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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 47-51

Clinical competence with central venous lines by resident doctors in a Nigerian teaching hospital

1 Divisions of Cardiothoracic Surgery, ABU, Zaria, Nigeria
2 Plastic and Reconstructive Surgery, ABU, Zaria, Nigeria
3 Department of Surgery, ABU Teaching Hospital, Zaria, Nigeria

Date of Web Publication29-Mar-2018

Correspondence Address:
Sunday A Edaigbini
Division of Cardiothoracic Surgery, ABU, Zaria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssajm.ssajm_37_16

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Introduction: Central venous catheterization has become not only common but a very useful clinical procedure in all well-established tertiary hospitals world over. This study aims to assess the competence of resident doctors with central venous lines in a tertiary institution in the subregion. Materials and Methods: A structured proforma was used to assess the information from resident doctors in four departments of the training institution. The result was analyzed with SPSS version 15.0 software program (SPSS 2006, Inc., Chicago, IL, USA). Results: A total of 40 residents were assessed, 30 (75%) males and 10 (25%) females with a mean age of 35.08 ± 4.999 years. Twelve (30%) and 28 (70%) had spent <2 years and >2 years in residency, respectively. Nineteen (47.5%) ticked that a line in the subclavian vein is a central line while 1 (2.5%) ticked same for femoral vein. Fifteen (37.5%) ticked correctly types of central line. Nineteen (47.5%) had observed the procedure in their institution and 7 (17.5%) elsewhere. Eleven (27.5%) knew that any experienced doctor could insert a central. Only 1 (2.5%) resident had inserted a central line. Ten (25%) knew that central line is inserted by ‘’SELDINGER’S’’ technique. Fourteen (35%), 4 (10%), and 20 (50%) said central line can be inserted only in the theatre, by the bedside, and both respectively. Thirty (75%) ticked correctly the uses of central line. Only 3 (7.5%) knew correctly a combination of central line complications. Twenty-five (62.5%) knew that chest X-ray is required after central line insertion. Conclusion: Based on knowledge assessment, the resident doctors in this institution are clinically incompetent in central venous line and efforts must be made to reverse the situation.

Keywords: Africa, central venous lines, clinical, competence, doctors

How to cite this article:
Edaigbini SA, Aminu MB, Delia IZ, Ibrahim A, Okwunodulo O, Alegbejo-Olarinoye M. Clinical competence with central venous lines by resident doctors in a Nigerian teaching hospital. Sub-Saharan Afr J Med 2017;4:47-51

How to cite this URL:
Edaigbini SA, Aminu MB, Delia IZ, Ibrahim A, Okwunodulo O, Alegbejo-Olarinoye M. Clinical competence with central venous lines by resident doctors in a Nigerian teaching hospital. Sub-Saharan Afr J Med [serial online] 2017 [cited 2024 Feb 26];4:47-51. Available from: https://www.ssajm.org/text.asp?2017/4/2/47/228961

