Invited Commentary
March 4, 2024
Enhancing Quality and Safety in Critical Care—Challenges and Strategies for Central Venous Catheters
Elie A. Saade, Francis T. Lytle, Peter J. Pronovost
JAMA Intern Med. 2024;184(5):482-483. doi:10.1001/jamainternmed.2023.8243
Central venous catheters (CVCs) are widely used in US critical care settings, providing essential functions such as medication administration, hemodynamic monitoring, and reliable venous access. Despite the benefits of CVCs, complications, particularly infections, have become a major focus of US hospital quality improvement efforts due to federal and state initiatives that emphasize patient safety, transparency, and accountability. The Centers for Medicare & Medicaid Services mandate reporting hospital-acquired infections through the Hospital Inpatient Quality Reporting Program, which significantly affects hospital operations nationwide. The program specifically targets certain hospital-acquired infections, such as central line–associated bloodstream infections (CLABSIs), and can result in financial penalties for hospitals with elevated rates. Additionally, complications that are not solely related to CVC use, such as iatrogenic pneumothorax and deep venous thrombosis, are included in the quality metrics that hospitals must report.1
In their systematic review and meta-analysis in JAMA Internal Medicine, Teja et al2 investigated 15 CVC-related complications. The study found significant rates of placement failure, arterial puncture, pneumothorax, catheter malfunction, infections, and thrombosis. Notably, 3% of patients with a CVC for 3 days experienced serious complications, such as arterial cannulation, pneumothorax, infection, or deep vein thrombosis. A smaller percentage of these complications was tracked by the Hospital Inpatient Quality Reporting Program. The infection rates were similar for subclavian and femoral insertions, with a slightly higher rate observed for internal jugular insertions, although the confidence intervals overlapped, suggesting no significant difference. Arterial puncture and placement failure rates were similar across all CVC insertion sites, and the subclavian site had a significantly higher risk of pneumothorax than the internal jugular site did. The authors underscored the effectiveness of ultrasonography guidance in reducing complications such as arterial puncture, pneumothorax, deep venous thrombosis, and infections.2
As new research and changing practices emerge, the traditional reliance on CVCs for various clinical applications is being reevaluated. Studies suggest that peripheral administration of vasopressors for patients with septic or cardiogenic shock, among others, is feasible and safe.3 International surveys indicate a trend toward peripheral administration of medications such as norepinephrine, which is traditionally administered centrally due to its vesicant nature and risk of extravasation. Advances in parenteral nutrition and chemotherapeutic agent formulations have made peripheral administration more viable, further reducing the need for CVC placement. Recent developments in medical technology have led to minimally invasive and noninvasive hemodynamic monitoring techniques, reflecting a growing focus on patient safety and comfort in critical care settings.4 However, CVC use remains high, which suggests that additional efforts need to be made to educate and incentivize frontline clinicians to minimize their use; including measures of utilization of CVCs in pay-for-performance programs might be considered for this goal.
The broadened use of point-of-care ultrasonography and other advanced peripheral intravenous access placement techniques has significantly contributed to the reduced need for traditional CVCs in patients with difficult venous access. Despite the technological advancements that enhance the precision and user-friendliness of ultrasonography guidance for peripheral intravenous access and CVC placement, the full potential of these technologies has not been realized in the absence of up-to-date clinical protocols and comprehensive education programs. The current academic discourse emphasizes that without such frameworks and a commitment to ongoing professional development, the efficiency and safety benefits of these technologies remain suboptimal.5 A systematic approach to clinician training and adherence to evidence-based protocols is essential to ensure that these minimally invasive techniques are effectively utilized, thereby maximizing patient outcomes and resource utilization in clinical settings.
There is growing debate surrounding the reliability of hospital-acquired infection metrics, with infection control experts raising concerns about potential misinterpretations and susceptibility to manipulation by external factors. Adjustment of CLABSI rates for quality reporting and comparison remains suboptimal and often fails to account for multifactorial influences affecting infection rates; this has been highlighted in the recent literature, emphasizing the need for refined methodologies that accurately reflect a health care facility’s quality of care.6 Furthermore, an overemphasis on hospital-acquired infection reporting could unintentionally shift the focus away from direct infection prevention activities within hospitals, leading to potential negative impacts on patient care and overall hospital quality. In states where reporting is mandatory, infection preventionists report being stretched thin and juggling compliance with reporting mandates and their traditional roles in infection prevention, resulting in less influence on hospital policymaking and a shift toward advisory roles. While a definitive consensus is yet to be reached, the complexities inherent in current hospital quality assessment methods suggest that it is an opportune time to consider a paradigm shift toward more comprehensive, process-oriented measures. Such a shift could potentially cultivate a more nuanced, effective, and holistic approach to improve hospital quality assessment and enhancement strategies. It also highlights the importance of developing reporting systems that accurately reflect the quality of care without compromising the core activities of hospital infection prevention and control programs.
The adoption of practices proven to lower the risk of complications from CVCs, such as ultrasonography-guided placement and insertion and maintenance bundle, has been suboptimal, thus limiting their potential benefits.7 To ensure a comprehensive and balanced assessment of health care quality, it is proposed that process measures be incorporated into the quality reporting and reimbursement models in place of outcome measures. An emphasis on process measures offers a proactive approach to infection control by promoting the standardization of practices known to reduce infection risk. Furthermore, this strategy promotes a culture of prevention and continuous improvement, aligning health care practices with evidence-based standards and the principles of patient-centered care, and fosters transparency and accountability. By linking financial rewards to the adoption of evidence-based practice measures, hospitals can achieve enhanced compliance, potentially optimizing the effectiveness of these practices in preventing harm. Expanding the scope of process measures could provide more comprehensive quality assessments that offer insights into the day-to-day practices of health care clinicians and could uncover areas for improvement at the caregiver level, thereby enhancing patient care. This strategy encourages caregiver accountability and incentivizes adherence to best practices. Prioritizing process over outcome measures yields additional benefits such as timely feedback on health care protocols, consistent care delivery, early identification of harmful practices, and continuous performance monitoring. This approach also enables health care clinicians to adjust to new best practices and ensures patient-centric care, thereby improving patient experiences. Moreover, centering on process measures redirects infection preventionists from merely quantifying outcomes to actively monitoring processes, which brings them closer to the point of care. Such proximity is crucial for preventing hospital-acquired infections, rather than just recording their occurrence. This proactive approach not only bolsters patient safety and elevates care quality but also solidifies a more efficient and resilient health care quality management framework.
