Central Vascular Catheter Insertion in the NICU: A Lean Approach Xinran Liu, MD Gautham Suresh, MD

Disclosure The author has no relevant financial interest or affiliations with any ­commercial interests related to the subjects discussed within this article. No commercial support or ­sponsorship was provided for this educational activity.

Abstract Purpose: To apply Lean principles to the process of inserting central lines into neonates in the NICU. Design: The authors used standard interviews and live observations to obtain concrete data on the current process of central line insertions. Recommendations for improvement were then suggested based on Lean principles. Sample: NICU care providers. Main Outcome Variable: Non-value-added time (waste), provider confidence, and variation in placing central lines. Results: There was large variation in how providers inserted central lines, and providers were least confident with placing peripherally inserted central catheter lines (55 percent confident). Live observations showed that 53 percent of the current process consisted of waste, with the line insertion and radiography phases of the process as the most wasteful. Lean principles can be applied to a neonatal clinical setting and can be an effective methodology for NICU care providers to improve the way that we care for our patients. Keywords: central vascular catheter; umbilical catheter; newborn; Lean; efficiency; errors; process improvement; quality improvement

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Accepted for publication December 2013.

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i­mproving quality and eff iciency that is becoming increasingly popular in hospitals across the United States. The Lean methodology originated as a result of observations of the work culture found at the Toyota company in Japan, which valued total elimination of waste in the workplace, continuous improvement (Kaizen), getting to the root cause of a problem, a visually oriented workspace, and continuous production (just-in-time production). Toyota employees were also empowered and encouraged to make improvements to their own workflows to maximize steps that added value to the end product and eliminate steps that did not add value to the end product. Activity that did not add value, that is, waste, can be classified into one of these following eight types1: 1. Defects—time that is spent doing something incorrectly or fixing mistakes

2. Overproduction—producing more than what is needed and doing it before it is needed 3. Transportation—unneeded movement of patients, specimens, or materials 4. Waiting—idle time spent waiting for a step to finish before continuing work 5. Inventory—excessive storage of inventory leading to increased costs 6. Motion—unneeded movements performed by employees in their workflow 7. Overprocessing—doing more work than is valued by the end user 8. Human potential—waste because of not listening, engaging, or supporting employees By eliminating steps that did not create value, or waste, from their processes, Toyota was able to signif icantly streamline its processes: improving quality, efficiency, and satisfaction and decreasing

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costs—accomplishments that are desperately sought after in health care. Although treating patients in a hospital setting is, in many ways, different from creating products in a factory, there are also numerous processes in health care that do mimic those in manufacturing and for which a methodology like Lean can have a positive impact. In fact, Lean has already been used in many such hospital settings. A few common examples include improving operating room turnover time, 2,3 pathology department quality and efficiency,4–6 pharmacy efficiency,7 and laboratory efficiency8,9 and improving patient flow in the emergency room.4,10,11 Some articles have also described the application of Lean principles to improve clinical outcomes such as reducing methicillin-resistant Staphylococcus aureus (MRSA) infection rates in intensive care unit (ICU) and surgical patients,12,13 improving perioperative antibiotic prophylaxis, 14 and decreasing central line infections.15 Most of these articles have described the application of Lean methods in the care of adult patients. The application of these methods in the care of newborn patients has not been described. Central vascular catheters (CVCs) are frequently used in the NICU. Neonates require CVCs for various reasons including blood sampling, blood pressure monitoring, infusion of intravenous (IV) fluids, and infusion of medications. The umbilical arterial catheter (UAC), umbilical venous catheter (UVC), and the peripherally inserted central catheter (PICC) are three different types of CVCs that are frequently used in neonates. Each of these has an ideal anatomic location for the catheter tip and a method of determining the ideal depth of insertion. The ideal anatomic location for the catheter tip of UACs is above the diaphragm between T6 and T9 vertebral body levels. The ideal anatomic location for the catheter tip of UVCs is in the inferior vena cava above the level of the ductus venosus and the hepatic veins and below the level of the right atrium. The method of determining the ideal depth of insertion for UACs and UVCs is either to use a formula based on birth weight provided in standard neonatology textbooks and manuals or to use a reference graph, also usually provided in these resources, based on the shoulder-to-umbilical length. The ideal anatomic location for the catheter tip of PICC lines is in the inferior vena cava just above the right atrium, and there are various ways to estimate the depth of insertion based on surface landmarks.16–19 Although there is a large amount of literature on the complications associated with CVCs,16–18,20 there is no literature on the quality of the process of inserting them, which anecdotally can often be filled with error and inefficiency. In this study, we applied the tools and principles of Lean to evaluate the process of inserting CVCs in neonates. In doing so, we hope to identify the value-added versus the non-value-added steps in the current CVC insertion process and then make recommendations for improvement based on the principles of Lean to improve quality, safety, and efficiency.

