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Training and Certification for Central Vascular Access Devices ("CVADs") (43.20)

Training and Certification for Central Vascular Access Devices ("CVADs") (43.20) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)

43.20


Graduate Medical Education Departmental Policy
Policy Title: Training and Certification for Central Vascular Access Devices
(“CVADs”)
Policy Number: 43.20
Effective Date: November 15, 2017
Version: Revision

I. PURPOSE

To establish a formal, systematic approach for training and certifying residents in the insertion, removal
and replacement over a guidewire of Central Vascular Access Devices (“CVADs”), in order to minimize
complication risks associated with CVADs, including central line-associated bloodstream infection.
CVADs are also known as “central line catheters”, “central lines” and “central venous lines.”

II. PERSONS AFFECTED

This policy applies to all Graduate Medical Education (GME) programs sponsored by the University of
Wisconsin Hospitals and Clinics Authority (UWHCA).

III. DEFINITIONS

A. The term “resident” refers to UWHCA residents and fellows.
B. Program(s) will refer to ACGME-accredited program(s).
C. The term “privileged provider” refers to a provider who has privileges for central lines.
D. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of
Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME-
accredited training programs. “UW Health” is a cohesive, united, and integrated academic
medical enterprise comprised of several entities. This policy applies to facilities and programs
operated by the University of Wisconsin Hospitals and Clinics and the University of Wisconsin
Medical Foundation, Inc., and to clinical facilities administered by the University of Wisconsin
School of Medicine and Public Health.
E. Direct Supervision: The supervising physician is physically present with the resident and patient.
(ACGME Common Program Requirements VI.D.3.a)
F. Indirect Supervision with direct supervision available (hereinafter “indirect supervision”): the
supervising physician is not physically present within the hospital or other site of patient care, but
is immediately available by means of telephonic and/or electronic modalities, and is available to
provide direct supervision. (ACGME Common Program Requirements VI.D.3.b.(2))

IV. POLICY

As part of our effort to make UW Health the safest patient care environment possible, this policy requires
all incoming residents to complete an online and simulation-based training before a resident is allowed to
insert, remove, and/or replace a CVAD under direct supervision, regardless of a resident’s prior
experience with CVADs at a prior institution.

It also provides a minimum number of successful insertions, and/or removals, and/or replacements of a
CVAD a resident must complete under direct supervision before being allowed to be assessed for
competency, in order to insert, and/or remove, and/or replace under indirect supervision. For some
residents, the minimum number of successful insertions, and/or removals, and/or replacements may be
enough to adequately assess competency for indirect supervision. For other residents, additional direct
observations beyond the minimum number may be required before a resident is allowed to complete a
CVAD activity under indirect supervision. Certain residents, due to prior GME training experience, may
qualify for an expedited certification process, as detailed below. A program may elect to have more
restrictive measures than provided in this policy, including requiring a higher number of minimum
insertions, and/or removals, and/or replacements, or limiting who is allowed to supervise a resident who
has not received certification (e.g., only allowing privileged providers to supervise uncertified residents).
V. PROCEDURE

A. Required On-Line and Simulation Training

Before a resident attempts to insert, remove, or replace a CVAD from a patient under the direct
supervision of a privileged provider, a resident must:
1) complete the CVAD online training; and
2) complete the simulation-based training.
All incoming residents and fellows from other institutions are required to complete the online and
simulation training, regardless of their prior experience with CVADs at a prior institution. The program
coordinator shall ensure that the online training and simulation-based training is documented, preferably
in MedHub.

Upon completion of the above, a resident may now insert, remove, and/or replace a CVAD under the
direct supervision of a privileged provider or a resident who has obtained specific certification for the
CVAD activity that s/he will be supervising, pursuant to this policy. It is strongly recommended that a
resident spend time observing a privileged provider perform these procedures, prior to inserting, and/or
removing, and/or replacing a CVAD under direct supervision.

B. Prerequisites to Inserting, and/or Removing, and/or Replacing a CVAD Under Indirect
Supervision

In order to insert, and/or remove, and/or replace a CVAD under indirect supervision, a resident must
complete the following minimum number of insertions, and/or removals, and/or replacements under direct
observation, as detailed below. Programs that receive residents from another program for a rotation
should notify the sending program of these prerequisites, if the resident from the sending program will be
inserting, and/or removing, and/or replacing a CVAD under indirect supervision.

It is strongly recommended that written feedback be provided to the resident after each direct observation.
Any and all written evaluations should be documented in the resident’s file.

