Clinical Outcomes of Standardized Central Venous Catheterization Simulation Training: A Comparative Analysis

Abstract

Objective:

A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital.

Design and Participants:

A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022.

Setting:

A teaching hospital institution in Pennsylvania.

Results:

Results showed a correlation between years and complications indicating, (1) mechanical complications _{billable ultrasound,} (2) infectious complications _{billable ultrasound,} and (3) thrombosis complications _{billable ultrasound} were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported.

Conclusion:

These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

INTRODUCTION

Central Venous Catheterization (CVC) is a common surgical procedure, with more than 5 million procedures completed annually in the United States ^1–4. However, it is associated with high mechanical, infectious, and thrombotic complication rates ³. Mechanical complications can occur in 5%−19% of patients, including hematoma, arterial puncture, pneumothorax, hemothorax, arrhythmia, catheter malpositioning, and stenosis^{1, 5, 6}. Infectious complications, including bloodstream infections, range from 5% to 26% ^{1, 5, 6}. While thrombotic complications can arise between 2% to 26% ^{1, 5, 6}; see Table 3. These complications lead to increased mortality, morbidity, and prolonged hospitalization of patients ^7–9. One of the leading causes of these complications is the physician’s experience, with those who have performed the procedure less than 50 times being more than twice as likely to incur complications ¹⁰. As such, there has been a large focus on transforming CVC education.

Table 3:

CVC complications _{billable and no billable ultrasound}. Black is iterative design and blue is large-scale deployment.

		Billable Ultrasound?	Years			Reported Ranges
			2016	2017	2022
# CVC		Yes	1060	1050	1230
		No	470	530	870
Mechanical	Overall	Yes	110 10.38%	130 12.38%	90 7.32%	5%−19% 1, 5, 6
		No	40 8.51%	40 7.55%	50 5.75%
	Arterial Puncture	Yes	10	0	10	4.2–9.3% 33, 34
			0.94%	-	0.81%
		No	0	10	10	4% 35
			-	1.89%	1.15%
	Catheter Misplacement	Yes	20	20	10
			1.89 %	1.90%	0.81%
		No	10	10	10
			2.13%	1.89%	1.15%
	Hematoma	Yes	10	10	10	1% 35
			0.94%	0.95%	0.81%
		No	10	10	10
			2.13%	1.89%	1.15%
	Hemothorax	Yes	10	10	10	< 1% 35
			0.94%	0.95%	0.81%
		No	10	10	10
			2.13%	1.89%	1.15%
	Pneumothorax	Yes	30	40	40	< 1% 35
			2.83%	3.81%	3.25%
		No	20	20	30
			4.26%	3.77%	3.45%
	Stenosis	Yes	50	60	30	Up to 40% 36, 37
			4.72%	5.71%	2.44%
		No	10	10	10
			2.13%	1.89%	1.15%
Infection	Overall	Yes	70	80	50	5%−26% 1, 5, 6
			6.60%	7.62%	4.07%
		No	10	20	20
			2.13%	3.77%	2.30%
	Insertion Site	Yes	10	10	20
			0.94%	0.95%	1.63%
		No	0	10	10
			-	1.89%	1.15%
	CLABSI	Yes	0	0	0	0.5–1.4% 6
			-	-	-
		No	0	0	0
			-	-	-
Thrombotic	Overall	Yes	130	120	100	2%−26% 1, 5, 6
			12.26%	11.43%	8.13%
		No	30	30	50
			6.38%	5.66%	5.75%

CVC education typically relies on non-interactive didactic lectures that teach procedural knowledge paired with hands-on manikin training ^{11, 12}. Manikin trainers provide physical realism with anatomical landmarks, use of a real ultrasound to identify vessels, and ability to practice in a safe environment and with minimum stress ^{13, 14}. While manikin trainers can improve CVC procedural skills and learning ^2,10, it has several limitations. First manikin simulators only train the ultrasound and needle insertion, neglecting the other CVC skills as shown in Table 1.

