Ultrasound puts emergency lines in the right place

Training emergency department (ED) staff in use of ultrasound to guide difficult peripheral intravenous catheter placement appears to reduce the unnecessary use of central venous lines, a study suggests.

The reduction in central venous line use after the introduction of ultrasound training was particularly notable for patients who were not critically ill, report Hamid Shokoohi (George Washington University, DC, USA) and colleagues.

The researchers stress that they did not specifically record the numbers of peripheral intravenous lines that were placed using ultrasound or traditional means during the study period (2006-2011), so the association can only be inferred.

But they note that the reduction in central venous lines was "remarkable" and that the "only major practice change" during the study period was the training of emergency medicine residents and technicians in use of ultrasound in patients with difficult peripheral venous access, which began in early 2008.

"The implications for the rate of central venous catheter placement in the ED and similar settings with a high prevalence of such placement could be dramatic," Shokoohi et al write in the Annals of Emergency Medicine.

They say that this has "potentially major implications for patient safety," noting that around 15% of the 5 million central venous catheters placed in the USA annually result in complications, which can include blood infections, thrombosis, vessel damage, and hematomas.

In the team's study, 1583 (0.39%) of 401,532 patients received a central venous catheter, but the annual rate fell from 0.81% in 2006 to 0.16% in 2011, representing an 80% reduction. The number of patients seen annually in the ED rose by 24% during this time, but their age, gender, Emergency Severity Index, and ED deposition remained stable.

The fall in central venous catheter use applied only to noncritically ill patients, with an average monthly decrease of 4.4% and 4.8% for patients admitted to telemetry and the ED floor, respectively, and of 7.6% for those discharged home. Indeed, by 2011, no patient discharged home received a central venous catheter, down from about 0.2% in 2006.

By contrast, there was a nonsignificant average monthly decrease of 0.9% among critically ill patients - those admitted to the intensive care unit or to emergency surgery. By 2011, critically ill patients accounted for 81% of all central venous lines, up from 34% at the beginning of the study.

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