Article Text

Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion
  1. Enyo A Ablordeppey1,
  2. Byron Powell2,
  3. Virginia McKay2,
  4. Shannon Keating3,
  5. Aimee James4,
  6. Christopher Carpenter5,
  7. Marin Kollef6,
  8. Richard Griffey5
  1. 1Department of Anesthesiology and Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  2. 2Brown School at Washington University in St Louis, St Louis, Missouri, USA
  3. 3Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  4. 4Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  5. 5Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  6. 6Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  1. Correspondence to Dr Enyo A Ablordeppey; ablordeppeye{at}


Introduction Avoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention.

Methods The intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion.

With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments.

Ethics and dissemination Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

Trial registration number Identifier, NCT04324762, registered on 27 March 2020.

  • implementation science
  • qualitative research
  • quality improvement methodologies
  • clinical protocols

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials


  • Contributors EAA is the PI on the study, led the protocol development, conception and study design, acquisition of data, analysis and interpretation of data, drafting and revising the manuscript. BP, VM and RG have been integral to the development of the study protocol, planned analysis and interpretation of data, drafting and revising the manuscript. AJ, CC and MK are involved in analysis design and interpretation of data, drafting and revising the manuscript. SK is a qualitative moderator, involved in data collection and revising the manuscript. All authors read and approved the final manuscript.

  • Funding EA is funded by the Washington University School of Medicine K12 Mentored Training in Implementation Science grant, Grant Number: K12HL137942. BP is supported by the National Institute of Mental Health K01MH113806; VM is supported by the Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Centre for Advancing Translational Sciences of the National Institutes of Health. AJ is supported by the Siteman Cancer Centre and the Barnes Jewish Foundation. CC is supported by grants from the John A. Hartford Foundation and West Health Institute. RG is supported by grant 1 R18 R18 HS025052-01 from the Agency for Healthcare Research and Quality, grant P30DK092950 from the NIH/National Institute of Diabetes and Digestive and Kidney Disorders, Washington University Centre for Diabetes Translation Research.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.