METHODS

To evaluate and understand the workflow surrounding CVC insertions in the NICU, the investigator (XL) used two methods in July–August 2011. First, a standard set of interview questions was created and used to interview staff members who were most prominently involved with the CVCinsertion process. These included two pediatric fellows, one pediatric resident, eight nurse practitioners, and one charge nurse. The goal of the interview questions was to determine what methods providers used to determine what they considered the ideal depth of insertion to be, where the ideal tip location of different types of CVCs should be, how confident they felt about placing CVCs (self-efficacy), if they felt like they had enough education and support, and what suggestions they had to improve the safety and efficacy of inserting CVCs. To assess the level of confidence, providers were asked to estimate how many umbilical catheters and PICC lines out of their next ten attempts would be placed perfectly without multiple attempts or require more than one radiograph for placement confirmation. They were asked to report their confidence on a scale of 0–100 percent, with 100 percent representing the maximum possible level of confidence. The responses across all the providers were averaged. Second, the investigator (XL) observed and documented each step of a CVC insertion during eight separate instances, from the step of gathering supplies at the start of the procedure until the final step of the procedure, where the CVC was confirmed to be in the correct position on radiographic assessment. Four of the observations were on PICCs, two on UVCs, and two on UACs. All lines were placed by nurse practitioners. Observations were written down as free text on a sheet of paper on a clipboard, and a stopwatch was used to keep track of time. A flowchart documenting each step of the CVC-insertion process was then created using these data. For each of the eight observations, the investigator then reviewed all actions performed and determined whether each action was value-added or non-value-added, defining nonvalue-added actions as those that fit into one of the eight categories of waste listed earlier. Common non-value-added actions were the following: time spent to pull the catheter back and check catheter tip position with radiographs more than once, time delay between writing orders for radiographs and asking the secretary to call and radiology department for a stat radiograph, multiple attempts to insert a catheter, and waiting for the radiograph to be taken and uploaded into the electronic medical record (EMR) system so that it can be viewed. These data were then analyzed to determine the amount of time spent on value-added steps as compared with the total amount of time spent in each main phase of the current process of CVC placement. This project was done as a quality-improvement project under the supervision of the NICU medical director, and, therefore, institutional review board (IRB) approval was not sought. Support for this project was provided by the NICU medical director throughout.

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RESULTS

Standard Interviews

The interviews showed that there was a large amount of variation between providers in what they considered as the ideal depth of insertion for each type of central catheter as well as the ideal anatomic location of the central catheter tip (Table 1).

The assessment of provider conf idence showed that, although providers mostly felt confident about their skills with UACs and UVCs, they were much less confident about their skills with inserting PICC lines (Table 2). In fact, only one provider was .75 percent confident.