  Introduction Top

A central venous line (CVL) is an in-dwelling catheter in any vein that ends up in the superior or inferior vena cava (derivatives of the “cardinal system” or their direct tributaries) or the right atrium.[1],[2] These include catheters inserted via the subclavian, internal jugular, femoral, the umbilical vein or “long lines” through forearm veins. Central venous catheterization was first described by Aubaniac in 1952.[3] Today millions of central venous catheters are inserted annually in the United States and the developed world.[3],[4] Central venous catheterization was made possible by two important medical landmarks; first was the daring experiment in 1929 by the German, Werner Forssmann, a medical intern who performed the first central venous catheterization on himself.[5],[6] The second is the description of the catheter over guide wire technique (“Seldinger’s technique”) by the Swedish Radiologist Sven-Ivar Seldinger in 1952.[5],[6] Today, the uses and advantages of central venous access are so immense that not only the intensive care management of the critically ill patient would be practically impossible, but also invasive cardiology and interventional procedures would be inconceivable without central venous catheterization.[6] It allows for frequent access to the central circulation while avoiding the trauma of frequent needle pricks due to the longer in-dwelling time compared to peripheral lines.[1] Some of the uses of central venous access include the following: (1) therapeutic procedures such as administration of fluids (including parenteral nutrition, blood and blood products), drug administration (including cytotoxics), exchange blood transfusion, hemodialysis, and plasmapheresis, (2) interventional procedures on coronary vascular anatomy, and (3) related pathologies, cardiac morphology, and function including complex congenital anomalies and insertion of transvenous pacemakers.[1],[6] The procedure is not without complications which include not only septic complications such as thrombophlebitis, endocarditis and septicemia, but also mechanical complications such as catheter embolism, cardiac arrhythmias and cardiac perforation, deep venous thrombosis, hemothorax, pneumothorax, and hemorrhage.[1],[7] Awareness of these possibilities behoves the physician to exercise extreme caution while carrying out the procedure. Also, confirmation of proper placement and the presence of complications can best be confirmed by conducting some investigations such as chest X-ray. CVL can be inserted by the beside (on the ward), in the operating room under local or general anesthesia. Central venous access has become a routine procedure performed by all cadres of doctors including medical interns in all advanced and standard hospitals world over and in the United States, specially trained nurses (intravenous therapists) are engaged in the insertion and care of these lines.[1],[8] This is, however, not the case in most Nigerian hospitals, where there is both extensive dearth of knowledge and gross underutilization of CVLs. It is, therefore, not surprising that there is dearth of literature on the utilization and complications of central lines in our environment compared to other regions in the continent.[9],[10] The aim of this study is to assess the competence of resident doctors with CVLs with respect to insertion, utilization, advantages, and complications in a tertiary health institution in Nigeria.

  Materials and methods Top

A structured proforma was used to assess the above information from 10 resident doctors, five junior, and five senior residents each from Paediatrics, Obstetrics and Gynaecology, Medicine and Surgery departments of the training institution. The result was analyzed with the Statistical Package for the Social Sciences version 15.0 software program (SPSS Inc., Chicago, IL, USA).

  Results Top

A total of 40 residents were assessed, comprising 30 (75%) males and 10 (25%) females with a mean age of 35.08 ± 4.999 years. The modal and median ages were 34 and 34.05 years, respectively, with a range of 24 (26–50 years). Twelve (30%) and 28 (70%) had spent <2 and >2 years in residency, respectively. Nineteen (47.5%) ticked that a line in the subclavian vein only is a CVL, while 1 (2.5%) ticked same for femoral vein but none ticked both. Fifteen (37.5%) ticked correctly examples of CVL while 7 (17.5%) were undecided [Figure 1]. Only 19 (47.5%) had observed the procedure in their institution and 7 (17.5%) had observed it elsewhere. Eleven (27.5%) knew that any experienced doctor could insert a CVL, while 1 (2.5%), 3 (7.5%), 9 (22.5%), and 15 (37.5%) said only the intensivist, anesthetist, surgeon, and combination of these specialists are responsible for inserting the CVL respectively; 1 (2.5%) respondent was undecided. Only 1 (2.5%) resident had inserted a CVL. Ten (25%) knew that central line is inserted by “Seldinger’s” technique. Fourteen (35%), 4 (10%), and 20 (50%) said that CVL can be inserted only in the theater, by the bedside and both respectively; 2 (5%) were unsure. Thirty (75%) ticked correctly the uses of CVL, 6 (15%) knew only one use, 3 (7.5%) ticked combination of uses, and 1 (2.5%) left this option blank. Only 3 (7.5%) knew correctly a combination of CVL complications, 15 (37.5%) ticked a single correct option, 16 (40%) ticked a combination of wrong and correct options, and 3 (7.5%) left this question blank. Twenty-five (62.5%) knew that chest X-ray is required after CVL insertion, while 2 (5%) were undecided. Four (10%) said that chest X-ray is requested to confirm proper positioning, 5 (12.5%) ticked that it is to rule out complications such as pneumothorax and hemothorax. Another 5 (12.5%) left the options blank, while the remaining 26 (65%) either ticked only one of the complications or a combination of a right and a wrong options. Twenty-eight (70%) believe CVL should be inserted frequently, 9 (22.5%) thought otherwise, while 3 (7.5%) left the options blank.
Figure 1: Framework for clinical assessment by Miller[11]

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The reasons afforded for more frequent insertion included; improvement in patient care 26 (65%), a necessity for all intensive care unit (ICU) patients, 1 (2.5%), reduction of complications associated with frequent peripheral vein cannulation 1 (2.5%), while, 12 (30%) were uncertain.