Table 1:

CVC Procedural (black) and Mechanical Skills (italic and blue) and automated feedback on skills on different systems and feedback . – indicates procedural training without feedback on knowledge, ✓ procedural training with feedback, + indicates hands-on

Technique	Skill	Online Training	CathSkills	DHRT	DHRT+
Procedural Preparation	Explain procedure and consent patient	-	✓
	Select insertion site	-	✓
Aseptic Technique and Site Preparation	Place bed in 10–15-degree Trendelenburg position	-	✓
	Hand hygiene and aseptic technique	-	✓
	Maximal sterile barrier precautions	-	✓
	Prepare clean skin with antiseptic and chlorohexidine	-	✓
	Drape the site	-	✓
	Administer local anesthesia	-	✓
Ultrasound-guided Needle Insertion	Use ultrasound to locate target vessel	-	✓	+	+
	Insert needle into vessel	-	✓	+	+
Catheter Placement	Disconnect syringe and occlude hub	-	✓		+
	Insert guidewire	-	✓		+
	Remove needle while leaving wire	-	✓		+
	Make 1–2mm incision with scalpel	-	✓		+
	Place and remove dilator	-	✓		+
	Place catheter and remove guidewire	-	✓		+
	Secure catheter, suture, and apply dressing	-	✓		+
	Obtain chest X-Ray for proper placement	-	✓		+

Second, manikins only simulates one specific patient’s anatomy, limiting exposure to diverse anatomical landmarks found in the clinical environment ⁴. Third, while simulators allow for multiple needle insertions in a safe environment ^{13, 14}, repeated needle punctures creates marks indicating the vessel locations. This can lead residents to rely on these marks rather than learning to locate the vessels on the ultrasound image. Fourth, manikins rely on a trained preceptor that uses proficiency checklists for performance feedback ^15–16. This leads residents’ feedback to depend on the teacher’s knowledge and skills. Consequently, due to the absence of formal and standardized feedback, if the teacher makes errors, the resident may adopt those same errors ¹⁷.

To improve upon current CVC education, we iteratively designed a standardized ultrasound-guided internal jugular CVC (US-IJCVC) training that uses online- and simulation-based learning. Since previous research is unclear if skills acquired through simulation training improve skills in the clinical environment ¹⁸, the goal of this study is to identify the impact of the US-IJCVC training on clinical complications at a teaching hospital. We aim to compare CVC complications for 2016, 2017, and 2022 due to the first deployment of the training, COVID-19 challenges, and the educational revamp caused by COVID-19. The following section outlines the design of this training and the methodology deployed to analyze its clinical effectiveness.

US-IJCVC STANDARDIZED TRAINING DEVELOPMENT

A standardized US-IJCVC training was developed in two phases: (1) Iteratively Design and (2) Large Scale Deployment (Figure 1). It was implemented at a teaching hospital from 2016 to 2022. Initially, US-IJCVC training across all residency bootcamps used didactic lectures for procedural knowledge and manikin simulators for mechanical skills. In the large-scale deployment phase, the training transitioned to include an online training, non-immersive virtual reality (CathSkills), Dynamic Haptic Robotic Trainer (DHRT), and DHRT+.

Figure 1:

The Evolution of the Standardized US-IJCVC Training

The online training focused on CVC procedural knowledge and involved pre- and post-tests to evaluate residents’ knowledge. CathSkills assessed residents’ procedural knowledge and correct ordering of US-IJCVC steps. The DHRT offered ultrasound and needle insertion training, simulated various patient profiles to address anatomical variations through visual and tactile feedback ¹⁹, and provided automated performance feedback ²⁰. Additionally, the DHRT+ allowed practice for post-needle insertion steps and provided automated performance feedback.

Between 2016 and 2019, surgical residents completed training using didactic lectures, manikin simulators, and DHRT₁. Skill transfer to the clinical environment was compared between manikin- and DHRT-trained residents ²¹. Then residents were evaluated in a complete US-IJCVC in a manikin by an expert observer using a US-IJCVC checklist²². As the DHRT proved to be as effective as manikin ²¹, surgical residents were required to use the DHRT simulator.

In response to the COVID-19 challenges ²³, an online procedural knowledge training was developed. In 2020, surgical residents completed online training, DHRT_1, and manikin performance evaluation conducted by an expert²². Procedural knowledge and mechanical skills performance was compared between surgical residents that were trained using didactic lectures- and online training ²². As the online training proved to be as effective as didactic lectures ²², the residency bootcamp replaced didactic lectures with the online training.

