Board Authorizes Certain PA Training for Tunneled CVLs

Supervising Physician: Limited to board certified interventional radiologists.

Practice Site: Procedures will be performed at locations where physicians from the Radiology Division of Interventional Radiology practice, all of which have rapid access to the supervising interventional radiologist, a medical emergency team, a code blue team, urgent care, and Emergency Departments.

Physician Availability: An attending physician will be in immediate proximity (adjacent reading room or lab) and immediately available (direct supervision) for assistance if needed. Attending physician must always be present in the immediate proximity. Resident physicians are not allowed to supervise PAs.

Physician Assistant (PA) Training and Competency:

Prior to the PA performing the procedure, the supervising physician will demonstrate how to perform the procedure, and the PA will observe three procedures.

The PA will perform 25 tunneled central venous line procedures under the direct observation and supervision of the physician.

Following approval, the PA must perform no less than 15 procedures per year to maintain competency.

After approval of supervised practice and demonstrating competency, PAs may only perform this procedure when an attending physician is in the immediate area (adjacent reading room or lab) while being immediately available to provide assistance.

Documentation of training logs documenting the 3 observed procedures and 25 directly observed procedures must be kept on file and available for review, if necessary.

The supervising physician must annually review the number of tunneled central venous catheter insertions performed by the PA to ensure the 15 procedures per year, minimum requirements, are met.

Patient Diagnosis and Referral: The procedure will only be performed when delegated by the supervising physician or covering physician. Resident physicians are not allowed to delegate procedural responsibility to the PAs.

Treatment Overview:

A tunneled central venous catheter reduces risk of infection and maintains vascular access for longer periods of time compared to non-tunneled catheters.
1. After central venous access has been obtained, an appropriate catheter exit site is chosen at an appropriate distance from the venous access site.
2. The anticipated exit site is anesthetized with lidocaine and a small incision made at the exit site.
3. The blunt, malleable tunneling device with the catheter attached is inserted into the exit site incision and advanced parallel to the skin surface in the subcutaneous tissues toward the venous access site for catheter insertion into the central vasculature.

Contraindications and Limits on PA Performance of Treatment: Treatment by the PA is contraindicated if the patient has a local skin infection, impaired blood clotting, difficult anatomy, or sepsis. Insertion via the internal jugular or femoral vein may be permitted while insertion via the subclavian vein is not permitted. The PA may place catheters with a diameter of 14.5F and below.

Potential complications from tunneled central venous catheters: The following are the most common immediate complications (with incidence) of tunneled central venous access: pneumothorax (1%), hemothorax (1%), hematoma (1%), air embolism (1%), and vessel perforation (0.5%). Even though a major complication is very uncommon, an attending interventional radiologist must always be immediately available to assist if one were to occur. 

The most common long-term complications (with incidence) of tunneled central venous access include: bacteremia (1%), wound dehiscence (1%), and thrombosis (clotting) of the line (4%). In these relatively uncommon instances, an attending interventional radiologist must always oversee the management of these delayed complications.

Quality Monitoring: All procedures performed by the PA must be recorded in a database which allows for tracking of frequency of procedures performed and complication. Any adverse outcome must be recorded and discussed at the monthly morbidity and mortality conference. Quality must also be monitored using both qualitative and quantitative data through Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) as required by the Joint Commission, which is the national accreditation and certification body for institutional health care providers.

**Training may not begin until the supervising physician receives written approval from the Board of Medical Examiners.**

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