ASSESSING OUTCOMES OF CENTRAL VENOUS CATHETER INSERTION WITH AND WITHOUT ULTRASOUND GUIDANCE, FOLLOWED BY A QUALITY IMPROVEMENT INITIATIVE INTRODUCING MANDATORY ULTRASOUND USE IN A TERTIARY CARE HOSPITAL IN PAKISTAN

Abstract

Background Central venous catheter (CVC) insertion is a commonly performed and high-risk procedure in acute medical practice, particularly in patients requiring urgent hemodialysis. Although ultrasound guidance is recommended internationally to improve safety and procedural success, its routine use remains limited in many resource-constrained settings. At Ayub Teaching Hospital, Abbottabad, CVCs were traditionally inserted using landmark techniques due to lack of bedside ultrasound availability in the medical wards, leading to potentially avoidable complications. Objective To assess baseline outcomes of CVC insertion performed with and without ultrasound guidance and to evaluate the impact of a quality improvement initiative introducing mandatory ultrasound guidance in the general medicine ward. Methods A clinical audit followed by a quality improvement intervention was conducted in the general medicine ward of Ayub Teaching Hospital. Baseline data were collected from 10 April to 10 July 2025, including 96 CVC insertions. The intervention consisted of ensuring bedside ultrasound availability, staff training, and implementation of a mandatory ultrasound policy. Post-intervention data were collected from 25 July to 25 September 2025 and included 82 CVC insertions. Process measures, procedural outcomes, and complication rates were compared between the two phases. Results Ultrasound-guided CVC insertion increased from 18.7% (18/96) at baseline to 92.7% (76/82) post-intervention. First-attempt success rates improved from 40.6% (39/96) to 72.0% (59/82). The overall complication rate decreased significantly from 19.8% (19/96) during the baseline period to 6.1% (5/82) following the intervention. Reductions were observed in arterial puncture, hematoma formation, and multiple needle attempts. The need for senior clinician assistance also declined post-intervention, indicating improved procedural confidence among trainees. Sustained improvement in complication rates was observed over time. Conclusion Implementation of mandatory ultrasound guidance for CVC insertion resulted in significant and sustained improvements in procedural safety and success in a high-volume tertiary care medical ward. This quality improvement initiative demonstrates that evidence-based procedural practices can be successfully adopted in resource-limited settings through structured system-level interventions, leading to meaningful improvements in patient care.