Background: Central venous catheters (CVC), including temporary dialysis catheters, are a relatively frequent procedure needed in the inpatient setting. Historically in our institution, CVC have been placed in the intensive care unit (ICU) by critical care staff or in the radiology suite by interventional radiology staff. The reasons for this placement preference have included the degree of illness of a patient needing central access, need for continuous monitoring, availability of sedation, and the perceived degree of complexity of the procedure. However, in the right patient population, we have found that CVC placement on the medical-surgical wards can be safe and efficient.
Methods: The Hospitalist Bedside Procedure Service (BPS) at our institution began to perform CVC placement at the patient bedside on medical-surgical wards in 2015. Patients were monitored via a portable cardiac monitor system during the procedure. All CVC placements were done under direct ultrasound guidance. Sedation is not available on the medical-surgical wards, so patients who were unable to tolerate the procedure were not eligible. We evaluated internally collected data from the procedures performed by the BPS from 2015-2021.
Results: The BPS performed 15 CVC on medical-surgical wards from 2015-2016, 58 from 2016-2017, 78 from 2017-2018, 50 from 2018-2019, 49 from 2019-2020, and 121 from 2020-2021 for a total of 371 procedures. There were 3 complications (0.8% rate) including a ventricular tachycardia arrest following guidewire placement, vasovagal bradycardia, and a pneumothorax. Thirty-six (9.7%) of the attempted CVC were unsuccessful and required transfer for placement. The most common reasons for unsuccessful CVC placement were anatomical abnormalities (eg, stenosis leading to inability to pass guidewire) and failure of the patient to tolerate the procedure without sedation. Residents assisted in 119 (32.1%) of the procedures with one of the total three complications occurring during a resident-performed or assisted procedure.
Conclusions: In 2015, the BPS began to perform CVC placement at bedside on the medical-surgical wards with excellent success rates and a very low number of complications. This arrangement allowed for more efficiency in performing line placement, avoided otherwise unnecessary ICU transfers, and improved the use of resources by obviating the need for radiology services for a standard bedside medicine procedure. Internal medicine residents were able to get more exposure to a procedure in which they should be competent by the end of their training. We hope that this model can provide a framework for other institutions with similar restrictive policies and expand the procedural abilities of hospitalists while saving time and resources for the hospital system and patients.
