An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and chronic kidney disease was transferred to a referral hospital for percutaneous coronary intervention after presenting to a community hospital with hypotension and chest pain. At the community hospital, a central venous catheter was placed in the patient's right internal jugular vein for administration of vasopressors. When he arrived at the referral hospital, he was hemodynamically stable and the vasopressors had been discontinued for an unspecified period of time, although the central line remained in place "just in case." The patient underwent successful stenting of his coronary arteries and was discharged to an assisted living facility within 48 hours of admission.

On arrival at the assisted living facility, it was discovered that the central line was still in place. The caregivers at the assisted living facility noticed the line and returned the patient to the referral hospital the same day to have the central line safely removed. The incident was reported and investigated, revealing several contributing factors. First, the patient was a transfer who was admitted late at night, and who was signed out the next morning as 1 of 12 holdovers to the admitting teams. Second, it was "switch day" for the interns and early in the academic year, so many of them were still getting used to a new system. Third, the line had been placed somewhere else, for an indication (hypotension) that no longer existed, and it had not been used at any point during his 48-hour admission. Lastly, while the nurse noticed the line during the routine predischarge examination, she assumed that the patient was supposed to be discharged with it in place and did not call anyone from the medical team to get clarification.

by Marta L. Render, MD

There was drama in the first minutes following presentation by this patient with acute myocardial infarction—rapid diagnosis, stabilization, interfacility transfer, and then successful intervention. . . heart muscle saved. The story illustrates something far less dramatic, but potentially just as important for the patient's outcome: how unanticipated or underappreciated gaps in the system of care can contribute to complications. In this case, a fragmented system for central line management hampered by gaps in communication and diffusion of responsibility increased this patient's exposure to infectious and mechanical complications from central line placement.

Access to central blood vessels for administration of life-saving therapies and measuring hemodynamics is critical in emergencies, but that access leaves 15% of patients with mechanical, infectious, or thrombotic complications.(1) In the past, such complications were often considered to be inevitable consequences of central line access. We now know differently: the Centers for Disease Control and Prevention (CDC) recently reported a 58% reduction in central line–associated blood stream infections (CLABSI) (2), representing the results of a national focus on improving patient safety, public reporting of infection rates, Medicare's "no pay for errors" policy, and a national campaign supported by the Agency for Healthcare Research and Quality. The campaign built on work by Pronovost and others demonstrating that systematic implementation of protocols and guidelines (3,4) for best practices, combined with effective change management strategies, could result in major improvements in infection rates.(5,6)

Updated guidelines for central line management from the CDC emphasize training and education, use of maximal sterile barriers, skin cleansing with a greater than 0.5% chlorhexidine solution, avoidance of routine line replacement, removal of central lines when they are no longer needed, and using antiseptic antibiotic impregnated central venous catheters and/or chlorhexidine sponge dressings when high infection rates appear refractory (Table).(7) Timing for central line removal is often a matter of clinical judgment. However, the central line described in this case met two reasonable criteria for removal. First, it is a best practice to determine daily whether lines are needed and to remove those that are not.(7) Second, we know that lines placed during emergencies (in this case, treatment of hypotension) are more likely to become infected; therefore, such lines should be removed as soon as possible.(7)

The use of checklists for central line insertion has been recommended to improve adherence to evidence-based practices. Moreover, use of a daily goal sheet in the intensive care unit (ICU) can also help systematize removal of central lines.(8) Tools such as checklists and goals sheets can facilitate guideline adherence by acting as a memory and learning tool simultaneously.(9-13) In this case, use of a checklist or daily goal sheet might have stimulated the providers to discuss whether the line was still necessary and prompted consideration of its removal.

Central line removal can have serious and even fatal complications (air embolism, catheter fracture and embolism, dislodgement of a thrombus or fibrin sheath, hemorrhage/bleeding).(14) Thus, trained nurses are generally responsible for this task. Training manuals and online resources note that patients should be well hydrated before lines are removed. Patients should be placed in the Trendelenburg or, at minimum, supine position (to elevate central venous pressure [CVP] above atmospheric pressure). They should be instructed to perform a Valsalva maneuver or forced expiration (where atmospheric pressure is less than intrathoracic pressure) during removal, and removal should be followed by applying pressure and an airtight dressing for 24 hours.

This case illustrates a classic story of gaps or fracture points, in which critical patient information is lost at the time of transfer to a new hospital or provider. Health care workers spend considerable time and energy trying to bridge such gaps, better system design could reduce our reliance on individuals.(15) Other factors that may contribute to gaps include organizational memory loss (such as occurs when residents rotate off a service), ineffective coping strategies such as problem simplification (the central line should stay in), missing ad hoc cognitive tools (the missing daily goal sheet or discharge checklist), or a culture that suppresses "unnecessary questions" because of time pressure or concerns about demonstrating their "ignorance." Because the gaps are continuously changing, static solutions are unlikely to be effective.

Take-Home Points

Strategies for reducing gaps in central line safety identified in this case include:

• Simplifying the work environment by: (i) increasing the visibility of a central line, (ii) assigning the emergency department to plan removal of central lines placed outside the hospital in patients received on transfer (and writing on the dressing), (iii) assigning the attending physician the responsibility for central line ownership (both for the line and any complications), and (iv) establishing policies for automatic removal for central lines once disconnected from therapy for 6–12 hours or within 24 hours if inserted emergently.
• Creation of redundancy surrounding removal of central lines by adopting multiple systems to promote central line removal, including: (i) daily goal sheet in physician rounds, (ii) standard query in handoffs between nurses (e.g., does the patient have a central line; do they need a central line), and (iii) encouraging patients to query health care personnel daily about the need for the line.
• Implementation of information tools: discharge checklist for physicians and nurses.
• Reducing authority–responsibility mismatches, such as where both the nurse and the junior resident are perceived as "responsible" for removing a central line at discharge but lack authority and training to do so independently.
• Developing policies, training, and a safety culture that reduce the risk of injury by making it easier to know what to do and safer to ask questions, and rewarding staff who ask questions.
• Restructuring team rounds to promote independent information generation and verification by: (i) expecting all team members to have a talking role in daily rounds, (ii) assigning roles to team members (e.g., the nurses talk about pain, family issues, lines; the pharmacists review medications; the residents consider the physiology and greatest source of danger for the patient that day), (iii) the attending with the team pulls the information shared into a plan that systematically addresses most likely areas of risk (e.g., central line infection, urinary infection, delirium, pressure ulcers), and (iv) using the daily goal sheet to promote ongoing open dialogue.

Marta L. Render, MD
Veterans Health Administration, National Program Director, Critical Care, Lung Disease, Sleep
Professor, University of Cincinnati College of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine

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Table. Guideline recommendations for central line insertion and maintenance and removal [Grade of Recommendation] (Grading system: http://www.uptodate.com/contents/grade/1?title=Grade%201A).