Central venous lines (CVL) are being placed in a majority of ICU patients for infusion of complex medications, rapid delivery of blood products and monitoring of central venous pressures. Often, the CVL is removed during the patient's ICU stay. In May 2008, a sentinel case of air embolism was attributed to removal of a CVL while patient was in a sitting position. The Organization re-educate all ICU RNs yet ongoing educational opportunites required continual learning models.
The TeleICU teams and VCRMC Leadership reviewed existing policies concerning CVL removal. Determination that the AACN recommended position, Trendelenburg, required at the time the case occurred, was appropriate. Removal during mechanical ventilation was reviewed.Mandatory in-services for all RNs was completed emphasizing the CVL removal policy. Central Venous Access Removal Quality Monitoring Tool© (CVAR-QM) was implemented. Each time a CVL was removed, the bedside RN calls the eCare RN to document proper procedure and to provide coaching to prevent improper technique.
In the first six months of implementation the eCare Team identified, educated and intervened in 4 separate cases to ensure appropriate agreed upon procedures were followed. Nursing Leadership determined this warranted system wide utilization of the eCare monitoring, coaching and intervention to all ICUs. This collaboration is fully backed by the MEC, Clinical Quality & Patient Safety and CMO.
With the eCare monitoring, mentoring and intervening capabilities has resulted in preventing three potential cases of air embolism during the first two months of use. Preventing personal tragedy with cost avoidance estimated at $180,000 per case or $720,000 in non-reimbursable patient care costs under the CMS Never Events rule.
Clinical quality and patient safety requires vigilance including TeleICU and is attainable in a facility that encourages continual learning. VCRMC is committed to zero Never Events.
Elizabethann Cowboy, No Financial Disclosure Information; No Product/Research Disclosure Information