In light of the effectiveness of the online and DHRT training, the large-scale deployment phase initiated. In 2021, residents across all residency bootcamps completed the online training, DHRT_2, and manikin performance evaluation by an expert²². In 2022, all residents also completed the online training but were randomly assigned to complete either the post-test or CathSkills. Following this, residents underwent DHRT_3, DHRT+, and manikin performance evaluation by an expert²². Once training was completed, residents entered the clinical environment.

METHODS

The purpose of this study was to identify the impact of a US-IJCVC training on clinical complications at a teaching hospital during 2016–2017, 2017–2018, and 2022–2023. The remainder of this section outlines the methodology used to accomplish this goal.

Study design and setting

TriNetX, a global health research network, provides de-identified electronical medical record data, including demographics, diagnoses, genomics, medications procedures, and laboratories ²⁴. It only includes summary demographic data and no other identifiable information of specific patient cases ^24–26. TriNetX was used to collect and analyze CVC patients recorded annually between July 1 to June 30 in 2016, 2017, and 2023 aligning with the deployment of the training, the residency programs starting in late June, and educational revamp due to COVID-19.

Patient records of placed CVC were identified using Current Procedural Terminology (CPT) codes 36555, 36556, 36557, and 36558 ^27–28, see Appendix I. CPT codes included CVCs that were placed in the teaching hospital regardless of the insertion site (IJ, subclavian, femoral). Then patient records were organized as CVCs placed with and without billable ultrasound. While ultrasound is common in CVC²⁹, recording these ultrasound records with the patient file is not standardized. To account for the occurrence that CVCs might be placed using ultrasound but are not recorded, complications with and without ultrasound (CPT 72937) were explored.

Demographics for these CVC patient cases included mean age and standard deviation, gender, race, and ethnicity, see Table 2. Total percentages for demographics might exceed 100% due to obfuscation of the results since TriNetX rounds patient counts to the nearest 10th.

Table 2:

Number of patients, proportion of patients, and patient demographics that received a CVC

		Billable Ultrasound?	2016	2017	2022
Total Number of Patients with CVCs		Yes	1060	1050	1230
		No	470	530	870
Patient Gender	Male	Yes	57%	58%	58%
		No	53%	56%	54%
	Female	Yes	43%	42%	42%
		No	48%	45%	46%
Ethnicity/ Race	White	Yes	82%	80%	81%
		No	80%	79%	80%
	Unknown Race	Yes	11%	13%	11%
		No	12%	11%	12%
	Black or African American	Yes	7%	6%	5%
		No	8%	%	6%
	Asian	Yes	-	1%	2%
		No	2%	1%	2%
	American Indian	Yes	-	-	1%
		No	2%	-	1%
	Native Hawaiian	Yes	-	-	-
		No	2%	0%	1%
	Not Hispanic or Latino	Yes	91%	90%	90%
		No	89%	90%	91%
	Hispanic or Latino	Yes	8%	8%	9%
		No	8%	7%	8%
	Unknown	Yes	1%	2%	1%
		No	4%	3%	1%
	Min	Yes	6	5	0
Age		No	6	5	0
	Max	Yes	90	90	90
		No	90	90	90
	Mean ± SD	Yes	59±23	59±22	58±21
		No	59±25	55±25	54±26

We then searched for CVC complications using the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes ³⁰. CVC complications were identified starting at the instance that the CVC was placed. Mechanical, infectious, and thrombosis complications with and without billable ultrasound were identified using ICD-10 codes ^{1, 5, 6}, see Appendix I. Mechanical complications included an ICD code for hematoma, arterial puncture, hemothorax, pneumothorax, catheter misplacement, and stenosis ^{31, 32}. Infectious complications included ICD codes for insertion site and central-line associated bloodstream infections (CLABSI) ^{31, 32}. Thrombotic complications included ICD codes for thrombosis ^{31, 32}. Individual queries were conducted to identify the prevalence of each type of specific complication (e.g. stenosis, CLABSI).

