Procedural Competency: How to Log and Maintain Your Numbers for Central Lines, Arterial Lines, and Intubations

Procedural skills are a significant part of many ICU APP roles. But maintaining competency requires intentional tracking and practice—especially as simulation and supervision requirements have increased.

Why Tracking Matters

Credentialing Requirements

Most hospitals require documented procedure numbers for privileging:

• Initial credentialing: Minimum numbers to be granted privileges
• Maintenance of competency: Ongoing minimums to maintain privileges
• Reactivation: If privileges lapse, requirements to regain them

Career Mobility

When you apply for new positions, you'll be asked about procedure volumes. Having documented numbers is far more convincing than "I've done a lot."

Self-Assessment

Tracking helps you identify:

• Which procedures you're confident in
• Where you need more practice
• Success and complication rates

Common Procedural Requirements

Requirements vary by institution, but typical ranges:

Central Venous Catheter (CVC)

• Initial: 10-25 supervised successful placements
• Maintenance: 10-20 per year
• Sites typically included: IJ, subclavian, femoral

Arterial Line

• Initial: 5-15 supervised placements
• Maintenance: 5-10 per year
• Sites: Radial, femoral, brachial

Endotracheal Intubation

• Initial: 10-25 supervised successful intubations
• Maintenance: 10-20 per year
• May include: Direct laryngoscopy, video laryngoscopy, rescue airways

Lumbar Puncture

• Initial: 5-10 supervised
• Maintenance: 3-5 per year

Other Procedures (Variable)

• Chest tube insertion
• Paracentesis
• Thoracentesis
• Bronchoscopy assistance
• Temporary pacing wire placement

How to Log Procedures Effectively

What to Document

For each procedure, record:

1. Date
2. Patient identifier (MRN or initials for privacy)
3. Procedure type and site (e.g., "Right IJ CVC")
4. Indication
5. Supervision level (independent, supervised, assisted)
6. Outcome (successful, unsuccessful, complications)
7. Supervisor name (if applicable)

Tools for Tracking

Spreadsheet (Simple) Create a Google Sheet or Excel file with columns for each data point. Easy to filter and count.

Dedicated Apps

• MedHub: Many residencies use this
• New Innovations: Common in academic settings
• Custom hospital systems: Check if your facility has one

Paper Log Old school but effective. Keep in your locker/office.

Sample Logging Format

Strategies for Maintaining Competency

When Volume Is Adequate

If your unit does enough procedures:

• Volunteer for procedures rather than deferring to residents or attendings
• Rotate through procedure-heavy services periodically
• Take call (procedures often cluster overnight)

When Volume Is Low

If procedures are infrequent:

Simulation

• Most academic centers have simulation labs
• Many hospitals offer periodic simulation sessions
• Some credentialing committees accept simulation for maintenance
• Seek out simulation-based courses (e.g., difficult airway workshops)

Cross-Coverage

• Offer to help on other units when procedures arise
• Build relationships with ED, floor teams who might call for help

Procedure Services

• Some hospitals have dedicated IV/line teams—consider occasional shifts
• Anesthesia rotation or collaboration for airway skills

Skills Labs and Courses

• ACLS renewal with hands-on airway stations
• Ultrasound-guided vascular access courses
• Critical care procedure workshops at conferences

The Simulation Alternative

Increasingly, hospitals accept simulation-based competency assessment. Advantages:

• Controlled environment
• Immediate feedback
• Can practice rare scenarios
• No patient risk

Check if your credentialing office accepts simulation hours for maintenance.

Ultrasound Competency

Procedural ultrasound has become standard of care. Document separately:

• IJ/subclavian CVC with US guidance
• Peripheral IV with US
• Arterial line with US
• FAST exam
• Lung ultrasound
• Basic echo

Many institutions now require documented US-guided procedure training.

Dealing with Low Numbers

Honest Self-Assessment

If you haven't done a procedure in 18 months, are you truly competent? Consider:

• Refresher training/simulation before next attempt
• Supervised practice before returning to independent performance
• Honest discussion with medical director about comfort level

Reactivation Pathways

If privileges lapsed, typical requirements:

• Simulation session with documented assessment
• Supervised procedures (often 3-5)
• Sign-off from supervising physician
• Committee approval

When to Limit Your Scope

It's okay to say: "I'm not comfortable with subclavian lines—I'd prefer IJ or femoral." Patient safety trumps ego.

Complication Tracking

Track complications honestly:

• Pneumothorax
• Arterial puncture
• Hematoma
• Failed attempts
• Infection (if attributable)

Why?

• Required for some credentialing
• Identifies areas for improvement
• Demonstrates professional self-awareness

A 5-10% complication rate for CVC is typical; significantly higher should prompt review.

Advocating for Procedure Opportunities

Make Your Interest Known

Tell attendings, medical directors, and charge nurses that you want procedure experience.

Be Available

Procedures often happen at inconvenient times. Being willing to come in or stay late builds your reputation and volume.

Teach Others

Once competent, precepting students or new APPs cements your skills and demonstrates leadership.

Join Committees

Quality improvement or procedural safety committees keep you engaged and visible.

The Bottom Line

Procedural competency isn't set-it-and-forget-it. It requires ongoing tracking, intentional practice, and honest self-assessment. Log every procedure, seek opportunities proactively, and use simulation when volume is low.

Your privilege to perform procedures is earned through demonstrated competency—maintain it deliberately.