TABLE 1  n  Standard Interviews of Providers—Central Vascular Catheter Ideal Depth of Insertion, Measurement Methods, and Ideal Catheter Tip Positions Type of Catheter and Measure Umbilical artery catheter ideal depth of insertion

Providers’ Response Categories

Ideal or Acceptable Response for our Unit

No. of Providers (N 5 11)

Equation found in The Harriet Lane Handbook (a popular manual for pediatric care) that uses a formula based on birth weight Equation found in a neonatal procedure handbook (different from The Harriet Lane Handbook) that uses a formula based on birth weight Direct shoulder-to-umbilicus measurement method

Equation found in The Harriet Lane Handbook that uses a formula based on birth weight or reference graph found in The Harriet Lane Handbook that is based on shoulder-toumbilicus length

Umbilical artery catheter ideal tip position on radiographs

T6–T9 vertebral body level Around T8 vertebral body level T8–T10 vertebral body level T8–T9 vertebral body level

Between T6 and T9

 8  1  1  1

Umbilical venous catheter ideal depth of insertion

Equation found in The Harriet Lane Handbook that uses a formula based on birth weight Equation found in neonatal procedure handbook (not The Harriet Lane Handbook) that uses a formula based on birth weight Direct shoulder-to-umbilicus measurement method

Equation found in The Harriet Lane Handbook that uses a formula based on birth weight or a reference graph found in The Harriet Lane Handbook that is based on shoulder-toumbilicus length

 9

At the diaphragm or ,1 cm above the diaphragm Could not recall but looked it up just before placing lines

In the inferior vena cava above the level of the ductus venosus and the hepatic veins and below the level of the right atrium

10  1

Used measuring tape to measure along the estimated path of the vein from the anticipated insertion site to the visually approximated location just above the right atrium Used measuring tape to measure from the anticipated insertion site to the clavicle to just above the visually approximated position of the right atrium Used measuring tape to measure from the anticipated insertion site to the shoulder to the midclavicular line 11 cm Used measuring tape to measure from the anticipated insertion site to the shoulder to the visually approximated position of the right atrium Used measuring tape to measure from the anticipated insertion site to the shoulder to the visually approximated position of the right atrium 11–2 cm

No standard length recommended

 7

Superior vena cava, just above the level of the right atrium

In the inferior vena cava below the caval–right atrium junction or in the high superior vena cava, outside the reflection of the pericardium

Umbilical venous catheter ideal tip position

Peripherally inserted central catheter ideal depth of insertion

Peripherally inserted central catheter ideal tip position

 9

 1

 1

 1

 1

 1

 1

 1

 1

11

Note: Accepted answers are included for comparison. One provider, the charge nurse, did not provide responses since she currently does not insert central lines.

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TABLE 2  n  Confidence Level with Placing Central Vascular Catheters

Confidence level Average (range)

Umbilical Artery Catheters (UACs)

Umbilical Venous Catheters (UVCs)

Peripherally inserted central catheter lines (PICCs)

70% (50% –100%)

70% (50% –100%)

55% (25% –100%*)

Note: Providers were asked to estimate what percentages of UAC, UVC, and PICC lines out of their next ten attempts would be placed perfectly without multiple attempts or require more than one radiograph for placement confirmation. *One provider answered 100% confidence for placing PICC lines.

Direct Observation and Analysis

In evaluating the CVC insertion process from a valueadded perspective of Lean, we see that around 47 percent of the current process consisted of value-added steps, and 53 percent of the current process was non-value-added (Table 3), demonstrating that there is a significant amount of waste in the process and that there is much we can do to improve the workflow surrounding placing CVCs. A detailed breakdown of the steps involved in CVC insertion is depicted in Figure 1. This complex process can be broken down into three phases: (1) setting up and getting supplies, (2) inserting the catheter itself, and (3) obtaining a radiograph to confirm that the catheter is in the right position (see Figure 1). The percentages of time spent on value-added work for each respective phase were 92 percent, 41 percent, and 46 percent (see Table 3). Hence, the percentages of time spent on non-value-added work, or waste, for each respective