Variables and Outcome Measures

Once the TriNetX data was identified, the following variables were computed:

# CVC _{with and without billable ultrasound}:

The total number of CVC patient files generated from TriNetX that included or excluded billable ultrasound. See Table 1 for ICD code summaries.

Mechanical Complications:

The number of mechanical complications (ICD codes for hematoma, arterial puncture, hemothorax, pneumothorax, catheter misplacement, and stenosis ICD codes) was identified for # CVC _{no billable ultrasound} and # CVC _{billable ultrasound}. The same process was followed for each mechanical complication (e.g hematoma, hemothorax) individually.

Infectious Complications:

The number of infectious complications (ICD codes for insertion site and bloodstream infections) was identified for # CVC _{no billable ultrasound} and # CVC _{billable ultrasound}. The same process was followed for CLABSIs and insertion site individually.

Thrombotic Complication:

The number of thrombotic complications (ICD codes for thrombosis) was identified for # CVC _{no billable ultrasound} and # CVC _{billable ultrasound}.

RESULTS

There were 5,210 CVC records identified in 2016, 2017, and 2022 (Table 3). Two chi-square tests of independence evaluated the association between mechanical, infectious, and thrombotic _{billable and no billable ultrasound} (dependent variable) and years (independent variable). This was performed due to the absence of standardized practices for billing ultrasound. Post-hoc analysis using Z-scores with Bonferroni correction, p ≤ 0.0036, were also conducted.

Mechanical Complications

Two chi-squared tests evaluated the association of Mechanical Complication _{billable and no billable ultrasound} and years. Expected cell frequencies were greater than five with small association Cohen ³⁸ Cramer’s V = .07 and V = .05, respectively. There was a significant association between years and Mechanical _{billable ultrasound} (p < .001). With Bonferroni correction, Mechanical _{billable ultrasound} was higher in 2016 (10.4%) and 2017 (12.4%) than in 2022 (7.3%). There was no significant association between years and Mechanical _{no billable ultrasound} (p =.14), see Figure 2.

Figure 2:

Chi-Squared results for mechanical complications with post-hoc testing using Bonferroni. Each letter denotes a subset of years whose mechanical complication proportions did not differ significantly from each other.

Arterial Puncture

In both chi-square tests for Arterial Puncture _{billable and no billable ultrasound} revealed that expected cell frequencies were greater than five and the association was small association Cramer’s V = .05 and V = .07, respectively. There was a significant association between years and Arterial Puncture _{billable ultrasound,} (p = .01). With Bonferroni correction, Arterial Puncture _{billable ultrasound} were less in 2017 (0%) than in 2016 (0.9%) and 2022 (0.8%). There was also a statistically significant association between years and Arterial Puncture _{no billable ultrasound} (p = .01). With Bonferroni correction, Arterial Puncture _{no billable ultrasound} was higher in 2017 (1.9%) than in 2016 (0%).

Catheter Misplacement

In both chi-square tests for Catheter Misplacement _{billable and no billable ultrasound}, expected cell frequencies were greater than five and small association Cramer’s V = .04 and V = .03, respectively. There was no significant association between years and Catheter Misplacement _{billable ultrasound} (p = .05), and Catheter Misplacement _{no billable ultrasound} (p = .33).

Hematoma

In both chi-square tests for Hematoma _{billable and no billable ultrasound,} expected cell frequencies were greater than five and small association Cramer’s V = .01 and V = .03, respectively. There was no significant association between years and Hematoma _{billable ultrasound} (p=.92) and Hematoma _{no billable ultrasound} (p = .33).

Hemothorax

In both chi-square tests for Hemothorax _{billable and no billable ultrasound,} expected cell frequencies were greater than five with small association Cramer’s V = .01 and V = .05, respectively. There was no significant association between years and Hemothorax _{billable ultrasound} (p=.92) and Hemothorax _{no billable ultrasound} (p = .33).

Pneumothorax

In both chi-squared tests for Pneumothorax _{billable and no billable ultrasound,} expected cell frequencies were greater than five, with small association Cramer’s V = .02 and V = .08, respectively. Results showed no statistically significant association between years and Pneumothorax _{billable ultrasound} (p = .45), and Pneumothorax _{no billable ultrasound} (p = .76).

