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.

Introduction of a mandatory pre-block safety checklist into a regional anaesthesia block room service: a quality improvement project.

Wrong-side block is an uncommon yet potentially preventable complication of regional anaesthesia. One strategy for reducing the incidence of wrong-side block is to introduce an additional check into the pre-block workflow in the form of a block 'time out' or 'stop before you block'. In the aftermath of a wrong-side block incident at our institution, the mandatory use of a pre-block safety checklist was successfully introduced into the workflow of the block room. Compliance with the checklist rose from 31% in the six-month pre-intervention phase to over 90% in the six-month post-intervention phase. This was achieved without any negative effect on block efficacy, theatre efficiency, complication rates or patient satisfaction. The high rate of checklist utilisation was associated with an increased rate of ultrasound video documentation. This suggests that there may be collateral benefit to using a pre-block safety checklist in addition to merely reducing the risk of wrong-side block.