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Todd Fraser wrote 07-24-2010 09:55:11 am
There is no doubt that U/S has changed our practice, and it pretty clearly improves insertion times and reduces complication rates. So I think its here to stay. But it does highlight the issue of looking at all the effects of an intervention - it works in context, but has ramifications in settings where the technology is not available.

I guess another question is what does it take to achieve competency?

doug lynch wrote 07-24-2010 12:52:34 pm
Is it fair to say that new intensivists will have to demonstrate competence in both U/S guided and Traditional methods of CVC placement?

Starting with "Traditional" methods. We don't have to reinvent the wheel. In the states Peter Pronovost has had a lot of success with a simple "bundle" and "checklist" approach. His CVC checklist starts with the practitioner demonstrating 5 successful supervised CVC placements in both "chest and femoral" sites.

http://www.safercare.net/OTCSBSI/Home.html

See appendix L onthe resources page;

http://www.safercare.net/OTCSBSI/Resources.html

In Australian/NZ we could adapt this sort of approach to our needs. I would suggest some agreement should be sought across the appropriate colleges and a similar minimum standard established. Then when CICM/ACEM/ANZCA trainees rotate through different posts we will all be speaking the same language. In the present system the work of accreditation would be duplicated and triplicated unnecessarily.

I think we should use a similar log format across the colleges and importantly we should follow up our lines for evidence of infective complications.

I cannot comment on the training for U/S guided placement having never used it. Perhaps we should ask Andrew Hilton at the Alfred?

I asked him at the Box Hill course about Intensivist Echo accreditation. He suggested two levels of Intensivist Echo; Basic and Advanced. He suggested that the higher level should do the same

Todd Fraser wrote 07-28-2010 06:15:18 pm
Great ideas Doug,

Has anyone had experience trying to tie this together in their institution? I know Peter Cook in Brisbane has been doing work in this area. Does anyone collaborate with the ED, theatre etc in terms of credentialling?

The Echo one is very interesting. It seems to me that within 5 years it will be a mandatory skill for graduating intensivists. Gaining accreditation is something we've not yet been able to deal with as a craft group, but work is being done (by Tony McLean and others). In terms of getting enough numbers, Crit-IQ is planning something to help with that. Stay tuned for more details....

Neil Orford wrote 07-29-2010 06:33:56 pm
I think there are 3 separate issues emerging, cardiac echo training for intensivists, US guided CVC placement, and all other critical care US. The 3rd is perhaps a minor player that can be tacked on to the 1st 2.

Cardiac echo is a big subject that has been difficult for colleges to address, as expert opinion about acquisition and maintenance of TTE and TOE practical and theoretical skills is divided around how many, basic vs advanced vs expert, etc. Theoretical knowledge is relatively easy to obtain through courses such as Melb Uni Post Grad Dip Crit Care Echo. Gaining and maintaining practical skills is harder (TOE perhaps 100-150 1st yr, then 30-50 yr thereafter, similar for TTE, the difference between reporting and performing). Then there is a background discussion around whether or not you need to take this on as a college, ie we dont apply same standards to PAC or CVC insertion, and once you start demanding accreditation you are resposnible for providing training and education during fellowship training.

The issue around CVC insertion and US guidance has taken me by surprise, having spent 10 years in an institution that informally mandates the use of US for CVC insertion, I naively thought everyone was doing it. There is a reasonable body of literature suggesting US guidance is safer, particularly while learning (I accept that this is a debatable point), it is an easy technique that takes minimal training, and the equipment is suited to transport (eg the little sonos

Todd Fraser wrote 07-29-2010 07:29:20 pm
Interesting points Neil,

Queensland Health has introduced a payment for providing a bundle of care for insertion of CVCs (each CVC inserted in accordance with the bundle attracts a payment). For IJ catheters, payment only occurs if an U/S is used (presuming it is available). It would certainly be worth putting an instructional video on the site. Others are available (NEJM has one I think).

A recent coroner's report recommended bronch for all trachy insertions - I believe ANZICS have drafted a position statement which will follow the coroners recommendations.

Jane McKenzie wrote 08-05-2010 09:38:22 am
As technology and credential requirements seem to change with time perhaps we should record all procedures that we undertake.
The NBE (National Board of Echocardiography) in America has set their requirement at repeating your echo credentialling exam every ten years to cope with changes in technology.

YOGESH APTE wrote 04-11-2011 05:40:44 pm
Using ultrasound guidance for Jugular or Femoral or PiCC lines is fine but what about subclavian access? One still has to perform it using anatomical landmarks and this approach has the maximum risk of causing complications like pneumothorax, arterial puncture etc despite being the 'cleanest' site! US guidance has proven tricky when it comes to subclavian vein puncture atleast to me.

James Doyle wrote 07-09-2010 07:12:42 pm
Perhaps this is something the colleges could take on. With the new on-line trainee portfolios surely a tool could be added for trainees to 'tick' the competencies for various interventional procedures, this could then be confirmed by their current SOT.

In the meantime if the unit protocol minimum requirement has NOT been met (i.e. at least 1 direct supervision of a CVC if a new registrar claims to be highly comptent) then get out of bed!

doug lynch wrote 07-20-2010 09:47:40 pm
We are struggling with the same question in our unit at the moment.

The simple answer is YES get out of bed and supervise the line.

I agree that a simple log-book could be very easily adapted to include a record of supervision of CVC placement and if appropriate..."credentialling".

I think we should have a similar process across the critical care training programs such that we could accept credentials of a trainee of the ACEM or ANZCA or even ACRRM/RACGP (JCCA). This would surely decrease anxiety amongst senior staff in multiple specialties and probably complications due to suboptimal catheter placement.

I think in an ideal world we would review the skills of a registrar coming through the ICU and ensure that those requiring supervision were on day shifts initially. This should be possible. If this is not possible then arrange for them to be "supernumery" before they start nights and confirm in the unit or in OT that their skills are up to scratch.

This seems like a lot of work but then so does getting up out of bed and driving in to supervise a CVC in the middle of the night and all the tiredness that will follow.

Of course then we have to consider blind versus U/S guided lines and perhaps accrediting all trainees for both......

In general all ACEM registrars we have are U/S familiar and not so confident without it.

Does everyone have access to U/S in their ICU's?

Todd Fraser wrote 07-21-2010 06:17:25 pm
Thanks Doug

We certainly have U/S access - it appears we are becoming more and more reliant on it. This does concern me, as I do a bit of retieval and it is not that uncommon to have to put one in without the benefit of U/S. It is certainly in our interests to maintain the "by landmarks" skill I think.

I agree - it would be great to see a transferrable credentialling process, and there is no reason this cannot cross the specialties. So the big question is how to make that happen...

Kristine ESTENSEN wrote 07-22-2010 10:05:46 pm
I agree with James analysis - "get out of bed" with anyone new !! I would like to add to the other comments by saying as a very junior person in ICU that I also think it is my responsibility as a trainee to be aware of my limitations and make this known to my supervisors. Then also hope that supervisors are responsive and keen to teach. I also think that supervisors need to be really communicative by expressing that they do / or do not feel we can safely perform procedures unsupervised and feedback what stage of learning / competence we are at. We all want to be viewed as competent and "able to do things" ... just getting that balance right I suppose. At UQ in the SOM we are currently throwing around ideas where the medical students have a " memory stick" type set-up (like a log-book) where it is portable and can be used to tick off certain procedures they have completed / observed etc.

On Dr Frasers comments regarding the USS usage - I certainly hope to be very competent with the landmarks without USS, but the temptation is so great....