(1054) Deimplementing CXR After Central Venous Catheterization: A Quest for Sustained Behavior Change

Introduction: Ultrasound (US) guided central venous catheter (CVC) confirmation offers similar sensitivity and safety to chest x-ray (CXR) while decreasing radiation exposure, saving time to CVC use, and conferring cost savings via resource conservation. However, few clinicians in the U.S. have moved to using US in lieu of CXR. A deimplementation program called DRAUP was initiated in an emergency department (ED) in January 2020 with 50% adoption in the first 6 months. Sustained adoption and adaptations to the original implementation strategies have not been reported.

Methods: DRAUP was developed using the Consolidated Framework in Implementation Research to identify barriers and facilitators to substituting US guided CVC confirmation for CXR. The DRAUP program utilizes 7 implementation strategies that align with the behavioral change model, COM-B (capability, opportunity, motivation). We hypothesize that best-worst scaling (BWS) surveys can guide strategy adaptations to boost DRAUP adoption rates back to similar levels as the initial implementation period. A Total Unduplicated Reach and Frequency (TURF) analysis from BWS identifies which strategies influence behavior of the largest number of clinicians. Thus, we used this data to select the implementation strategies to adapt.

Results: From July 2022-June 2023, the ED placed 402 CVCs. Supradiaphragmatic CVCs eligible for DRAUP made up 51% (205). US guided CVC confirmation was attempted on 38% of DRAUP eligible CVCs and 85% of attempts were successful. CXR after CVC insertion was avoided in 174 patients. Common reasons for not attempting DRAUP were ‘staffing challenges’, ‘unstable patients’ and ‘need for CXR for other indications’. From the BWS survey, top strategies predicted to influence behavior addressed “physical capability”, such as comfort with using US or the DRAUP program, and “social opportunity”, including visible support from the hospital or ED leaders. Strategies targeting motivation were maximized. Based on TURF analysis, adaptations to DRAUP program strategies should include more targeted education and training, in-person clinical decision support, and more visible organizational support.

Conclusions: The BWS survey analysis, used for the DRAUP program, is a unique approach to adapting implementation strategies to achieve sustained adoption.