Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

Enyo A Ablordeppey, Byron Powell, Virginia McKay, Shannon Keating, Aimee James, Christopher Carpenter, Marin Kollef, Richard Griffey, Enyo A Ablordeppey, Byron Powell, Virginia McKay, Shannon Keating, Aimee James, Christopher Carpenter, Marin Kollef, Richard Griffey

Abstract

Introduction: Avoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention.

Methods: The intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan's framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor's outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion.With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments.

Ethics and dissemination: Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

Trial registration number: ClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.

Keywords: clinical protocols; implementation science; qualitative research; quality improvement methodologies.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Point-of-care ultrasound-guided catheter confirmation protocol (after right internal jugular vein cannulation). CVC, central venous catheter; IJ, internal jugular; RASS, right atrial swirl sign.
Figure 2
Figure 2
Morgan’s framework for conceptualising interventions to reduce medical overuse with embedded strategies from DRAUP (red) and their primary level of influence. (Source: Morgan et al, 2017.)
Figure 3
Figure 3
DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound -guided insertion and confirmation of central venous catheter protocol) algorithm for deimplementation of chest radiography after central line insertion. POCUS, point-of-care ultrasound; IJ, internal jugular vein; CVC, central venous catheter; PACS, picture archiving and communications system; DRAUPOUT/.DRAUPIN, electronic record documentation template of findings; CXR, chest X-ray
Figure 4
Figure 4
Operationalisation of implementation plan using Proctor’s conceptual model for implementation research (source: Proctor et al, 2009) with embedded DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) strategies and outcomes. ED, emergency department; POCUS, point-of-care ultrasound.

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