The reasons afforded against frequent insertions included; it is expensive 2 (5%), difficult to care for 3 (7.5%), the complications outweigh the usefulness 5 (12.5%), 30 (75%) were nonrespondents. Concerning frequency of insertion, of CVL in the index institution [Figure 2]; 1 (2.5%) respondent believed central line is frequently inserted (e.g., daily), 15 (37.5%) believed that it is infrequent (once or twice monthly), 6 (15%) respondents did not believe that central line has been inserted, 17 (42.5%) were not sure, while 1 (2.5%) said that only during surgery central line could be inserted. The reasons suggested for the infrequent insertion of central line in the institution were given as follows: lack of expertise 11 (27.5%), lack of the kit 2 (5%), cost 5 (12.5%), rarely indicated 10 (25%), lack of awareness 1 (2.5%), not part of routine work 1 (2.5%), variable combination of above reasons 2 (5%) and 8 (20%) nonrespondents.
Figure 2: Insertion of central venous line in the institution

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  Discussion Top

According to the U.S. Library of Medicine, clinical competence is the capability, to perform acceptably those duties related to patient care.[12] Simply put, Burg et al., defined, clinical competence, as the possession of knowledge, judgment, skills, and experience to diagnose correctly, and provide appropriate treatment interventions.[13] These definitions apparently imply that one who knows but lacks the requisite skills is incompetent. This assertion can further be buttressed by Millers framework for the categorization of clinical competence [Figure 1].[11] At the base of the triangle is “knowledge,” while “action” is at the summit. Our assessment of clinical competence with CVL is limited only to knowledge considering that from the assessment only one resident had inserted a central which in itself is inadequate to attain proficiency. There would be no basis, therefore, to assess skill since 97.5% of the residents had not inserted CVL. It would be safe, therefore, to say that, based on Miller’s framework, these residents are incompetent as far as CVL is concerned. Furthermore, if we contemplate to limit the assessment purely to knowledge, then the residents would still be adjudged incompetent for the following reasons among many. Firstly, only 47.5% of the resident doctors knew that a line in either the subclavian or femoral vein is a central line, but none considered both as correct. Secondly, only 37.5% of the residents knew correctly the examples of CVL, while only 27.5% knew that CVL could be inserted by any doctor. The fact that 47.5% of the residents had observed CVL insertion in the index institution is a testament that this procedure is not alien ([Figure 2]; insertion of a CVL in the institution). In addition that, only 17.5% observed it elsewhere is a pointer that this procedure is infrequently followed in the institution and in most hospitals present in the sub-region. This infrequency of insertion is corroborated by the percentage of those (37.5%) who believe that the procedure is infrequently done, those who believe that CVL has not been inserted in the institution (15%), and those who were not sure (42.5%). Furthermore, this infrequency of insertion may be a contributory factor to the apparent lack of knowledge by the resident doctors. Lack of expertise as suggested by 27.5% of the respondent is the major militating factor affecting frequency of insertion. As at the time, this test was conducted, only the cardiothoracic surgeons had the capability to insert CVL competently. The other militating factors include lack of knowledge on the part of clinicians, on the uses and advantages of the indwelling CVL, and the availability of competent hands in the institution. There is, therefore, the need to increase awareness by organizing workshops and seminars in this regard while also promoting hands-on training of all resident. The training of all residents is important as CVL insertion is not the specific prerogative of a particular specialty of medicine.[1] These programs, when vigorously pursued, would erase some of the misconceptions revealed by this study. For example, while chest X-ray is required to rule out complications (e.g., hemothorax and pneumothorax) immediately after the procedure, it could also help to suggest proper positioning because most of them are radio-opaque to some extent as rightly indicated by only 10% of the respondents. The one among other factors militating against frequent insertion as noted by some respondents is the availability or accessibility to the CVL kits, and even when available, many patients cannot afford the cost of the kit. The impact of cost can best be appreciated when the economic reality of the country of practice is taken into consideration [average gross domestic product (GDP) with a poverty ration of 70%].[14] These factors are encountered almost on a daily basis, and the impact on service delivery is not only for CVL insertion but is felt also in all aspects of clinical practice and often times leading to avoidable morbidity and mortality. Though 75% of respondents did not suggest reasons against frequent insertion, probably due to the lack of knowledge on the advantages and uses of CVL, the erroneous response that it is expensive (5%), it is difficult to manage (7.5%) and the disadvantages outweigh the merits (12.5%) has not been corroborated from our local experience (unpublished). Chi-square test of association showed that there was no significant difference in knowledge between the various departments [[Table 1] and [Table 2]], at a P value of 0.05.
Table 1: The 2 × 2 contingency table of departments and necessity of chest X-ray after CVL insertion