phase were 8 percent, 59 percent, and 54 percent. The average total amount of time spent on each of the three phases was 8 minutes, 45 minutes, and 60 minutes (Figure 2), respectively, which means that the average total time spent to place a CVC from start to finish was 113 minutes. Regarding the entire insertion procedure, an average of 113 minutes is a very long time to spend on one procedure, especially one that is so common and essential to care in the NICU. The first phase, which was setting up, took a relatively brief amount of time and had very little waste involved. The two phases that contributed the most to this lengthy time were placement of the catheter and the radiograph. Our aforementioned data also showed us that these two phases were not only lengthy but also consisted of significant waste (see Figure 2). The second phase, placing the line, averaged 45 minutes in length, of which only 41 percent was valueadded. From our observations, most but not all of the issues were related to the insertion of PICCs, not UACs or UVCs, because three out of the four PICC attempts had to be aborted. The vast majority of waste was because of actions such as difficulty placing the introducer into the vessel, repeated failed attempts to advance the catheter, repeated attempts to reposition the line, time spent looking for another introducer or catheter, trying a second or third location for vascular access, or aborting the procedure entirely. From a Lean perspective, this waste falls under the category of underused human potential. The third phase, radiography, averaged 60 minutes in length, of which only 46 percent was value-added. This phase surprisingly consumed the most amount of time, and there were two main reasons for this. The first was that multiple radiographs were often needed to confirm the position of the catheter tip, and the second was that providers often spent

TABLE 3  n  Value-Added Time Compared with Total Time for Setting Up, Line Insertion, and Radiograph Phases of Central Vascular Catheter Insertion Process for Each of the Eight Observations Value-Added Time/Total Time (min) Observation (No.)

Type of Catheter

Setting Up

Line Insertion

Radiograph Process

Total (% Value-Added Time)

1

UAC

5/5

25/41

20/42

50/88 (57)

2

UAC

5/5

41/46

46/69

92/120 (77)

3

UVC

4/6

10/13

20/79

34/99 (34)

4

UVC

15/15

10/59

22/73

47/148 (32)

5

PICC

1/1

18/21

30/36

49/60 (82)

6

PICC

4/4

19/82

N/A

23/86 (27)

7

PICC

17/17

14/58

N/A

31/75 (41)

8

PICC

8/11

15/52

N/A

23/63 (36)

59/64 (92%)

152/372 (41%)

138/299 (46%)

349/735 (47)

Total

Note: In observations 6–8, procedures were aborted because a catheter could not be placed; no radiographs were taken. All catheters were placed by nurse practitioners. Abbreviations: N/A 5 not applicable; PICC 5 peripherally inserted central catheter; UAC 5 umbilical arterial catheter; UVC 5 umbilical venous catheter.

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Provider sometimes forgets

Provider walks over to supply area to collect supplies

Provider prepares insertion area with Betadine and blue towels

Provider orders another x-ray, repeat as needed until tip position is satisfactory

Can get called to do other things

The catheter has to be pulled back often

No signal to check x-ray

X-ray technician takes x-ray

X-ray technician arrives on floor, checks in with secretary

Secretary calls down to x-ray department

Provider waits for x-ray results

Provider cleans up area and used supplies when done

Finds computer to order x-ray to confirm catheter tip position

Nurse would sometimes have to go to supply area for extra supplies

Provider gowns up and starts time-out

Time-out not always performed

Provider asks secretary to call down to x-ray for stat x-ray

Provider sets up area including setting up barrier, getting a tray, and opening supplies one by one

Individually opens 10 packets

Provider asks nurse to adjust catheter tip position if needed

Provider checks for x-ray on EPIC

X-ray technician takes film to computer room to upload into system

Provider inserts central catheter to estimated length

Provider accesses lumen, cuts umbilicus for UVC/ UAC, introduces PICCs

If tip position okay, done

No signal to check x-ray

Measurement equation and methodology differ

No real time visualization of catheter tip

Steps are represented by boxes, and potential areas of waste for each step are represented by yellow clouds surrounding each step. This flow map can be broken down into three main phases: (1) setting up and getting supplies (tan-colored boxes), (2) inserting the line (light-blue-colored boxes), and (3) ordering radiographs to confirm the location of the catheter (light-orange boxes). Abbreviations: EPIC 5 Electronic Patient Information Chart; PICC 5 peripherally inserted central catheter; UAC 5 umbilical arterial catheter; UVC 5 umbilical venous catheter.

