Authors (including presenting author) :
Chu NW, Kwok WY
Affiliation :
Intensive Care Unit, Prince of Wales Hospital
Introduction :
Many adult critical ill patients have a central access devices (CAD) that includes central venous catheter (CVC), continuous renal replacement therapy (CRRT) catheter, or femoral arterial line during their acute phase of illness in the intensive care unit (ICU) for invasive monitoring of physiological status and treatment responsiveness. Bleeding is the most likely complication to occur after removal of the CAD when direct pressure is applied to the puncture site, is not long enough, to achieve adequate haemostasis. This kind of complication can be fatal especially if the larger size (such as 13FR) CRRT catheters are used.
Therefore, a Continuous Quality Improvement team has developed a removal of central access devices label aimed to provide quick clinical guide to bedside ICU nurses for the removal of CAD.
Objectives :
1. To deliver safe and standardize care to ICU patients during the removal of CAD
2. To prevent bleeding after removal of CAD
Methodology :
Having wide staff consultation to various kinds of method to remind nurses important clinical steps on removal of CAD, finally a removal of central access device label is developed. The label reinforces the following critical actions for the removal of these line / catheter:
1. Application of direct pressure to the CAD exit site after the line has been removed for at least 10 minutes
2. Re-checking of the removal site 5 minutes later after direct pressure was stopped for any bleeding / haematoma
3. Removal of all central venous & arterial lines as early as possible while the patient is waiting to transfer out to general ward
4. Checking the integrity of removed lines to avoid any retention of lines material
5. Enhancement of nursing clinical handover through standardization of nursing documentation
Promotion of the project:
Staff education during briefing
Eye catching smart point posted in the common staff areas of the unit
Ad hoc compliance check during daily round
Result & Outcome :
Result: The program was implemented in May 2016. Every year, the Intensive Care Unit of Prince of Wales Hospital has around 1800 admissions of which 450 CVC lines and CRRT catheters were removed. A regular surprise audit on removal of CAD and implementation of the label was 100% compliance. Moreover, there were no incidences of immediate bleeding. However, there were 2 reported cases of delay bleeding after removal of CRRT catheters due to the patient’s underlying illness in 2018. Therefore, 2nd check was made 15 to 30 minutes after direct pressure was stopped in order to close this loophole. As of July 2019, there were no any immediate or delay bleeding cases reported. Conclusion: Development of a removal of central access devices label has demonstrated it’s effectiveness in preventing post removal bleeding complication in ICU. Nurses also feedback to enhance clinical documentation and handover as a bi-product of the project.
