SCCM Resource Library-22-Outcomes of a Chest Radiograph De-Implementation Program: An Implementation Effectiveness Study

Video Transcription

Hi, my name is Enyi Rablodepe. I'm coming to you from Washington University, where I serve as co-director for the Critical Care Ultrasound Training Program and Emergency  Ultrasound Research Program. The title of our project today is Outcomes of a Chest X-ray Deimplementation Program, an Implementation and Effectiveness Study. I have no disclosures.  This project is supported through an institutional care award through the NHLBI. So for many  decades we've known that point-of-care ultrasounds is an effective and faster alternative to chest X-rays for confirming central venous catheter position and excluding pneumothorax.  And again, while this may be news to you, this is well supported in the literature. However, the application for point-of-care ultrasound for central line confirmation is  relatively low. The process though is relatively easy as depicted in the picture here. Essentially  it is visualization of the heart with a rapid flush through the central venous catheter  demonstrating rapid atrial swirl sign or pacification. There's evaluation of the neck vessels showing  no echogenic material when the catheter is flushed again, and then evaluation of pleural slide on the side of the catheter's place. The goal of the study was to develop a program,  a deimplementation program that would foster an opportunity to increase the adoption of point-of-care ultrasound for this application. Now the steps of developing an implementation  program are beyond this particular discussion. However, one should know that there has been  a lot of background work similar to building a house with plans and blueprints, foundation,  and setups that were arranged before the project could begin. So data analyses, interviews,  focus groups, logic models, mappings, and strategy identifications were all done preliminarily  to develop the DROP program, which is being evaluated for this study. In a nutshell, the DROP program consists of several strategies, and one of the strategies is an algorithm,  and I wanted to share the algorithm here because it explains how the project happened in our emergency department. So patients who had a right IJ central venous catheter place  that was ultrasound guided were eligible to be part of the DROP protocol. DROP protocol  meaning that you would confirm the ultrasound, you would confirm the central line by ultrasound  and not get a chest x-ray. Three things were required to be demonstrated, as I showed before, which is first the right atrial swirl sign, that there was no echogenic material when  looking at the neck vessels, and then there was adequate pleural imaging. Images had to  be stored in our PAC system as well as a procedure note written in our EMR to be able to share  information with other services. If all those things were met, chest x-ray was not needed and central venous catheters were ready to be used.  So the study methods is that this is an implementation effectiveness study, so the project is not  studying ultrasound's ability to confirm central lines, but instead looking at how a program like DROP can help to change behavior and increase adoption of point and carotene for  this purpose. So the intervention strategy is actually the DROP program or the de-implementation  plan. The implementation strategies that were identified from evidence-based methods done in prior work include education and training, clinical decision support, which includes  supervision, audit and feedback, leadership support, algorithm development, one of which  I just showed you, and then planned adaptations throughout the course. The outcomes that we're  looking for were primarily from an implementation standpoint, looking at feasibility, adoption  rates, de-adoption, and then fidelity. Fidelity defined here as something being done as it was intended, both for the algorithm as well as the point of care ultrasound images. We  did also look at effectiveness outcomes, specifically diagnostic accuracies and safety. Our results  demonstrate again primarily from an implementation outcome that we would look at feasibility  here defined as the opportunity to perform DROP or DROP again being defined as the program  for which one incorporates point of care ultrasound for central line confirmation and de-adopts  or de-implements chest x-rays afterwards. Fidelity for the DROP protocol, which includes fidelity of the algorithm compliance, as I pointed out before, by checklist, as well  as fidelity for the ultrasound images as that is a critical portion of safety. Adoption of point of care ultrasound was measured by looking at the DROP initiation, so patients  who had Rite-IJ central lines placed by ultrasound guidance were all eligible, and the rate of  those attempts were all classified as de-adoption or x-rays that were afforded when DROP was initiated. And then effectiveness, we looked at complication rates and again diagnostic  accuracies of point of care ultrasound's ability to confirm central lines. This is what's called  a hybrid study. There are three types of hybrid studies. Traditionally, the hybrid study that we  use is called a hybrid three, where again we focus primarily on implementation outcomes, and then we also collect some effectiveness outcomes. Our results are the following. So over  the time period, January 1st through the end of July, of course, understanding that that was at  the height of this new coronavirus, that there were 252 central lines that were placed in our  emergency department. The primary source that we were looking for were Rite-IJ insertions. Rite-IJs  were initially chosen just for the ease of the procedure and the few complications that they're  known to have in the literature. And from an implementation standpoint, having something that  has the least amount of complications would be easier to get support for. So there were 89 Rite-IJs  that were placed during that period of time, about 35% of the entire central line population.  Of those 89, DROP could have been initiated, meaning that the provider could have decided to use point of care ultrasound instead of getting traditional x-ray. In our data set,  this interim analysis, about 50% of the population or opportunities when DROP could have been  initiated were initiated. So 44 times the provider did try to use point of care ultrasound instead of getting a chest x-ray. Of the 44 attempts, 36 of them, they were able to do  point of care ultrasound and not get an x-ray. That's what the N is for or drop in. That leaves  us at a feasibility of 81%. There were eight situations where while attempting to initiate  point of care ultrasound, the embedded safety mechanism and the algorithm allows a provider to  revert back to routine care or chest x-ray if they were inappropriate images or there were any  concerns. The fidelity of the required ultrasound images as well as the de-implementation algorithm  was about 86%. So people follow the algorithm well, meaning that if they could see the three  items that were required, that they did not have to get a chest x-ray. However, if they were not  able to see the three things that were required, they did need to go divert back to routine care  and get a chest x-ray. Of the patients where DROP was initiated, we did look at the effectiveness or  diagnostic accuracy of that sample population. You see that there was one true positive from  catheter malposition and one false negative. We specifically are paying attention to that false negative rate as the algorithm does not allow or does not have a safety process  for those patients. Those patients would have their malpositions discovered on a subsequent  chest x-ray. The incidence of malpositions in the population was about 4.5%, which is pretty consistent with RITE-IJ catheter malposition rates in the literature. There were no new  authorities in this population. These were patients who had their RITE-IJs placed in the  ER, subsequently go to an ICU, where the next day or several hours later, a chest x-ray is obtained  for routine patient care. As a side note for safety, that one false negative rate,  it was a venous catheter malposition. The clinical team continued to use that catheter for up to seven days. There were no complications that were reported during our chart review.  Limitations, obviously, of the study right now is that this is just an interim analysis.  There is a small sample size, and the methods that we're using, obviously,  limit the generalizability of some of the data points that I'm sharing with you now. There was a lower use of DROP, which may reflect some behavioral adaptation processes,  such as capacity, opportunity, and motivation. Then the strategies from the DROP program are all bundled or coupled, meaning that we are assuming that all of these strategies are  necessary to get this implementation outcome. Future studies would need to think about how  to uncouple or think about the absolute critical portions of those strategies that are necessary  to get the same outcome. Conclusion here is that through our multifaceted implementation strategies, which is the DROP program, we were able to see a reduction in chest x-rays  after ultrasound-guided central line conformation. Larger studies in the ED and or the ICUs are  going to be needed to be able to really measure the implementation reach of a de-implementation  program like DROP. This is a research team. Thanks at Washington University, and thank you for your time.

