A checklist to improve the quality of central venous catheter tip positioning.

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n = 84) in 2016 and a post-intervention audit (n = 84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.

The influence of the current medicolegal climate on New South Wales anaesthetic practice.

A survey was posted to all New South Wales and Provisional Fellows of the Australian and New Zealand College of Anaesthetists to assess the influence of the current medicolegal climate on their anaesthetic practice. Information collected included demographics, opinions regarding the current medico-legal climate, medical defence organizations, and the implications for anaesthetic practice. The response rate was 78% (640/820). Nearly all (95.3%) were concerned about the current medical indemnity crisis and 80.5% felt concerned about the financial security of medical insurers. Of all these respondents 23.6% had personal experience of litigation and 73.6% expected to have a claim made against them during their career: Respondents spent an average of 8.3% of their gross annual income on medical insurance premiums and 47.2% are concerned about the viability of their practice given the rising costs of medical insurance. Obstetric anaesthesia was the most common area of practice to be ceased due to medicolegal concerns. In the next two years, 20.2% of obstetric anaesthetists who responded intend to cease practice. In the past two years, 3.1% of respondents retired due to their litigation concerns, while 12.8% (average age 56.7y) are intending to retire in the next two years for the same reasons. Changes to the conduct of the preoperative consultation were common. Other changes to practice included more thorough documentation of complications (50.8%) and a strong reluctance to perform neuraxial blocks (54%). This survey suggests that anaesthetists are concerned about the current medicolegal climate and as a result, some are retiring earlier and giving up high-risk areas of practice.