Preventing Retention of Central Line Guide Wires physician education module July 2013

1. Preventing Retention of Central Line Guide Wiresphysician education moduleJuly 2013

2. Background • A series of our patients experienced retained guide wires after central line placement • All residents who insert central lines are required to complete this module • Until a new resident competency system is in place, the requirement for direct supervision of PGY1 and PGY2 resident insertion of central lines will continue as per prior communications

3. Central Line Education • NEJM article with video (15 minutes) • bookmark this link for your reference

4. To prevent retained guide wires… • Never let go of the guide wire during the procedure.  Once the guide wire is in the patient, either the primary operator or an assistant should have at least one hand on the wire at all times. • The guide wire in most kits is 35 cm and the length of most central lines in 20 cm, so there is plenty of room to spare. Do not put too much wire in as this may cause you to not have enough to hold when the dilators are placed on the wire.  • Use proper technique while dilating – the guide wire must be "pinned" by the non-dominant hand during dilation. This means one hand must hold the guide wire and one hand must advance the dilator.

5. Complications • Complications of retained guide wires can include… • Cardiac Dysrhythmias • Thrombosis over the retained wire • Peripheral edema • Increased risk of pulmonary embolism • Distal Embolization of wire

6. Correction If a guide wire is retained or suspected of being retained, immediately: • Call the attending physician • Obtain an X-Ray • Attending physician will provide guidance on next steps based on X-Ray findings and the comfort level of all involved in resolving the situation

7. WakeOneChecklist for second licensed provider

8. Guidelines for Central Line Insertions Policy Addendum NSG-121 Central Venous CathetersWFBMC-126 Management of Intravascular Devices • These guidelines apply to all providers and health care personnel who participate in the insertion of central lines. • Prior to inserting a central venous catheter, the provider should notify the nurse, (or second licensed healthcare provider), to provide assistance and ensure/verify implementation of the “Central Line Insertion Checklist ” in all non emergent central line insertions. • Presence of the nurse or other second health care provider is required at a minimum of two critical time periods during insertion, as defined below.

9. Guidelines continued The responsibilities of the second licensed healthcare provider include: • Assisting with the preparation of items needed for the insertion • Ensuring maintenance of a sterile field and bundle compliance • Accepting the shared responsibility of communicating patient safety concerns. Using the “Chain of Command PPB- WFUBMC-NCBH-112” policy http://infinet.wfubmc.edu/policies/admin/NCBH-112%20-%20Chain%20of%20Command.pdf as a tool to assist with effective communication of safety concerns • Documenting each element on the Central Line Insertion Checklist (insert link here to access the checklist) in the EMR. • The critical time periods in which the second licensed healthcare provider should be present are included on the Vascular Access Infection Prevention Checklist and defined as: • Time Out/Before the Procedure • From completion of the ‘Time Out’ until the first attempt to insert the line (first stick) • After the Procedure • Reminder to the provider that all guide wires are removed • All ports are easily aspirated and flushed.

10. Reminder to be placed on kits REMEMBER TO COUNT IN AND COUNT OUT ALL GUIDE WIRES! Credit:DR P. MARAZZI/SCIENCE PHOTO LIBRARY