Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective?

Knowledge, Skills, and Compliance of Nurses Related to Central Line-Associated Bloodstream Infection in the Cardiovascular Department at King Faisal Hospital and Research Centre, Riyadh

Background and objective Healthcare-associated infections (HAIs), especially central line-associated bloodstream infections (CLABSI), are among the most critical public health problems worldwide. Knowledge, attitude, and skills of nurses are vital in HAI prevention. In this study, we aimed to assess nurses' knowledge, skills, and compliance related to CLABSI. Method This study was conducted in a heart center as a prospective interventional study. Eighty nurses were selected after obtaining their consent to participate in the pretest, posttest, and skills review. Qualified nurses registered with the Saudi Council and working for at least one month in the relevant unit at the time of the study were included. Nurse managers, interns, and student nurses were excluded. Nurses' skills were analyzed using a competency-based checklist approved by the hospital. Results We enrolled 80 participants in our study. The majority of the participants (51.25%) fell under the age group of 25-34 years. There were 68 females (85%). Participants with an experience of 6-10 years constituted the biggest proportion (37.5%) in the cohort in terms of work experience. The mean CLABSI knowledge-related pretest and posttest scores were 6.7 ±1.09 and 6.8 ±1.11, respectively, while the CLABSI compliance scores were 8.1 ±0.99 and 8.3 ±0.97, respectively. Conclusion Based on our findings, clinical experience of more than five years is associated with good CLABSI knowledge and compliance among nurses. Nurses' level of education also had a significant relationship with CLABSI pretest and posttest scores.

Proportional-assist ventilation with load-adjustable gain factors for mechanical ventilation: a cost-utility analysis

BACKGROUND

Mechanical ventilation is an important component of patient critical care, but it adds expense to an already high-cost setting. This study evaluates the cost-utility of 2 modes of ventilation: proportional-assist ventilation with load-adjustable gain factors (PAV+ mode) versus pressure-support ventilation (PSV).

METHODS

We adapted a published Markov model to the Canadian hospital-payer perspective with a 1-year time horizon. The patient population modelled includes all patients receiving invasive mechanical ventilation who have completed the acute phase of ventilatory support and have entered the recovery phase. Clinical and cost inputs were informed by a structured literature review, with the comparative effectiveness of PAV+ mode estimated via pragmatic meta-analysis. Primary outcomes of interest were costs, quality-adjusted life years (QALYs) and the (incremental) cost per QALY for patients receiving mechanical ventilation. Results were reported in 2017 Canadian dollars. We conducted probabilistic and scenario analyses to assess model uncertainty.

RESULTS

Over 1 year, PSV had costs of $50 951 and accrued 0.25 QALYs. Use of PAV+ mode was associated with care costs of $43 309 and 0.29 QALYs. Compared to PSV, PAV+ mode was considered likely to be cost-effective, having lower costs (-$7642) and increased QALYs (+0.04) after 1 year. In cost-effectiveness acceptability analysis, 100% of simulations would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained.

INTERPRETATION

Use of PAV+ mode is expected to benefit patient care in the intensive care unit (ICU) and be a cost-effective alternative to PSV in the Canadian setting. Canadian hospital payers may therefore consider how best to optimally deliver mechanical ventilation in the ICU as they expand ICU capacity.

Central Venous Catheter bundle: professional knowledge and behavior in adult Intensive Care Units

OBJECTIVE

To evaluate knowledge and behavior of professionals in Intensive Care Units regarding the actions recommended in the bundle on preventing central venous catheter-related bloodstream infection.

METHOD

Cross-sectional descriptive quantitative study, conducted in three Intensive Care Units. The data were collected through a face-to-face questionnaire applied to health professionals. The software R 3.3.1 was used for data analysis.

RESULTS

Two-hundred and ninety-two professionals participated. Regarding knowledge, the hand hygiene item presented a higher level both for the insertion (92.46%) and maintenance (97.27%) moments. Usage of chlorhexidine as an antiseptic, followed by alcohol (47.94%) and providing a date for hub or connectors (19.87%) were the least known items. As for behavior, the professionals reported: using always the correct attire for catheter insertion (84.25%), never waiting for the antiseptic to dry before catheter insertion (25.34%) and never cleaning hub or connectors with 70% alcohol (23.86%).

