The Impact of Provider Experience on Central 
Line Malposition

Abstract

Background: Central lines are frequently used in the Neonatal Intensive Care Unit (NICU). Incorrectly positioned central lines are associated with increased complications. Central line malposition has been related to prematurity, catheter size, and small-for-gestation-age status. The impact of provider experience on proper central line positioning has not been established. Methods: In this retrospective cohort study, neonates had central lines placed within the first 10 days of life. Central lines included umbilical artery catheters (UAC), umbilical vein catheters (UVC), and peripherally inserted central catheters (PICC). Central line malposition was confirmed with thoracoabdominal radiography. Different providers with various months/years of experience were coded. Logistic regression models were fit to adjust for potential confounders of the association of years of experience with line malposition. Results: Between 2019 and 2021, 301 neonates had 616 central lines. 66% (405/616) of all central lines were malpositioned. The median years of providers’ experience who placed malpositioned and properly positioned lines were 1.93 (interquartile range [IQR]: 1.03–5.48) years and 2.17 (IQR: 1.38–4.85) years, respectively ( P = .78). The distribution of malposition lines was UVC 49% (199/405), UAC 20.5% (83/405), and PICC 30.5% (123/405). Only UVC was significantly associated with malposition ( P = .002). Conclusions: Malposition of central lines frequently occurred in the NICU and was associated with UVC placement, irrespective of the provider’s experience who accessed it. Anatomical variations in neonates with different gestational ages and birth weights may mean that current methods to estimate insertion depth can be misleading. Future interventions should involve novel techniques of confirming real-time positioning during insertion rather than focusing on placement calculations.