring

15L high-flow O2 to maintain his oxygen saturation.

Tentative Dx of air embolism

CT neg. for PE, PNA, pulmonary edema, pneumothorax.

Case Study Overview cont.
Physician removed CVC w/ patient in upright position; not covered w/ occlusive
dressing.

Physician completed required central line training module 1yr prior, which
included one slide on proper removal technique.

Unaware hospital CVC removal protocol specified use of CVC removal kit,
available on the ward.

Kit contained instructions for procedure and appropriate materials, including

occlusive dressing.
Case Study Take-Home Points
Increase awareness that CVC removal is high-risk procedure.

Establish policies/procedures that contain specific air embolism prevention

protocols for CVC insertion, management, and removal.

CVC insertion & removal should only be performed by healthcare professionals

who have received adequate training and have been assessed as competent
in performing procedure.

Importance of increasing CVP by avoiding upright position during CVC removal

must be stressed in CVC removal training.

Establishment of dedicated infusion team and use of standardized CVC removal

kit, including step-by-step instructions for performing procedure and all
Policy/Procedure
Like the case study, we noticed that
nurses were not following hospital
policy for CVC removal.

Patients were not being placed

supine or in trendelenburg position,
increasing their risk for air
embolism.
CVC Removal Procedure
 Physician Removal
Patient upright Procedure
Lack of knowledge No occlusive
dressing
Lack of training Removal kit not
used
Air
Inadequate training No knowledge of kit Embolus

No competency test Kit not used

Protocol not
followed

Policies & Removal

Procedures Kit
What is an air embolism?
Occurs d/t 2 causes:

direct air insertion into vascular system

pressure gradient allows entry of air into bloodstream with venous pressure lower than
atmospheric pressure

Pulmonary artery pressure rises as blood is diverted away from pulmonary

arteries due to deadspacing

V/Q mismatching as improper gas exchange occurs

Signs and Symptoms of an Air Embolism
Agitation

Dyspnea

Cyanosis

Apnea

Tachycardia or bradycardia

Hypotension

millwheel heart murmur

High mortality rate (depends on quantity of air entering)

Management for Suspected Air Embolism
Place patient in left lateral decubitus position and trendelenburg position

Traps air in right ventricular apex

Administer O2 at 100%

Notify physician immediately

Root Cause
Lack of appreciation for CVC
Analysis removal as a high-risk procedure is
common among clinicians and
hospitals (Feil, 2014, para. 7).
Root Cause Analysis
Why did the patient receive an air embolus?

Why were there CVC removal complications?

Why did the physician remove the CVC improperly?

Why did the physician lack knowledge and training for proper CVC removal?

Why werent hospital policies, procedures, and training robust enough?

Lack of appreciation for CVC removal as a high-risk procedure is common among

clinicians and hospitals (Feil, 2014, para. 7)
Problem: Lack of Education on Critical Nature of CVC
Removal
PLAN DO
Educate clinicians on Training and
the seriousness of CVC Competency
removal on the critical Assessment
care floor
PDSA
ACT STUDY
Identify actions Random audits
needed to take as a Statistical evaluation
result of cycle
 Increase awareness regarding
complications r/t high risk CVC
PDSA: Aim procedure removal and educate
clinicians on up-to-date evidence-
based practice protocols that
ensure safety
PDSA: Plan
PDSA: Plan cont
PDSA: Do
Implement yearly online competency training

Post-test to ensure knowledge acquisition

Follow-up competency skills assessment in person to ensure safe performance

of CVC removal
PDSA: Study
PDSA: Study
Summary of findings:

Education and competency program increased awareness concerning the

potential critical nature of CVC removal and high risk of air embolism.

This was evidenced by:

No remediation efforts required during competency audits

Statistical reduction in incidence of CVC-associated air embolism.

PDSA: Act

Describe what modifications to the plan will be made for the next cycle from what
you learned
Empower nursing to enforce use of a central line checklist to be sure all
processes related to central line placement, including hand hygiene, are
executed for each line placement.

Empower nursing to enforce use of a central line checklist to be sure all

processes related to central line placement are executed for each line
placement.

Keep equipment stocked in a cart for central line placement to avoid the
difficulty of finding necessary equipment to institute maximal barrier
Stakeholder Analysis
Internal (unit) stakeholders

Physician

Nurse/Nurse Manager

Hospital Management Team

Educators

External stakeholders

Physician rep.

Nursing rep.
Force Field Analysis
Class Discussion
References
Feil, M. (2012). Reducing risk of air embolism associated with central venous
access devices. Pennsylvania Patient Safety Advisory (9)2, 58-64. Retrieved from
https://www.researchgate.net/profile/Michelle_Feil/publication/237154103_Reducing_Risk_of_Air_E
mbolism_Associated_with_Central_Venous_Access_Devices/links/0c96051b9efd5eda0c000000.pdf

Feil, M. (2014, June). CVC removal: A procedure like any other.

Retrieved from https://psnet.ahrq.gov/webmm/case/328

EmpoweRN. (2015, December 7). Removal a central line. [Video File]. Retrieved
from https://www.youtube.com/watch?v=H22PVadE6xg&t=17s

strongerthanleukemia. (2013, September 25). Central venous catheter removal.

[Video File]. Retrieved from https://www.youtube.com/watch?v=MXEteWZg1c4&t=338s

Urden, L.D., Stacy, K.M., & Lough, M.E. (2014). Critical care nursing (7th ed.). St.
Louis, MO: Elsevier Mosby