CONCLUSION

Results show that the professionals' knowledge and behavior regarding the central venous catheter bundle present deficiencies, revealing the importance of promoting training programs for this knowledge domain.

Cost-Effectiveness Studies in the ICU: A Systematic Review

OBJECTIVES

Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs.

DESIGN

We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist.

SETTING

Critical care units.

PATIENTS OR SUBJECTS

Critical care patients.

INTERVENTIONS

Identified studies with cost-effectiveness analyses.

MEASUREMENTS AND MAIN RESULTS

We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]).

CONCLUSIONS

Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.

Teaching module for improving oncology nurses' knowledge and self-confidence about central line catheters caring, complications, and application: A pretest-posttest quasi-experimental design

The aim of the present study was to assess the effectiveness of implementing an educational module based on the Centers for Disease Control and Prevention guidelines on the nurses' knowledge and self-confidence regarding central line catheters (CVCs) caring, complications, and application. A pretest-posttest quasi-experimental design was used. A sample of 100 oncology nurses from oncology units participated in two groups, experimental group (N = 50) and control group (N = 50). The participants completed knowledge test and self-confidence scale before and after the educational program. The results showed that there was a significant difference between the experimental and control groups regarding knowledge related to CVC guidelines and management after the interventional sessions (t = -7.85, P = .001). The mean and standard deviation for experimental group were 15.95 (5.45) and 7.35 (2.73) for the control group. Furthermore, the results showed significant difference (t = -22.20, P = .001) between the experimental group (M = 61.50, SD = 14.20) and the control group (M = 35.50, SD = 7.20) regarding self-confidence in managing CVCs. It is concluded that using educational program strengthens nurses' skills, improves safety, and increases opportunity to learn, and thus, it will increase the self-confidence.

Evaluating the Cost-Effectiveness of Proportional-Assist Ventilation Plus vs. Pressure Support Ventilation in the Intensive Care Unit in Two Countries

Background: Mechanical ventilation is an integral, but expensive, part of the intensive care unit (ICU). Optimal use of mechanical ventilation could save costs and improve patient outcomes. Here, the cost effectiveness of proportional assist ventilation (PAV™ ventilation by Medtronic) is estimated relative to pressure support ventilation (PSV).

Methods: A cohort-level, clinical model was built using data from clinical trials. The model estimates patient-ventilator asynchrony >10%, tracheostomy, ventilator-associated pneumonia, other nosocomial infections, spontaneous breathing trial success, hypoxemia, and death. Cost and quality of life are associated with all events, with cost effectiveness defined as the cost per quality-adjusted life year (QALY) gained in the US and UK.

Results: The mean cost of ICU care was lower with PAV™ than with PSV in the US and UK, but the total cost of care over 40 years was higher due to more patients surviving and incurring future care costs. Reduced time on mechanical ventilation, fewer nosocomial infections, and extended life expectancy with PAV™ drove QALY improvement. The cost per QALY gained with PAV™ was $8,628 and £2,985.

Conclusion: PAV™ improves quality of life and reduces short-term costs. PAV™ is likely to be considered cost-effective over 40-years in the US and UK.

Positive deviance as a strategy to prevent and control bloodstream infections in intensive care

OBJECTIVE

To describe the application of positive deviance as a strategy to prevent and control bloodstream infections.

METHOD

An intervention study with nursing and medical team members working in an intensive care unit in a university hospital, between June and December 2014. The four steps of the positive defiance methodology were applied: to define, to determine, to discover and to design.

RESULTS

In 90 days, 188 actions were observed, of these, 36.70% (n=69) were related to catheter dressing. In 81.15% (n=56) of these dressings, the professionals most adhered to the use of flexible sterile cotton-tipped swabs to perform antisepsis at catheter entry sites and fixation dressing.

