Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes
Abstract
:1. Introduction
2. Methods
2.1. Development of an Initial Process Model of Ultrasound Guided CVC Placement
2.2. Consensus through the Delphi Method
- Display of the proposed BPMN model (Supplementary Figure S1).
- Personal data acquisition: specialty, work area, contact data.
- Set of structured questions, where all the activities of the previously defined BPMN model are listed sequentially. Each question describes the activity and asks each expert to weigh the appropriateness of its inclusion in the model, based on a 5-point Likert scale: 1. Under no circumstances should be included, 2. Should not be included, 3. May or may not be included, 4. Should be included, 5. Must be included.
- Addition of new activities not included in the proposed model, defining the place they should occupy in the model.
- Proposal of other experts in the ultrasound guided CVC placement, who could participate in the research.
3. Results
3.1. Experts
3.2. Model
- Five were included as new activities in the second survey.
- Five activities already considered were modified, either by redefining an activity or by adding some qualitative attribute.
- Four activities were not included because they escaped the scope of the model (e.g., catheter tunneling, or avoiding the patient taking deep breaths).
- Of the three alternatives proposed as activities to verify the position of the vein with ultrasonography before puncture (Anatomical identification, compression, or use of Doppler), none reached the inclusion threshold. When analyzed as a whole, 92% of respondents used at least one of these three alternatives, so it was decided to include all the possibilities in the graphic model.
- “Check catheter in the vein with ultrasound in short axis” inside the vein lumen, obtained 67% on the inclusion criterion; and “Check catheter in the vein with ultrasound in long axis”, obtained 75%. Therefore, it was decided to include both as variants of the same activity.
- The activity “Put sterile gel on covered transducer” did not reach the inclusion criterion. However, we considered that the way the item was worded was incorrect, given that the sterile gel is sometimes used on the puncture site to generate an interface that avoids the presence of air and not necessarily on the transducer. This could have caused confusion among the experts. Therefore, we modified its name to “Put sterile gel” and included it as such in the final model.
4. Discussion
5. Limitations
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
Abbreviations
CVC | Central Venous Catheter |
BPMN | Business Process Model and Notation |
CTA | Cognitive Task Analysis |
ICSAD | Imperial College Surgical Assessment Device |
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Characteristics | Description | Number |
---|---|---|
Experts by Specialty | Anesthesiology | 8 |
Anesthesiology and Intensive Medicine | 4 | |
Nephrology | 1 | |
Experts by unit of work of work | Operating Room | 7 |
Operating Room and ICU | 4 | |
ICU | 1 | |
Dialysis Unit | 1 | |
Experts by type of hospital | Private Hospital | 4 |
Public Hospital | 3 | |
University Hospital | 4 | |
Military Hospital | 2 | |
Expert by geographic location | Capital City | 10 |
Regional Cities | 3 |
Proposed Activity | First, Survey | Second Survey | Change | ||||
---|---|---|---|---|---|---|---|
Not Include % | Neutral % | Include % | Not Include % | Neutral % | Include % | % | |
Prepare implements | 0.0 | 8.3 | 91.7 | 0 | 0 | 100 | 4.25 |
Perform surgical hand washing | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | 0.00 |
Get in sterile gown. gloves. hat and mask | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | −2.08 |