Video Summary

The video discusses a research study called "Outcomes of a Chest X-ray Deimplementation Program" which aims to increase the adoption of point-of-care ultrasound for confirming central venous catheter position and excluding pneumothorax, as an alternative to chest X-rays. The study developed a program called DROP (Deimplementation and Implementation Program) which consists of various strategies including education and training, clinical decision support, and algorithm development. The study evaluated the feasibility, adoption rates, de-adoption, and fidelity of the program. Results showed that approximately 50% of eligible cases initiated DROP, with a feasibility rate of 81% and a fidelity rate of 86%. Further studies are needed to assess the implementation reach of the program.

Asset Subtitle

Procedures, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Enyo Ablordeppey

Introduction/Hypothesis: Data suggest that point of care ultrasound (POCUS) for central venous catheter (CVC) confirmation may obviate the need for traditional post-CVC chest x-rays (CXR) to confirm catheter position and exclude pneumothorax (PTX), but this practice has had a slow rate of adoption. To facilitate uptake, we developed DRAUP (De-implementation of Routine cxr after Adoption of Ultrasound guided cvc insertion and confirmation Protocol), a program using 6 multifaceted strategies. In this study, we assess implementation and effectiveness outcomes using this program.

Methods: This is an interim analysis (1/1/2020 â€“ 7/31/2020) from a prospective, hybrid implementation and effectiveness study at an urban academic Emergency Department (ED). All patients with POCUS-guided right internal jugular (IJ) CVC placement were eligible. Using Morgan's framework for medical overuse, six implementation strategies were selected, including organizational support, algorithm development, audit and feedback, planned adaptation, education and training, and decision support. This study assessed adoption of POCUS confirmation after right IJ CVC insertion, de-adoption of post CVC CXR in the ED, and fidelity to the protocol. Effectiveness outcomes included feasibility of DRAUP and descriptive analysis (false negative (FN) rates of POCUS to detect malposition and PTX). Feasibility was measured by the number of opportunities to deimplement CXR based on the algorithm. Fidelity was measured by adherence to the protocol through checklist completion.

Results: There were 252 CVCs placed in the ED. Among 89 patients with right IJ catheters, DRAUP was used in 49% (44/89) with no ED CXR performed in 36 (82%) (feasibility). Fidelity of the required POCUS images and deimplementation algorithm was achieved in 86%. The incidence of CVC malposition and/or PTX seen on the next available CXR was 4.5% (2/44) and 0% (0/44) respectively. The FN rate of CVC malposition and PTX by POCUS were 2% (1/ 44) and 0%, respectively.

Conclusions: Multifaceted implementation strategies used in DRAUP can reduce CXRs after POCUS-guided CVC confirmation, thus reducing this evidence-to-practice gap in critically ill patients. Larger studies in other EDs or the intensive care units are needed to measure the implementation reach of DRAUP using multifaceted strategies.

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Tag Radiology

Tag Point of Care

Tag Cardiothoracic Critical Care

Year 2021

Keywords

Chest X-ray Deimplementation Program

Point-of-care ultrasound

Central venous catheter position

Pneumothorax

DROP program

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