CONCLUSION

Positive deviance contributed to the implementation of proposals to improve work processes and team development related to problems identified in central venous catheter care.

OBJETIVO

Descrever a aplicação do Positive Deviance como estratégia na prevenção e no controle da infecção de corrente sanguínea.

MÉTODO

Estudo de intervenção realizado na Unidade de Terapia Intensiva de um hospital universitário, com os membros das equipes de enfermagem e médica, de junho a dezembro de 2014. Foram aplicados os quatro passos da metodologia Positive Deviance: Definir, Determinar, Descobrir e Desenhar.

RESULTADOS

Em 90 dias 188 ações foram observadas, destas, 36,70% (n=69) estavam relacionadas aos curativos dos cateteres. Em 81,15% (n=56) desses curativos, o uso da haste flexível estéril para realização da antissepsia do local de inserção do cateter e de sua placa de fixação foi a ação de maior adesão.

CONCLUSÃO

O Positive Deviance auxiliou na implementação de propostas de melhorias de processo de trabalho e no desenvolvimento da equipe para os problemas identificados no cuidado com o cateter venoso central.

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review

IMPORTANCE

Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain.

OBJECTIVE

To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals.

EVIDENCE REVIEW

A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year.

FINDINGS

Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100 000-increase in program cost was associated with $315 000 greater savings (95% CI, $166 000-$464 000; P < .001). Infections and net costs declined when hospitals already used checklists or had baseline infection rates of 1.7 to 3.7 per 1000 catheter-days. Study quality was not associated with effectiveness or costs.

CONCLUSIONS AND RELEVANCE

Interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings. Although checklists are now widely used and infections have started to decline, additional improvements and savings can occur at hospitals that have not yet attained very low infection rates.

Central line-associated bloodstream infections in the intensive care unit: importance of the care bundle

Background

The importance and efficacy of a care bundle for preventing central line-associated bloodstream infections (CLABSIs) and infectious complications related to placing a central venous catheter (CVC) in patients in the intensive care unit (ICU).

Methods

A care bundle was implemented from July 2013 to June 2014 in a medical ICU and surgical ICU. Data were divided into three periods: the prior period (July 2012–June 2013), the intervention period (July 2013–June 2014; first and second periods), and the post-intervention period (July 2014–December 2014; third period). A care bundle consisting of optimal hand hygiene, skin antisepsis with chlorhexidine (2%) allowing the skin to dry, maximal barrier precautions for inserting a catheter (sterile gloves, gown, mask, and drapes), choice of optimal insertion site, prompt catheter removal, and daily evaluation of the need for the CVC was introduced.

Results

The catheterization duration was longer and femoral access was more frequently observed in patients with CLABSIs. CLABSI rates decreased with use of the care bundle. The CLABSI rate in the medical ICU was 6.20/1,000 catheter days during the prior period, 3.88/1,000 catheter days during the intervention period, and 1.05/1,000 catheter days during the third period. The CLABSI rate in the surgical ICU was 8.27/1,000, 4.60/1,000, and 3.73/1,000 catheter days during these three periods, respectively.

Conclusions

The choice of an optimal catheter insertion site, use of all barrier precautions, and removal of catheters when they are no longer needed are essential to decrease the CLABSI rate.

Evidence-based measures to prevent central line-associated bloodstream infections: a systematic review

Objective:

to identify evidence-based care to prevent CLABSI among adult patients hospitalized in ICUs.

Method:

systematic review conducted in the following databases: PubMed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf and Cochrane Studies addressing care and maintenance of central venous catheters, published from January 2011 to July 2014 were searched. The 34 studies identified were organized in an instrument and assessed by using the classification provided by the Joanna Briggs Institute.

Results:

the studies presented care bundles including elements such as hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement of facilities in and commitment of staff to preventing infections.

Conclusions:

care bundles coupled with education and the commitment of both staff and institutions is a strategy that can contribute to decreased rates of central line-associated bloodstream infections among adult patients hospitalized in intensive care units.

