Central lines and the general medical register – time for a change in the curriculum?

Editor – Napier and Mitchell¹ have highlighted concerns among some trainees in general internal medicine (GIM), both in terms of patient safety and the current relevance of the skill of central venous access to the GIM physician.

The need for central venous access, often in an emergency situation, is likely to always be within the remit of the on-call medical registrar although increasingly the role of performing the procedure is undertaken by an on-call anaesthetist or, during normal daytime hours, by a dedicated venous access team. However, the availability of anaesthetists and venous access teams out of hours is often very limited, especially in smaller hospitals.

Patient safety must be viewed from both the aspect of ‘do no harm’ and life-saving treatment that may be required within minutes rather than a procedure that can be delayed until a dedicated team or an anaesthetist is available.

The Specialty Advisory Committee in General Internal Medicine has discussed this issue extensively, taking into account the current guidelines from both the National Institute for Health and Care Excellence (NICE)² and those from the Royal College of Anaesthetists (RCA),³ and has sought the views of trainers and trainees.

In view of these concerns, the latest Joint Royal Colleges of Physicians Training Board (JRCPTB) decision aid for procedural competences (revised November 2014) used in conjunction with the specialty training curriculum for general internal medicine⁴ states that central venous access is an essential competence but does not mandate this as requiring ultrasound-guided jugular or subclavian venous access skill; instead, it states that resuscitation by means of the less hazardous femoral venous approach is sufficient as a minimum essential skill and can be acquired by skills lab training with certification or some clinical experience with directly observed procedural skill (DOPS) indicating ability to perform the procedure under supervision or with assistance.

Trainers and those assessing trainees’ acquisition of competence recognise that a compromise between aspiration and the current reality in hospital practice, coupled with patient safety, is needed. Thus, continuing to require a skill that may be life-saving should be maintained, but safety is paramount.

Conflicts of interest

The author has no conflicts of interest to declare.