Clean puncture area with chlorhexidine | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | 2.00 |
Drape puncture area in sterile fashion | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | 0.00 |
Ultrasound setup (deep and vascular mode) | 0.0 | 16.7 | 83.3 | 0 | 17 | 83 | −2.08 |
Put gel in probe | 8.3 | 8.3 | 83.3 | 8 | 17 | 75 | −4.08 |
Cover sterile probe | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | 4.17 |
Put sterile gel in covered transducer | 16.7 | 33.3 | 50.0 | 17 | 42 | 42 | −2.17 |
Probe position at puncture zone | 0.0 | 8.3 | 91.7 | 0 | 17 | 83 | 0.00 |
To give position to the patient ⋆ | 0 | 17 | 83 | ||||
Forced contralateral head rotation | 16.7 | 58.3 | 25.0 | 25 | 58 | 17 | −2.17 |
Do Valsalva maneuver | 25.0 | 58.3 | 16.7 | 33 | 67 | 0 | −8.42 |
Anatomical vein identification | 8.3 | 33.3 | 58.3 | 17 | 25 | 58 | −2.00 |
Identify vein with color Doppler | 0.0 | 50.0 | 50.0 | 0 | 83 | 17 | −14.58 |
Compression test identification | 0.0 | 33.3 | 66.7 | 0 | 33 | 67 | 2.17 |
Anesthetize puncture zone | 0.0 | 25.0 | 75.0 | 0 | 25 | 75 | −2.00 |
Puncture with fine needle | 41.7 | 33.3 | 25.0 | 42 | 50 | 8 | −8.25 |
Vein puncture with trocar under ultrasound vision | 0.0 | 8.3 | 91.7 | 0 | 0 | 100 | 2.08 |
Venous blood return + | 0.0 | 16.7 | 83.3 | 0 | 17 | 83 | −2.00 |
Set probe in sterile area ⋆ | 0 | 17 | 83 | ||||
Remove syringe from the puncture trocar | 0.0 | 25.0 | 75.0 | 0 | 17 | 83 | −2.17 |
Advance Seldinger guidewire through puncture trocar | 0.0 | 8.3 | 91.7 | 0 | 0 | 100 | 2.08 |
Remove puncture trocar ⋆ | 0 | 17 | 83 | ||||
Verification of the guide with ultrasound in long axis | 0.0 | 16.7 | 83.3 | 0 | 25 | 75 | −10.33 |
Verification of the guide with ultrasonography in short axis | 0.0 | 33.3 | 66.7 | 0 | 33 | 67 | −4.25 |
Guidewire in good position (in the vein) | 0.0 | 0.0 | 100.0 | 0 | 8 | 92 | −4.08 |
Cut skin | 25.0 | 58.3 | 16.7 | 33 | 58 | 8 | −4.25 |
Widen subcutaneous pathway | 0.0 | 8.3 | 91.7 | 0 | 0 | 100 | −4.08 |
Advance catheter over guidewire without losing control | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | 2.17 |
Remove guidewire entirely | 0.0 | 0.0 | 100.0 | 0 | 0 | 100 | −0.08 |
Check flow and reflow in each catheter port | 0.0 | 8.3 | 91.7 | 0 | 17 | 83 | −2.17 |
Check catheter in the vein with ultrasound in long axis | 0.0 | 41.7 | 58.3 | 8 | 50 | 42 | −8.42 |
Check catheter in the vein with ultrasound in short axis | 8.3 | 41.7 | 50.0 | 17 | 50 | 33 | −8.42 |
Catheter in good position (in the vein) | 0.0 | 8.3 | 91.7 | 0 | 8 | 92 | −2.17 |
Secure catheter with knots | 8.3 | 0.0 | 91.7 | 0 | 17 | 83 | −0.08 |
Secure catheter with other systems ⋆ | 8 | 58 | 33 | ||||
Place catheter patches | 0.0 | 8.3 | 91.7 | 0 | 8 | 92 | −0.08 |
Check catheter position with radiology method ⋆ | 0 | 17 | 83 |
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de la Fuente, R.; Fuentes, R.; Munoz-Gama, J.; Dagnino, J.; Sepúlveda, M. Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes. Int. J. Environ. Res. Public Health 2020, 17, 3889. https://doi.org/10.3390/ijerph17113889
de la Fuente R, Fuentes R, Munoz-Gama J, Dagnino J, Sepúlveda M. Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes. International Journal of Environmental Research and Public Health. 2020; 17(11):3889. https://doi.org/10.3390/ijerph17113889
Chicago/Turabian Stylede la Fuente, Rene, Ricardo Fuentes, Jorge Munoz-Gama, Jorge Dagnino, and Marcos Sepúlveda. 2020. "Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes" International Journal of Environmental Research and Public Health 17, no. 11: 3889. https://doi.org/10.3390/ijerph17113889