Defining the Specialty of Vascular Access through Consensus: Shaping the Future of Vascular Access

The Association for Vascular Access (AVA) is an organization of health care professionals founded in 1985 to support and promote the specialty of vascular access. The mission of AVA is to distinguish the vascular access specialty and define standards of vascular access through an evidence-based approach designed to enhance health care. There is little guidance for multidisciplinary procedures/practice, and this is the case for vascular access. There are also inconsistencies and conflicts in terminology. Additionally, there is no consensus of vascular access as a specialty. It is the focus of AVA to promote consistency in vascular access practice. This document embraces a common title for a clinician with knowledge and skills in the area of vascular access. This establishes a new paradigm that will strengthen the advancement of the vascular access specialty.

Chlorhexidine hexametaphosphate as a wound care material coating: antimicrobial efficacy, toxicity and effect on healing

Aim: In this study, chlorhexidine hexametaphosphate (CHX-HMP) is investigated as a persistent antimicrobial coating for wound care materials. Materials & methods: CHX-HMP was used as a wound care material coating and compared with chlorhexidine digluconate materials with respect to antimicrobial efficacy, toxicity and wound closure. Results: Antimicrobial efficacy at day 1, 3 and 7 was observed with experimental and commercial materials. CHX-HMP coated materials had less toxic effect on human placental cells than commercial chlorhexidine dressings. CHX-HMP in pluronic gel did not delay healing but reduced wound colonization by E. faecalis. Conclusion: CHX-HMP could become a useful component of wound care materials with sustained antimicrobial efficacy, lower toxicity than chlorhexidine digluconate materials, and reduction in wound colonization without affecting closure.

Comparison of alcoholic chlorhexidine and povidone-iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study

PURPOSE

Compare the effectiveness of different cutaneous antiseptics in reducing risk of catheter-related infection in intensive care unit (ICU) patients.

METHODS

We compared the risk of central venous catheter-related infection according to four-step (scrub, rinse, dry, and disinfect) alcoholic 5 % povidone-iodine (PVI-a, n = 1521), one-step (disinfect) alcoholic 2 % chlorhexidine (2 % CHX-a, n = 1116), four-step alcoholic <1 % chlorhexidine (<1 % CHX-a, n = 357), and four-step aqueous 10 % povidone-iodine (PVI, n = 368) antiseptics used for cutaneous disinfection and catheter care during the 3SITES multicenter randomized controlled trial. Within this cohort, we performed a quasi-experimental study (i.e., before-after) involving the four ICUs which switched from PVI-a to 2 % CHX-a. We used propensity score matching (PSM, n = 776) and inverse probability weighting treatment (IPWT, n = 1592). The end point was the incidence of catheter-related infection (CRI) defined as catheter-related bloodstream infection (CRBSI) or a positive catheter tip culture plus clinical sepsis on catheter removal.

RESULTS

In the cohort analysis and compared with PVI-a, the incidence of CRI was lower with 2 % CHX-a [adjusted hazard ratio (aHR), 0.51; 95 % confidence interval (CI) (0.28-0.96), p = 0.037] and similar with <1 % CHX-a [aHR, 0.73; (0.36-1.48), p = 0.37] and PVI [aHR, 1.50; 95 % CI (0.85-2.64), p = 0.16] after controlling for potential confounders. In the quasi-experimental study and compared with PVI-a, the incidence of catheter-related infection was again lower with 2 % CHX-a after PSM [HR, 0.35; 95 % CI (0.15, 0.84), p = 0.02] and in the IPWT analysis [HR, 0.31; 95 % CI (0.14, 0.70), p = 0.005]. The incidence of CRBSI or adverse event was not significantly different between antiseptics in all analyses.

CONCLUSIONS

In comparison with PVI-a, the use of 2 % CHX-a for cutaneous disinfection of the central venous catheter insertion site and maintenance catheter care was associated with a reduced risk of catheter infection, while the benefit of <1 % CHX-a was uncertain.

CLINICAL TRIALS IDENTIFIER

NCT01479153.

