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A6816 - The Central Line “Mental Model”: A Novel Quality Improvement Initiative to Identify and Reduce Unnecessary Central Venous Catheters in Surgical and Cardiothoracic ICUs
Author Block: M. Hoyler1, M. Rivera2, C. Rosenbauer3, V. K. Moitra4; 1Anesthesiology, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, United States, 2Nursing, Surgical Intensive Care Unit, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, United States, 3Nursing, Cardiothoracic Intensive Care Unit, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, United States, 4Anesthesiology, Columbia University, New York, NY, United States.
Introduction:Mental models, or shared understandings of how the world “works,” can have significant effects on individual behavior and group performance. In healthcare settings, appropriate mental models can help shape clinical practice and improve patient care. Central venous catheters (CVCs) represent an important quality improvement opportunity: although frequently necessary for ICU care, CVCs are associated with notable risks, including blood stream infections. The goal of this quality improvement initiative was to introduce a mental model of appropriate CVC usage in surgical and cardiothoracic ICUs, and to monitor central line utilization patterns in those units.Methods:Through an iterative and multidisciplinary process, our team developed a mental model for CVC usage in SICU and CTICU. The mental model included technical standards for CVC placement and maintenance, as well as specific central line appropriateness criteria. Over the course of 4 months, our team revised these criteria through a data- and consensus-driven process. Notably, we removed central venous pressure (CVP) and pulmonary artery pressure (PAP) monitoring from the list of central line indications. CVP and PAP monitoring was felt to be indicated only in patients who had additional, concurrent indications for CVC placement (e.g. inotropes). We then conducted standardized, biweekly audits of CVC necessity.Results:In the four months following introduction of the CVC mental model, rates of unnecessary CVCs were 22% in the SICU (21/95 line observations) and 19% in the CTICU (41/266). After the revision of appropriateness criteria, rates and absolute numbers of unnecessary lines decreased to 14% (11/77) in the SICU but increased to 25% (78/311) in the CTICU.Conclusions:The findings from this quality improvement initiative suggest that a shared mental model may significantly impact central line utilization; however, its effects may not be uniform. In our experience, the revised mental model was associated with increased central line appropriateness in the SICU but not the CTICU. This effect variation likely reflects unit-specific practice patterns (e.g. routine CVP and PAP monitoring in the CTICU only) and organizational and cultural norms; it may indicate the importance of cultural context in the implementation of mental models and in quality improvement work. Nonetheless, our experience demonstrates that a carefully revised mental model can help identify and reduce unnecessary central lines. This represents a meaningful opportunity for the prevention of central-line associated complications. The next steps in our initiative will include tailored interventions to reduce unnecessary CVCs, consistent with our mental model, across ICUs.