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Table 2: The test of association between department of respondents and knowledge of the necessity of CXR after CVL insertion

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Also, the test of association showed that there was no significant relationship between duration of residency and knowledge of CVL insertion [[Table 3] and [Table 4]], at a P value of 0.05.
Table 3: The 2 × 2 contingency table of number of years in residency and place of insertion of CVL

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Table 4: The test of association between years in residency and knowledge of place of insertion of CVL

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Despite the apparent lack of knowledge, it is consoling that 70% of the respondents as against 30%, who were unsure, supported more frequent insertion of CVL. It is believed that it would improve patient care (65% of respondents) especially for patients in the intensive care unit (2.5% of respondents). It is also more convenient (2.5%) to the patients, especially those who would require prolonged intravenous therapy, and avoid the trauma and complications associated with repeated peripheral cannulation.

  Conclusion Top

The result shows that the knowledge (insertion, uses, and complications) of central line is limited among clinicians in the index institution. A multicentre evaluation is required to ascertain the degree of competence in other tertiary institutions within the sub-region. Meanwhile, necessary mechanisms must be put in place to improve on the present level of competence in the index institution.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mooney G, Comerford D. Central venous lines. Nursing Times.net 2003;99:28. Available from: http://www.nursingtimes.net/nursing-practice/clinical-zones/practice-nursing/central-venous-lines/205670.article. [Last accessed on 2014 Jul 27].  Back to cited text no. 1
http://www.fraserhealth.ca/media/CentralVenousCatheters.pdf. [Last accessed on 2014 Jul 27].  Back to cited text no. 2
Taylor RW, Palagiri AV. Central venous catheterisation. Crit Care Med 2007;35:1390-6.  Back to cited text no. 3
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 4
Kwong RY, Loscalzo J. Diagnostic and therapeutic procedures. Circulation 2010;122:1897.  Back to cited text no. 5
Doby T. A tribute to Sven-Ivar Seldinger. AJR 1984;142:1-3.  Back to cited text no. 6
Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg 2007;204:681-96.  Back to cited text no. 7
Benton S. Training Nurses to Place Central Venous Catheter. Available from: http://www.nursingtimes.net/training-nurses-to-place-tunnelled-central-venous-catheters/197709.article. [Last accessed on2014 Jul 27].  Back to cited text no. 8
Nahirya P, Byarugaba J, Kaddu-Mulindwa D. Intravenous catheter related infections in children admitted on the paediatric wards of Mulago hospital, Uganda. Afr Health Sci 2008;8:206-16.  Back to cited text no. 9
Badr RI, Hammad E, Salama MF, Shouman B, Abdel-Hady H, Nasef N. Central venous catheter-related blood stream infections in a neonatal care unit: Short report. Int J Infect Control 2013;8:1-8.  Back to cited text no. 10
http://www.definitions.net/definition/clinical%20competence. [Last accessed on 2014 Jul 24].  Back to cited text no. 11
Burg FD, Llyod JS, Templeton B. Competence in medicine. Med Teach 1982;4:60-4.  Back to cited text no. 12
Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65:63-6.  Back to cited text no. 13
Edaigbini SA, Delia IZ, Aminu MB, Orogade AA, Anumenechi N, Aliyu ID. Indications and complications of tube thoracostomy with improvised underwater seal drainage bottles. Niger J Surg 2014;20:79-82.  Back to cited text no. 14
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