During right internal jugular vein cannulation, complications can arise due to transfixion of the posterior wall and damage to other vessels. The risks to the subclavian artery and its branches are less well appreciated than the carotid artery. Example images are lacking in the literature. Using ultrasound and cadaveric studies, we aim to provide clinically relevant images of at-risk vessels posterior to the right internal jugular vein to emphasise their close proximity, and provide strategies to avoid potential complications. Using ultrasound in 24 patients, we found the presence of numerous arterial vessels (excluding the carotid) within 8.0 mm of the posterior wall of the right internal jugular vein at the levels of the mastoid, cricoid and supraclavicular region. Cadaveric dissections further highlighted the close proximity of numerous branches of the subclavian artery. Vulnerable branches of the subclavian artery include the thyrocervical trunk, inferior thyroid and vertebral arteries. More inferior approaches to right internal jugular vein cannulation are likely to put more arterial branches at risk. Higher resolution ultrasound enables visualisation of these arteries prior to cannulation. If identified, measures should be taken to avoid vein transfixion and arterial damage.
AimsThe aim of the study was to determine adherence to MidYorkshire Hospitals NHS Trust inpatient prescribing standards while implementing change and education in written prescribing to promote safe prescribing and patient safety. MethodsThe retrospective audit was undertaken at Pinderfields General Hospital in a medical ward for older people with use of a generic audit prescribing proforma. This was used to determine compliance with correct patient identification, allergy status, senior review and venous thromboembolism (VTE) risk assessment and prescription. The initial audit cycle included a random sample of 10 current inpatients' prescription charts on the ward over a period of 5 days.Results identified two key areas for improvement: senior review and VTE prophylaxis. We then implemented the promotion of an algorithm: Swabs, Thromboprophylaxis, Antibiotics, Cannula, Oxygen, Drug chart, and Do Not Attempt Cardiopulmonary Resuscitation status (STACODD) during daily ward rounds. We reviewed the compliance with a second audit cycle 4 months later. Data were obtained from the patient's current medical notes, which included the inpatient prescription chart, intravenous fluid chart and any chart that had previously been in use during the current admission prior to transcription. Once the data were collected, the results were compiled into Microsoft Excel and data analysis was performed. ResultsWe demonstrated a 10% increase in the number of prescription charts that had been reviewed by a senior post-implementation of STACODD. Despite the percentage increase, the overall total of senior reviews remained low (20%). Compliance with VTE prophylaxis prescribing was shown to have increased from an initial 10% on the first audit cycle to 50% on the second cycle. In the 50% that had been completed, all sections had been completed fully and the written prescription itself had been prescribed correctly. ConclusionsThe implementation of STACODD onto the older care ward had an improvement on the number of prescriptions that had been reviewed by a senior and had correct VTE prescriptions. The implementation achieved the aim of educating other healthcare professionals and promoted safe prescribing. The team, however, noted that the compliance could be increased further and allowed us to gather evidence in order to identify specific areas of prescribing that required improvement. The implication of this resulted in further education of healthcare professionals on the importance of good prescribing and enabled use of the algorithm, which can be used on a daily basis within ward rounds. ■ Conflict of interest statementThere are no conflicts of interest to declare.
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