Rates and timing of central venous cannulation among patients with sepsis and respiratory arrest admitted by the emergency department*

Abstract

Objectives: Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients.

Design: Retrospective cross-sectional analysis of emergency department visits using 2003-2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

Setting: General medical or general surgical hospitals (n = 310).

Patients: Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest).

Interventions: None.

Measurements and main results: We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1-2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03-1.12) in 2004, 1.19 (95% CI, 1.14-1.23) in 2005, and 1.28 (95% CI, 1.23-1.33) in 2006.

Conclusions: Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.

Figure 1

Flow Chart Demonstrating Visits Included in the Study

Figure 2

Rates of Central Venous Catheter Insertion by Procedure Day During the Years 2003-2006