Sustained Reduction in Bloodstream Infections in Infants at a Large Tertiary Care Neonatal Intensive Care Unit

BACKGROUND

Bloodstream infections (BSI) cause significant morbidity and mortality among hospitalized infants.

PURPOSE

Reduction of BSIs has emerged as an important patient safety goal. Implementation of central line insertion bundles, standardized line care protocols, and health care provider education programs have reduced BSI in NICUs around the country. The ability of large tertiary care centers to decrease nosocomial infections, including BSI, has been demonstrated. However, long-term BSI reductions in infants are not well documented. We sought to demonstrate that a low incidence of BSI can be maintained over time in a tertiary care NICU.

RESULTS

Baseline BSI incidence for infants admitted to the NICU was 5.15 and 6.08 episodes per 1000 infant-days in 2005 and 2006, respectively. After protocol implementation, the incidence of BSI decreased to 2.14/1000 infant-days and 2.44/1000 infant-days in 2008 and 2009, respectively. Yearly incidence remained low over the next 4 years and decreased even further to 0.20 to 0.45 infections per 1000 infant-days. This represents a 92% decrease in BSI over a period of more than 5 years.

IMPLICATIONS FOR PRACTICE

Implementation of a nursing-led comprehensive infection control initiative can effectively produce and maintain a reduction in the incidence of BSI in infants at a large tertiary care NICU.

IMPLICATIONS FOR RESEARCH

Additional research is needed to effectively expand prevention of central line-associated BSIs to BSIs of all etiologies.

Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital

The objective of this study was to assess the effectiveness of a catheter-related bloodstream infection (CR BSI) reduction programme and healthcare workers' compliance with recommendations. A 3-year surveillance programme of CR BSIs in all hospital settings was implemented. As part of the programme, there was a direct observation of insertion and maintenance of central venous catheters (CVCs) to determine performance. A total of 38 education courses were held over the study period and feedback reports with the results of surveillance and recommendations were delivered to healthcare workers every 6 months. A total of 6722 short-term CVCs were inserted in 4982 patients for 58 763 catheter-days. Improvements of compliance with hand hygiene was verified at the insertion (87·1–100%, P < 0·001) and maintenance (51·1–72·1%, P = 0·029) of CVCs; and the use of chlorhexidine for skin disinfection was implemented at insertion (35·7–65·4%, P < 0·001) and maintenance (33·3–45·9%, P < 0·197) of CVCs. There were 266 CR BSI incidents recorded with an annual incidence density of 5·75/1000 catheter-days in the first year, 4·38 in the second year [rate ratio (RR) 0·76, 95% confidence interval (CI) 0·57–1·01] and 3·46 in the third year (RR 0·60, 95% CI 0·44–0·81). The education programme clearly improved compliance with recommendations for CVC handling, and was effective in reducing the burden of CR BSIs.

Complications of Central Venous Access Devices: A Systematic Review

CONTEXT

The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources.

OBJECTIVE

To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics.

DATA SOURCES

Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015.

STUDY SELECTION

Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage.

DATA EXTRACTION

Data were independently extracted and critiqued for quality by 2 authors.

RESULTS

Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%-29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71-2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%-63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4-39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09-0.20]).

LIMITATIONS

The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research.

CONCLUSIONS

CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.

The Impact of Implementation of Bundle to Reduce Catheter-Related Bloodstream Infection Rates

Background

The aim of the study was to investigate how control bundles reduce the rate of central venous catheter-associated bloodstream infections (CVC-BSIs) rates in critically ill patients.

Methods

This is a prospective before-and-after study designed to evaluate whether a set of control measures (bundle) can help prevent CVC-BSI. The bundles included a checklist that aimed to correct practices related to CVC insertion, manipulation, and maintenance based on guidelines of the Center for Disease Control and Prevention (CDC).

Results

We examined 123 checklists before and 155 checklists after implementation of the training program. Compared with the pre-intervention period, CVC-BSI rates decreased. Hand hygiene techniques were used correctly. CVC-BSI incidence was 9.3 and 5.1 per 1,000 catheter-days before and after the training program, respectively.