1) Minimum Number of Insertions Under Direct Supervision

Certification for inserting a CVAD under indirect supervision is location specific (i.e., internal jugular,
and/or subclavian, and/or femoral). In order to become certified to insert a CVAD for a specific location
under indirect supervision, a resident must complete a minimum of three successful central line
placements of the same location under the direct supervision of a privileged provider (i.e., three

successful internal jugular placements, and/or three successful subclavian placements, and/or three
successful femoral placements). A resident may also provide such direct supervision, so long as s/he has
obtained certification for CVAD insertions for that specific location (i.e., internal jugular, and/or
subclavian, and/or femoral).

2) Minimum Number of Removals Under Direct Supervision

In order to become certified to remove a CVAD under indirect supervision, a resident must complete a
minimum of three successful removals from any location under the direct supervision of a privileged
provider or a resident who has certification for CVAD removals, pursuant to this policy

3) Minimum Number of Replacements Under Direct Supervision

In order to become certified to replace a CVAD over a guidewire, a resident must complete a minimum of
three successful replacements over a guidewire from any location under the direct supervision of a
privileged provider or a resident who has obtained certification for CVAD replacements, pursuant to this
policy

C. Certification Process

When a resident is ready for a check out assessment (which could be on the third or any subsequent
successful completion of an insertion at a specific location, and/or removal, and/or replacement), a written
objective evaluation, such as an Objective Structure Clinical Examination (OSCE), shall be completed by
a privileged provider. The Program Director will then verify and review the evaluation(s) and make a
final determination on whether to certify for competency within MedHub for:

a) a specific type of CVAD insertion (i.e., internal jugular certification, and/or subclavian
certification, and/or femoral certification); and/or
b) removal; and/or
c) replacement over a guidewire.

If the Program Director withholds certification, then the Program Director will notify the resident that
additional direct observations are needed before another check out assessment can be initiated.

If the Program Director grants certification within MedHub, the certified resident will be allowed to
complete such activity under indirect supervision by a privileged provider.

D. Expedited Certification Steps for Eligible Residents and Fellows

1) Eligibility for Expedited Certification

The following residents may obtain certification for a specified central line activity through the below
expedited process:

a) a resident who is board eligible or certified in a specialty that has central line privileges as part of
core at UW Health; or
b) a resident that can provide written evidence of substantial prior experience from prior GME
training. It is within the discretion of the Program Director to decide whether to allow this
resident to proceed under the below expedited certification process.

2) Expedited Certification Process


After completion of the CVAD online training and simulation-based training, a resident must undergo one
written objective evaluation, such as an Objective Structure Clinical Examination (OSCE), by a
privileged provider for the specific central line activity that the resident is seeking certification. The
Program Director will then review the evaluation and make a final determination on whether to certify for
competency within MedHub for:

a) a specific type of CVAD insertion (i.e., internal jugular certification, and/or subclavian
certification; and/or femoral certification); and/or
b) removal; and/or
c) replacement over a guide wire.

If the Program Director withholds certification, then the Program Director will notify the resident that
additional direct observations are needed before another check out assessment can be initiated.

If the Program Director grants certification within MedHub, the certified resident will be allowed to
complete such activity under indirect supervision by a privileged provider.

E. Verification of Certification

It is essential that certification of competency is logged in MedHub so that it can be later verified by other
members of the care team. Certification of residents within MedHub can be verified via U-Connect, by
clicking on “Quick Links” and then “Resident Competencies and Roster”.

Certification for a CVAD activity under indirect supervision does not supersede any UW Health Clinical
Policy regarding the need for a minimum number of staff being present in the room to observe or assist.
All residents are still required to follow any and all UW Health Clinical Policies for CVADs. To the
extent there is a conflict between this policy and a UW Health Clinical Policy, the UW Health Clinical
Policy take precedence.

This policy is inclusive of UW Health affiliates, including the VA, Meriter, St. Mary’s and other hospital
and clinic venues. Residents in GME Programs (accredited and unaccredited) that do not complete the
UW Health on-line CVAD and simulation-based trainings will not be permitted to insert, remove, or
replace CVADs in patients at UW Health or its affiliates.

COORDINATION
Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee

SIGNED BY

Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education

References:
UW Health Clinical Policy: Policy Title: Insertion, Maintenance and Discontinuation of Central Vascular


Access Devices for Prevention of Central Line-Associated Bloodstream Infection (CLABSI)