Opportunities for Improved Device Design Based on Central Line Placement Practices: Contextual Inquiry Study (Preprint)

<sec> <title>BACKGROUND</title> Central venous catheters (CVCs) are indispensable to contemporary critical care, perioperative management, and emergency resuscitation, yet their insertion remains fraught with preventable harm and inefficiency. </sec> <sec> <title>OBJECTIVE</title> This study aimed to identify all areas of CVC placement that can be improved through device design using human-centered design and qualitative research methods. </sec> <sec> <title>METHODS</title> This qualitative study was a contextual inquiry of CVC placement, which included observation alongside brief face-to-face interviews with physicians. It was aimed at providing a depth of understanding using evidence to demonstrate causality. This study was conducted at 3 hospitals in the emergency department, the intensive care unit, and the operating rooms. Where possible and with additional consent, sessions were recorded in video or still photography, or at times both. This study included 19 observations and 24 interviews. </sec> <sec> <title>RESULTS</title> In this study, the approach to CVC insertion was consistent across hospitals and care environments, with moderate variability spanning a few sections, such as suture and dressing use or lack thereof in specific care environments. The described and observed difficulties leave room for improvement in device design. The results of this study indicated that there are 34 discrete steps to placing a CVC line, with most time spent during sterile preparation. As a result of the device or kit design, challenges were observed. These included missing essential materials from kits, difficulty distinguishing between nonsterile and sterile items, challenges with lidocaine ampules, patient claustrophobia from draping, and a lack of user preference for kit contents. Additional challenges included obscured ultrasound views, kinked guidewires, overall procedural untidiness, and considerable waste management issues. </sec> <sec> <title>CONCLUSIONS</title> An intuitive kit that aligns with predictable human behavior and eliminates unnecessary multistep detours can reduce novice failure rates, cognitive load, and practice inconsistency, and it could also curb nonrecyclable waste from “backup” kits opened for a single missing item. By reframing CVC systems as sociotechnical solutions rather than static assortments of parts, the same design moves that minimize improvisation and coordination errors for physicians may also reduce dwell time and manipulation events for patients, thereby advancing the core triad of safety, procedural efficacy, and everyday usability. By examining how clinicians place central lines, this study reveals modifiable design flaws that perpetuate risk despite decades of procedural standardization. Contextual inquiry provides the evidentiary bridge between clinical imperatives to reduce complications and the practical realities of device use. Embedding such investigations at the outset of design and iteratively throughout product life cycles offers a path toward safer, more efficient, and more humane central venous access for both patients and providers. </sec>