Critical Care Medicine — Core of Discipline

C5 Performing procedures: Vascular access

Key features
- This EPA focuses on determining which procedures are necessary and appropriate to the patient’s condition, and performing the following procedures required for the care of complex or unstable patients, including arterial line insertion; central venous line insertion; dialysis catheter insertion.
- This EPA includes using ultrasonography for procedural guidance, where appropriate.
- This EPA may be observed in clinical or simulation settings.

Assessment Plan:
Direct observation by attending or consultant physician, or TTP resident
Use Form 2. Form collects information on:
- Procedure (select all that apply): arterial line; central venous line; dialysis catheter
- Complex/unstable: yes; no
- Site: jugular; subclavian; femoral; radial
- Setting: clinical; simulation
Collect 20 observations of achievement
- At least 7 arterial lines in clinical setting with 3 different observers
- At least 4 complex/unstable arterial lines
- At least 1 arterial line site other than radial
- At least 11 central venous lines in a variety of sites (subclavian may be in simulation)
- At least 8 complex/unstable central venous lines in a clinical setting
- At least 2 dialysis catheter insertions in a clinical setting

Form

F2: Procedure

Milestones

• ME 3.1. Preprocedure plan: Gather/assess required information to reach diagnosis and determine correct procedure required

• ME 3.4. Case preparation: Patient correctly prepared and positioned, understands approach and required instruments, prepared to deal with probable complications

• ME 1.3. Knowledge of specific procedural steps: Understands steps of procedure, potential risks, and means to avoid/overcome them

• ME 3.4. Technical performance: Efficiently performs steps, avoiding pitfalls and respecting soft tissues

• ME 3.4. Visuospatial skills: 3D spatial orientation and able to position instruments/hardware where intended

• ME 3.4. Efficiency and flow: Obvious planned course of procedure with economy of movement and flow

• ME 3.4. Postprocedure plan: Appropriate complete post procedure plan

• COL 1.3. Professional and effective communication/utilization of staff

Context Variables

• Procedure (select all that apply) (multiple-choice)
  • arterial line
  • dialysis catheter
  • central venous line
• Complex/unstable (single-choice)
  • no
  • yes
• Site (single-choice)
  • radial
  • femoral
  • jugular
  • subclavian
• Setting (single-choice)
  • clinical
  • simulation

Requirements

• Collect 20 observations of achievement (minimum 20)
• At least 7 arterial lines in clinical setting with 3 different observers (minimum 7)
  • Only counts when Procedure (select all that apply) is arterial line
  • Only counts when Setting is clinical
• At least 4 complex/unstable arterial lines (minimum 4)
  • Only counts when Procedure (select all that apply) is arterial line
  • Only counts when Complex/unstable is yes
• At least 1 arterial line site other than radial (minimum 1)
  • Only counts when Procedure (select all that apply) is arterial line
  • Only counts when Site is not radial
• At least 11 central venous lines in a variety of sites (subclavian may be in simulation) (minimum 11)
  • Only counts when Procedure (select all that apply) is central venous line
• At least 8 complex/unstable central venous lines in a clinical setting (minimum 8)
  • Only counts when Procedure (select all that apply) is central venous line
  • Only counts when Complex/unstable is yes
  • Only counts when Setting is clinical
• At least 2 dialysis catheter insertions in a clinical setting (minimum 2)
  • Only counts when Procedure (select all that apply) is dialysis catheter
  • Only counts when Setting is clinical