Variation in Nonelective Removal of Central Venous Catheters in NICUs

Research study background

Central venous catheters (CVCs) are life-sustaining devices for premature and critically ill infants that administer intravenous fluids, nutrition and medications. Sometimes, they’re removed unexpectedly, known as nonelective removal (NER). These removals often happen because the CVC has become unusable or unsafe due to a complication. NER can lead to additional procedures, loss of vascular access, patient and family stress, and adverse clinical outcomes due to catheter-related complications.

At Children’s Hospital Colorado, neonatologist Lauren Beard, MD, led a multicenter retrospective study examining NER across 37 level IV neonatal intensive care units (NICUs). The goal was straightforward: determine how often NER occurs, evaluate variation among hospitals and identify what’s most commonly causing NER.

By the numbers

Using data from the Children’s Hospital's Neonatal Database, researchers analyzed 71,865 patients and 135,671 CVCs from admissions between 2017 and 2023. The overall NER rate was 11.7%, meaning roughly 1 in 9 catheters were removed unexpectedly. The catheters were in place for a median of seven days.

The most significant finding though, Dr. Beard says, was the wide variation across centers. Researchers found that NER rates ranged from 3% to 19% at individual hospitals. And even after adjusting for catheter type, insertion location, gestational age and diagnosis, there was still a significant discrepancy.

“When we see a seven-fold difference in outcomes across high-performing level IV NICUs, it suggests there are opportunities to learn from one another and improve care,” Dr. Beard says.

The study found that malposition (52%) was the most common reason for NER, followed by breakage or leakage of the line (14.5%) and mechanical obstruction (12.4%). Central line associated bloodstream infection was not a leading cause of NER. In many cases, the NICU teams were able to treat the infection without removing the catheter.

Clinical implications and future research

The study’s findings indicate that NER can be prevented through improved insertion techniques, maintenance procedures and decision-making processes. Researchers say the next step is to better understand what the highest-performing centers are doing differently.

“Ultimately, our goal is to develop evidence-based strategies that reduce preventable complications, preserve vascular access and improve outcomes for infants who depend on central lines,” Dr. Beard says.

Current NICU initiatives include standardizing post-CVC insertion imaging at specific timepoints, utilization of catheter secure adhesives and clear silicone adhesive dressings to improve line securement, and multidisciplinary review of CVC necessity and frequency of line access.