Decision to insert central line

Numerous distractions throughout the procedure

FIGURE 1  n  Flow map of central vascular catheter insertion process.

FIGURE 2  n  Graph of average value-added time versus total time spent for setting up, line insertions, and radiograph phases of central vascular catheter insertion process.

Average Time Spent on Value-Added Steps versus Total Time 70 59.8

60 46.5

Time (min)

50 40

27.6

30

Total me

19

20 10

Value-added me

7.375

8

0 Seng up

Line inseron

X-ray process

Step

significant time waiting idly in between process steps. For example (see Figure 1), after ordering a radiograph on the computer, the provider had to ask the secretary to call down to the radiology department for a stat radiograph, but the provider often forgot to do so or delayed doing so because he or she was distracted by other work. Even after the secretary placed the phone call to the radiology department, a radiology technician was not always available, and time would be spent waiting for the technician to become available. When the radiograph technician did become available and came to the floor to take radiographs, the image was not immediately viewable because the technician had to upload the radiograph into the computer system before the provider could see it. However, even after the image was uploaded into the system, the provider had no signal to alert him or her that the radiograph was ready for viewing. The result was that the image could go unseen for a long period of time depending on how busy the provider was. If the catheter tip position was incorrect, which it often was, this entire process had to be repeated again. Although the provider could work on other things while waiting for the radiograph image, this often distracted the provider so that he or she forgot to look at the radiograph for extended periods of time. These effects were also compounded by changes in personnel during shift changes. These types of waste fall under the categories of waste in defects, transportation, waiting, and motion. However, the

root cause of all of this waste appears to be a lack of a clear signal in between different steps.

DISCUSSION

By applying Lean methodology to CVC insertion practices, we were able to identify several types of waste and opportunities for improvement that can be classified according to three sequential phases. In Phase 1, there was relatively little waste. In Phase 2, the main type of waste resulted from underused human potential, which we surmised to be caused by lack of sufficient training and support regarding placing CVCs. In particular, our data showed that providers have a relatively low level of confidence in inserting PICC lines (55 percent) compared with that of UACs or UVCs (70 percent). Although PICCs are inherently more difficult to insert, the high level of confidence exhibited by a subgroup of providers suggests that, with sufficient training and practice, confidence and performance of PICC insertion can improve. In Phase 3, the main type of waste was caused by defects, transportation, waiting, and motion. We surmised that the root cause of this waste was the lack of a clear signal in between different steps to communicate that a previous step had been completed. Based on these evaluations, we made the following recommendations to eliminate waste from Phase 2 to Phase 3 and

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FIGURE 3  n  Old radiograph process.

Provider asks secretary to call down to x -ray department for stat x-ray

Secretary calls down to x -ray department

X-ray technician arrives on floor, checks in with secretary

X-ray technician takes x-ray

X-ray technician takes film to computer room to upload into system

Provider waits for x-ray results

Provider checks for x-ray on EPIC

Provider orders another x-ray; , repeat as needed until tip position is satisfactory

Provider asks nurse to adjust catheter tip position if needed

If tip position okay, done

Abbreviation: EPIC 5 Electronic Patient Information Chart.

also pointed out some important cultural factors that could contribute to the success or failure of these solutions.

Phase 2—Improving Catheter Placement

Our analysis showed us that we needed to develop a process to provide better training and practice regarding inserting CVCs, especially PICC lines. There is one nurse practitioner in the unit who was very experienced with PICC lines and reported a confidence level of 100 percent with them. This nurse practitioner was willing to act as a PICC line champion to assist us in coaching the other providers on how to improve their skills with PICC lines. We also showed our data to the nurse practitioner group, who afterward agreed that there needed to be more training with PICC lines. We recommended using videotape to directly observe and provide direct feedback on the skills of individual providers. Whenever a PICC line was to be placed, a video cart containing all of the equipment needed to videotape the procedure could be used to record the insertion process. Afterward, the PICC line champion could then view the video with that individual provider and offer suggestions and tips to improve

his or her technique. Data on how often individual providers were successful in placing PICC lines would be collected before, during, and after this intervention to assess its effectiveness.