Stenosis

In both chi-square tests for Stenosis _{billable and no billable ultrasound,} expected cell frequencies were greater than five, with small association Cramer’s V = .07 and V = .03, respectively. There was a significant association between years and Stenosis _{billable ultrasound} (p < .001). With Bonferroni correction, Stenosis _{billable ultrasound} was higher in 2016 (4.7%) and 2017 (5.7%) than in 2022 (2.4%). No significant association between years and Stenosis _{no billable ultrasound} (p=.33) was seen.

Infectious Complications

Two chi-squared tests evaluated the association of Infectious Complication _{billable and no billable ultrasound} and years. Expected cell frequencies were greater than five with small association Cramer’s V = .06 and V = .04, respectively. There was a significant association between years and Infectious _{billable ultrasound} (p = .001). With Bonferroni correction, Infectious _{billable ultrasound} were higher in 2016 (6.6%) and 2017 (7.6%) than in 2022 (4.1%). Although there was a significant association between years and Infectious _{no billable ultrasound} (p = .18), it was not significant with Bonferroni (Figure 3).

Figure 3:

Chi-Squared results for infectious complications with post-hoc testing using Bonferroni. Each letter denotes a subset of years whose infectious complication proportions did not differ significantly from each other.

Insertion Site Complications

In both chi-square tests for Insertion Site _{billable and no billable ultrasound,} expected cell frequencies were greater than five and small association Cramer’s V = .03 and V = .07, respectively. There was no significant association between years and Insertion Site _{billable ultrasound} (p = .22). There was a statistically significant association between years and Insertion Site _{no billable ultrasound} (p = .01) With Bonferroni correction, Insertion Site _{no billable ultrasound} was higher in 2017 (1.9%) than in 2016 (0%).

Thrombotic Complications

Two chi-squared tests evaluated the association of Thrombosis Complication _{billable and no billable ultrasound} and years. Expected cell frequencies were greater than five with small association Cohen ³⁸ Cramer’s V = .058 and V = .044, respectively. There was a significant association between years and Thrombosis _{billable ultrasound} (p = .003). With Bonferroni correction, Thrombosis _{billable ultrasound} was higher in 2016 (12.3%) and 2017 (11.4%) than in 2022 (8.1%). No significant association was shown for Thrombosis _{no billable ultrasound} (p = .87), see Figure 4.

Figure 4:

Chi-Squared results for thrombosis complications with post-hoc testing using Bonferroni. Each letter denotes a subset of years whose thrombosis complication proportions did not differ significantly from each other.

DISCUSSION

The goal of this paper was to identify the impact of the integration of an US-IJCVC training on clinical complications at a teaching hospital. A comparative study was conducted between mechanical, infectious, and thrombosis complications with and without billable ultrasound reported in the teaching hospital where the training was deployed.

In the teaching hospital, Mechanical _{billable ultrasound} ranged from 7.32% to 12.38% and Mechanical _{no billable ultrasound} ranged from 5.75% to 8.51%, consistent with prior work (5% to 19%) ^{1, 5, 6}. Individual complications including billable Hematoma (0.81%−0.95%) and Hemothorax (0.81%−0.95%), and both billable and no billable Arterial Puncture (0%−0.94% and 0%−1.89%), Catheter misplacement (0.81%−1.90% and 1.15%−2.13%), and Stenosis (2.44%−5.71% and 1.15%−2.13%) were within the reported range.

Infectious _{billable ultrasound} ranged from 4.07% to 7.62% and Infectious _{no billable ultrasound} ranged from 2.13% to 3.77%, lower and within the reported range, 5% to 26% ^{1, 5, 6}. Individual complications for Insertion Site _{billable ultrasound} ranged from 0.94% to 1.63% and Insertion Site _{no billable ultrasound} ranged from 0% to 1.89%. These results align with literature which has reported that the insertion site in the internal jugular vein are one of the primary causes of catheter infections ³⁹.