Conclusions

The implementation of a bundle and training program effectively reduces CVC-BSI rates.

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

Background. Needleless connectors (NC) are used on virtually all intravascular devices, providing an easy access point for infusion connection. Colonization of NC is considered the cause of 50% of postinsertion catheter-related infections. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within NC and catheters increasing the potential for infection of central and peripheral catheters. Methods. This systematic review evaluated 140 studies and 34 abstracts on NC disinfection practices, the impact of hub contamination on infection, and measures of education and compliance. Results. The greatest risk for contamination of the catheter after insertion is the NC with 33-45% contaminated, and compliance with disinfection as low as 10%. The optimal technique or disinfection time has not been identified, although scrubbing with 70% alcohol for 5-60 seconds is recommended. Studies have reported statistically significant results in infection reduction when passive alcohol disinfection caps are used (48-86% reduction). Clinical Implications. It is critical for healthcare facilities and clinicians to take responsibility for compliance with basic principles of asepsis compliance, to involve frontline staff in strategies, to facilitate education that promotes understanding of the consequences of failure, and to comply with the standard of care for hub disinfection.

An Economic Analysis of Adherence Engineering to Improve Use of Best Practices During Central Line Maintenance Procedures

OBJECTIVE

Adherence engineering applies human factors principles to examine non-adherence within a specific task and to guide the development of materials or equipment to increase protocol adherence and reduce human error. Central line maintenance (CLM) for intensive care unit (ICU) patients is a task through which error or non-adherence to protocols can cause central line-associated bloodstream infections (CLABSIs). We conducted an economic analysis of an adherence engineering CLM kit designed to improve the CLM task and reduce the risk of CLABSI.

METHODS

We constructed a Markov model to compare the cost-effectiveness of the CLM kit, which contains each of the 27 items necessary for performing the CLM procedure, compared with the standard care procedure for CLM, in which each item for dressing maintenance is gathered separately. We estimated the model using the cost of CLABSI overall ($45,685) as well as the excess LOS (6.9 excess ICU days, 3.5 excess general ward days).

RESULTS

Assuming the CLM kit reduces the risk of CLABSI by 100% and 50%, this strategy was less costly (cost savings between $306 and $860) and more effective (between 0.05 and 0.13 more quality-adjusted life-years) compared with not using the pre-packaged kit. We identified threshold values for the effectiveness of the kit in reducing CLABSI for which the kit strategy was no longer less costly.

CONCLUSION

An adherence engineering–based intervention to streamline the CLM process can improve patient outcomes and lower costs. Patient safety can be improved by adopting new approaches that are based on human factors principles.

Infect Control Hosp Epidemiol 2015;00(0): 1–7

Cost effectiveness of different central venous approaches for port placement and use in adult oncology patients: evidence from a randomized three-arm trial

BACKGROUND

No randomized trials have so far investigated the cost effectiveness of different methods for implantation and use of central venous ports in oncology patients.

PATIENTS AND METHODS

Overall, 403 patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of port, either through a percutaneous landmark access to the internal jugular vein, an ultrasound (US)-guided access to the subclavian vein, or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Insertion and maintenance costs were estimated by obtaining the charges for an average implant and use, while the costs of the management of complications were analytically assessed. The total cost was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any.

RESULTS

A total of 401 patients were evaluable-132 with the internal jugular vein, 136 with the subclavian vein and 133 with the cephalic vein access. No differences were found for the rate of early complications. The US-guided subclavian insertion site had significantly lower failures. Infections occurred in 1, 3, and 3 patients (internal jugular, subclavian, and cephalic access, respectively; p = 0.464), whereas venous thrombosis was observed in 15, 8, and 11 patients, respectively (p = 0.272). Mean cost for purchase, implantation, diagnosis and treatment of complications in each patient was <euro>2,167.85 for subclavian US-guided, <euro>2,335.87 for cephalic, and <euro>2,384.10 for internal jugular access, respectively (p = 0.0001).

CONCLUSION

US real-time guidance to the subclavian vein resulted in the most cost-effective method of central venous port placement and use.