Phase 3—Improving the Radiograph Process

Our analysis showed us that we needed to develop a clear signal for providers to let them know that a previous step in the process had been completed. Our first recommendation was to implement a text page system in which the radiograph technician would text page the provider who ordered the radiograph once the radiograph technician had uploaded the image into the computer system. In the past, providers had no such signal, and the radiograph would sometimes go unnoticed for long periods of time. This step closes the miscommunication gap between the radiograph technician and the provider, establishing a clear signal so that work flows continuously—a core tenet of Lean (Figures 3 and 4). Our second recommendation focused more on waste associated with transportation and waiting. We recommended

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FIGURE 4  n  New recommended radiograph process.

Provider asks secretary to call down to x-ray department for stat x-ray

Secretary calls down to x-ray department

X-ray technician arrives on floor, checks in with secretary

X-ray technician takes x-ray

X-ray technician takes film to computer room to upload into system

X-ray technician text pages provider, stays on ICN floor until tip position is okay

Provider orders another x-ray, repeat as needed until tip position satisfactory

Provider asks nurse to adjust catheter tip position if needed

Provider checks for x-ray on EPIC

If tip position okay, done

Abbreviation: ICN 5 Intensive Care Nursery.

working with the radiology department to require that the radiograph technician stays on the NICU floor until the catheter tip has been confirmed to be in the correct position by radiograph. A significant number of central catheters required multiple radiographs, and each radiograph cycle required waiting for the radiograph technician to finish what he or she was doing and come to the NICU floor. From the NICU’s perspective, time spent waiting for the radiograph technician was waste, and from the radiograph technician’s perspective, the time spent traveling back and forth between the radiology floor and the NICU floor was waste. By requiring the radiograph technician to remain on the NICU floor until the catheter tip has been confirmed to be in the right location, we can eliminate some of the waiting time associated with multiple radiograph cycles, although we realize that not all NICUs could support a radiograph technician to remain in the NICU for one ­catheter insertion, especially during evening or night shift times or weekends when there is less staffing (see Figures 3 and 4).

CONCLUSION

The Lean philosophy for process improvement has long been an effective method used by the manufacturing industry to produce high-quality products at low cost, at high efficiency, and with little waste or errors. At the same time, the health care world is suffering from increasing costs, poor quality and efficiency, along with high rates of employee and patient dissatisfaction. Clearly, there is a lot that we can learn from the manufacturing industry on how we can improve our processes and how we can better treat out patients. The principles of Lean have already been applied in numerous hospital settings with great success. In this study, we used the Lean methodology to look at the process of inserting CVCs into neonates in the NICU. We were able to use Lean methods to not only evaluate for areas of waste in our CVC-insertion process but also guide us toward improvements of that process. In doing so, we showed that Lean can be applied to a neonatal clinical setting and that it can be an effective methodology for NICU care providers to improve the way that we care for our patients.

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About the Authors

Xinran Liu, MD, is an internal medicine intern at the University of Washington. His research interests include Lean process improvement, medical education, and entrepreneurship. Gautham Suresh, MD, is the medical director of the Intensive Care Nursery at Dartmouth-Hitchcock Medical Center. He is an associate professor of Pediatrics and Community and Family Medicine at the Dartmouth Institute for Health Policy and Clinical Practice and the Geisel School of Medicine at Dartmouth. For further information, please contact: Gautham Suresh, MD Rubin 529, Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03755 E-mail: [email protected]

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Central vascular catheter insertion in the NICU: a Lean approach.

To apply Lean principles to the process of inserting central lines into neonates in the NICU...
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