Lastly, Thrombosis _{billable ultrasound} ranged from 8.13% to 12.26% and Thrombosis _{no billable ultrasound} ranged from 5.66% to 6.38% which aligns with prior literature, 2% to 26% ^{1, 5, 6}. While previous work suggested that ultrasound can reduce complications ^40–42, our results showed fewer mechanical, stenosis, infectious, and thrombosis complications without billable ultrasound. This could be attributed to experienced physicians being less likely to incur in a complication ¹⁰ and due to the inconsistency of billing for ultrasound ⁴³.

Our results revealed that Mechanical, Stenosis, Infectious, and Thrombosis Complications _{billable ultrasound} were significantly higher in previous years (2016, 2017) compared to the year (2022) that the US-IJCVC training was implemented in all residency programs. This supports previous research highlighting the importance of educational training to decreases in complications⁴⁴. This is important because physician’s knowledge and skills can help prevent clinical complications ⁴⁵.

In light of this, the US-IJCVC training focuses on teaching skills related to managing complications, ultrasound, and catheter ²², needle insertions and ultrasound practice ²⁰, and post-needle insertion practice. Educating residents to mitigate and reduce complications is crucial. Specifically, since mechanical complications can increase the chance of infectious complication ^{46, 47} which can cause increase mortality, morbidity, prolonged hospitalization stay, and costs^48,8. Thrombosis complications also cause patient anxiety and discomfort⁴⁹, catheter dysfunction, long-term stenosis, and infections ⁵⁰, and increases in mortality and morbidity ⁵¹. Therefore, educating residents will ensure they are better prepared for the clinical environment and may help prevent complications. Given the correlation between years and billable complications, our results provide preliminary evidence that the US-IJCVC training might impact clinical complications.

Limitations

While this study shows promising results, there are some limitations. The literature provided a range of mechanical, infectious, and thrombosis complications, but the ICD-10 codes used were missing. TriNetX’s rounding to the nearest 10th might introduce uncertainty in complication counts. COVID-19 or the experience, knowledge, and skills of the physician conducting the US-IJCVC might have attributed to patient complications. Not all CVC complications are reported; thus, there is a risk that we are missing complications that have never been reported. For example, although CLABSIs were searched in the TriNetX database, future work should investigate the occurrence of CLABSIs more thoroughly. This highlights the need for a standardized reporting method to ensure that all complications are reported. The inability to filter for only Internal Jugular CVCs in TriNetX led to our analysis including all CVCs, irrespective of insertion site. Another limitation of TriNetX was that we were not able to identify the number of catheter days for this study. While CVC education throughout the reported year has included an emphasis on teaching the CVC bundle, we do not know the compliance rate for applying the CVC bundle. Recognizing the significance of catheter days, CVC complications across insertion sites, and the compliance rate of the knowledge taught, future work should deploy a tracking system for gathering detailed performance and complications data. This tracking system can monitor how residents trained with our training perform and use the knowledge taught in the clinical environment and if it relates to complications. Further studies should evaluate residents’ perspective on US-IJCVC training and its impact on training and clinical performance. Lastly, future work should explore the long-lasting effects of the US-IJCVC training on clinical outcomes.

CONCLUSION

This study identifies the impact of a US-IJCVC training on clinical complications at a teaching hospital. The main findings include a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported. Although complications are within the reported range, there has been a trend showing a decrease in complications correlating with the US-IJCVC training large-scale deployment. Further studies should evaluate if this trend continues to decrease as more residents are educated with the US-IJCVC training.

Appendix I:

Inclusion Criteria CPT and ICD-10 Codes

Inclusion Criteria		Current Procedural Terminology (CPT) 27 OR International Statistical Classification of Diseases and Related Health Problems (ICD-10) 30
Central Venous Catheterization		CPT 36555	Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age
		CPT 36556	Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
		CPT 36557	Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age
		CPT 36558	Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older
With Billable Ultrasound Guidance		CPT 76937	Ultrasound guidance for vascular access
Mechanical Complications	Hematoma	ICD-10 I97.63	Postprocedural hematoma of a circulatory system organ or structure following a circulatory system procedure
		ICD-10 I97.630	Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization
		ICD-10 I97.631	Postprocedural hematoma of a circulatory system organ or structure following a cardiac bypass
		ICD-10 I97.638	Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure
	Arterial Puncture	ICD-10 I97.5	Accidental puncture and laceration of a circulatory system organ or structure during a procedure
		ICD-10 I97.51	Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure
		ICD-10 I97.52	Accidental puncture and laceration of a circulatory system organ or structure during other procedure
	Pneumothorax	ICD-10 J93	Pneumothorax and air leak
		ICD-10 J93.8	Other pneumothorax and air leak
		ICD-10 J93.83	Other pneumothorax
		ICD-10 J93.9	Pneumothorax, unspecified
		ICD-10 J95.81	Postprocedural pneumothorax and air leak
		ICD-10 J95.811	Postprocedural pneumothorax
	Hemothorax	ICD-10 J94.2	Hemothorax
	Catheter Misplacement	ICD-10 T82.52	Displacement of other cardiac and vascular devices and implants
		ICD-10 T82.528	Displacement of other cardiac and vascular devices and implants
		ICD-10 T82.528A	Displacement of other cardiac and vascular devices and implants, initial encounter
		ICD-10 T82.528D	Displacement of other cardiac and vascular devices and implants, subsequent encounter
		ICD-10 T82.528S	Displacement of other cardiac and vascular devices and implants, sequela
		ICD-10 T82.529	Displacement of unspecified cardiac and vascular devices and implants
		ICD-10 T82.529A	Displacement of unspecified cardiac and vascular devices and implants, initial encounter
		ICD-10 T82.529D	Displacement of unspecified cardiac and vascular devices and implants, subsequent encounter
		ICD-10 T82.529S	Displacement of unspecified cardiac and vascular devices and implants, sequela
	Stenosis	ICD-10 T82.85	Stenosis due to cardiac and vascular prosthetic devices, implants and grafts
		ICD-10 T82.857	Stenosis of other cardiac prosthetic devices, implants and grafts
		ICD-10 T82.857A	Stenosis of other cardiac prosthetic devices, implants, and grafts, initial encounter
		ICD-10 T82.857D	Stenosis of other cardiac prosthetic devices, implants and grafts, subsequent encounter
		ICD-10 T82.857S	Stenosis of other cardiac prosthetic devices, implants and grafts, sequela
Infectious Complications	Insertion Site Infection	ICD-10 T80.21	Infection due to central venous catheter
		ICD-10 T80.212	Local infection due to central venous catheter
		ICD-10 T80.212A	Local infection due to central venous catheter, initial encounter
		ICD-10 T80.212D	Local infection due to central venous catheter, subsequent encounter
		ICD-10 T80.212S	Local infection due to central venous catheter, sequela
		ICD-10 T80.218	Other infection due to central venous catheter
		ICD-10 T80.218A	Other infection due to central venous catheter, initial encounter
		ICD-10 T80.218D	Other infection due to central venous catheter, subsequent encounter
		ICD-10 T80.218S	Other infection due to central venous catheter, sequela
		ICD-10 T80.219	Unspecified infection due to central venous catheter
		ICD-10 T80.219A	Unspecified infection due to central venous catheter, initial encounter
		ICD-10 T80.219D	Unspecified infection due to central venous catheter, subsequent encounter
		ICD-10 T80.219S	Unspecified infection due to central venous catheter, sequela
	Bloodstream Infection	ICD-10 T80.211	Bloodstream infection due to central venous catheter
		ICD-10 T80.211A	Bloodstream infection due to central venous catheter, initial encounter
		ICD-10 T80.211D	Bloodstream infection due to central venous catheter, subsequent encounter
		ICD-10 T80.211S	Bloodstream infection due to central venous catheter, sequela
Thrombotic Complications	Thrombosis	ICD-10 I74	Arterial embolism and Thrombosis
		ICD-10 I82	Other venous embolism and thrombosis
		ICD-10 T82.86	Thrombosis of cardiac and vascular prosthetic devices, implants, and grafts
		ICD-10 T82.867	Thrombosis due to cardiac prosthetic devices, implants and grafts
		ICD-10 T82.867A	Thrombosis due to cardiac prosthetic devices, implants, and grafts, initial encounter
		ICD-10 T82.867D	Thrombosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter
		ICD-10 T82.867S	Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela