Open vs closed-system endotracheal suctioning: a cost comparison

Impact of a Program of Intensive Surveillance and Interventions Targeting Ventilated Patients in the Reduction of Ventilator-Associated Pneumonia and Its Cost-Effectiveness

Objective:

We hypothesized that a program of prospective intensive surveillance for ventilator-associated pneumonia (VAP) and concomitant implementations of multimodal, multidisciplinary preventive and intervention strategies would result in a reduction in the incidence of VAP and would be cost-effective.

Setting:

Medical and surgical intensive care units (ICUs) in a university teaching hospital.

Interventions:

All ventilated patients in the medical and surgical ICUs were monitored for VAP from January 1997 through December 1998. Interventions including elevation of the head of the bed, use of sterile water and replacement of stopcocks with enteral valves for nasogastric feeding tubes, and prolongation of changing of in-line suction catheters from 24 hours to as needed were implemented.

Results:

The rates of VAP decreased by 10.8/1,000 ventilator-days in the medical ICU (CI95, 4.65-16.91) and by 17.2/1,000 ventilator-days in the surgical ICU (CI95> 2.85-31.56) when they were compared for 1997 and 1998. With the use of the estimated cost of a VAP of $4,947 from the literature, the reduction resulted in cost savings of $178,092 and $148,410 in the medical and surgical ICUs, respectively, for a total of $326,482. In addition, $25,497 was saved due to the lengthening of the time for the change of in-line suction catheters, resulting in a cost savings of $351,979. This total cost savings of $351,979 minus the cost of enteral valves of $2,100 resulted in total net savings of $349,899.

Conclusion:

Intensive surveillance and interventions targeted at ventilated patients resulted in reduction of VAP and appeared to be cost-effective.

Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients

BACKGROUND

Ventilator-associated pneumonia is a common complication in ventilated patients. Endotracheal suctioning is a procedure that may constitute a risk factor for ventilator-associated pneumonia. It can be performed with an open system or with a closed system. In view of suggested advantages being reported for the closed system, a systematic review comparing both techniques was warranted.

OBJECTIVES

To compare the closed tracheal suction system and the open tracheal suction system in adults receiving mechanical ventilation for more than 24 hours.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2006, Issue 1) MEDLINE, CINAHL, EMBASE and LILACS from their inception to July 2006. We handsearched the bibliographies of relevant identified studies, and contacted authors and manufacturers.

SELECTION CRITERIA

The review included randomized controlled trials comparing closed and open tracheal suction systems in adult patients who were ventilated for more than 24 hours.

DATA COLLECTION AND ANALYSIS

We included the relevant trials fitting the selection criteria. We assessed methodological quality using method of randomization, concealment of allocation, blinding of outcome assessment and completeness of follow up. Effect measures used for pooled analyses were relative risk (RR) for dichotomous data and weighted mean differences (WMD) for continuous data. We assessed heterogeneity prior to meta-analysis.

MAIN RESULTS

Of the 51 potentially eligible references, the review included 16 trials (1684 patients), many with methodological weaknesses. The two tracheal suction systems showed no differences in risk of ventilator-associated pneumonia (11 trials; RR 0.88; 95% CI 0.70 to 1.12), mortality (five trials; RR 1.02; 95% CI 0.84 to 1.23) or length of stay in intensive care units (two trials; WMD 0.44; 95% CI -0.92 to 1.80). The closed tracheal suction system produced higher bacterial colonization rates (five trials; RR 1.49; 95% CI 1.09 to 2.03).

AUTHORS' CONCLUSIONS

Results from 16 trials showed that suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator-associated pneumonia or mortality. More studies of high methodological quality are required, particularly to clarify the benefits and hazards of the closed tracheal suction system for different modes of ventilation and in different types of patients.

Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis

BACKGROUND

Closed suction systems (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients. Yet effectiveness regarding patient safety and costs of these systems has not been carefully analyzed.

OBJECTIVE

To review effectiveness of CSS and OSS, with respect to patient outcome, bacterial contamination, and costs in adult intensive care unit patients.

DATA SOURCE

Search of MEDLINE, CINAHL, EMBASE, and Cochrane databases and a manual review of article bibliographies.

STUDY SELECTION

Randomized controlled trials comparing CSS and OSS in adult intensive care unit patients were retrieved.

DATA EXTRACTION/SYNTHESIS

Assessment of abstracts and study quality was performed by two reviewers. Data were combined in meta-analyses by random effect models. Fifteen trials were identified. No significant differences were found in incidences of ventilator-associated pneumonia (eight studies, 1,272 patients) and mortality (four studies, 1,062 patients). No conclusions could be drawn with respect to arterial oxygen saturation (five studies, 109 patients), arterial oxygen tension (two studies, 19 patients), and secretion removal (two studies, 37 patients). Compared with OSS, endotracheal suctioning with CSS significantly reduced changes in heart rate (four studies, 85 patients; weighted mean difference, -6.33; 95% confidence interval, -10.80 to -1.87) and changes in mean arterial pressure (three studies, 59 patients; standardized mean difference, -0.43; 95% confidence interval, -0.87 to 0.00) but increased colonization (two studies, 126 patients; relative risk, 1.51; 95% confidence interval, 1.12-2.04). CSS seems to be more expensive than OSS.

CONCLUSIONS

Based on the results of this meta-analysis, there is no evidence to prefer CSS more than OSS.

Impact of the suctioning system (open vs. closed) on the incidence of ventilation-associated pneumonia: Meta-analysis of randomized controlled trials

OBJECTIVE

Ventilation-associated pneumonia (VAP) is a serious complication of patients in intensive care units (ICU) who require mechanical ventilation. The choice of suctioning system (open vs. closed) remains unresolved in evidence-based guidelines. This meta-analysis was carried out to analyze the effect of the type of suctioning system on the incidence of VAP.

DESIGN

A search of the literature was used to identify randomized controlled trials addressing this question. A meta-analysis was then performed to calculate the relative risk of ventilation-associated pneumonia acquisition with the two suctioning systems.

RESULTS

Nine trials were included, with 648 patients in the open suctioning group and 644 in the closed suctioning group. VAP occurred in 128 (20%) of the open suctioning group and in 120 (19%) in the closed suctioning group (relative risk 0.95).

CONCLUSIONS

At a given pneumonia prevalence of 20% in ICU patients there was no significant advantage for the use of either suctioning system in this meta-analysis. The choice of suctioning system should therefore be based on handling, cost, and individual patient's disease until more data are available.

A meta-analysis of the effects of various interventions in preventing endotracheal suction-induced hypoxemia

The purpose of this study was to clarify the effects of interventions that were applied to prevent endotracheal suction-induced hypoxia by meta-analysis. To obtain a sample for this meta-analysis, a computerized search was performed through MEDLINE in addition to tracking down additional references cited in bibliographies of past reports. Finally thirty research reports were examined. In terms of the application time of oxygenation, insufflation and preoxygenation were the most prevalently used in the studies. Regarding the methods of oxygenation, the most prevalent technique for oxygenation was hyperoxygenation in combination with hyperinflation. Hyperoxygenation and hyperinflation were most frequently induced by FiO2 of 1 and a 150% tidal volume of three to six breaths, respectively. Suctioning was commonly sustained for <15 seconds using pressures of -80 to -120 mmHg and with size 14 French catheters. Insufflation was less effective than the other methods examined in the present study. From this study, it can be concluded that the interventions that were applied to prevent endotracheal suction-induced hypoxia, regardless of their application times or methods, reduced suction-induced hypoxia significantly.

Epidemiology and risk factors for nosocomial pneumonia. Emphasis on prevention

VAP is a complex nosocomial infection, the disease expression and resulting patient outcome of which is dependent on host factors, the causative organism, the timing and adequacy of treatment, and the presence of intrinsic or inducible antibiotic resistance. Significant improvements have been achieved in our ability to reduce the occurrence of VAP in the hospital setting. Clinicians caring for mechanically ventilated patients should strive to develop focused programs for the prevention of VAP, other nosocomial infections, and the occurrence of antibiotic-resistant infections at their institutions. The benefits of such programs are well demonstrated. The components of a PDSA (Plan-Do-STUDY-Act) model that can be simply employed to develop a VAP prevention program are as follows: Stages Plan: 1. Identify potentially modifiable risk factors for VAP at the institutional level. 2. Develop a strategy to modify or prevent the occurrence of these risk factors. [figure: see text] Do: 1. Carry out the planned intervention strategy. 2. Identify problems in the implementation of the designed intervention. 3. Update the intervention with solutions for the identified problems. 4. Collect basic data (e.g., VAP rates, severity of illness).

STUDY

1. Analyze data. 2. Summarize the results. Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Prepare for next PDSA cycle. Inherent in the development and application of such programs is the concept that they are continuous processes striving to improve clinical performance over time (Fig. 3). At any given institution, the most likely approach to the prevention of NP and VAP will be a multifaceted one, employing interventions aimed at reducing the occurrence of aerodigestive tract colonization with pathogenic bacteria and aspiration. To be successful, such quality improvement programs must be embraced at the institutional level. Only in this way can hospitals hope to successfully reduce their rates of VAP and sustain or improve upon those efforts over time.

Mechanical ventilation with or without daily changes of in-line suction catheters

The purpose of this study was to determine the safety and cost-effectiveness of not routinely changing in-line suction catheters for patients requiring mechanical ventilation. Patients were randomly assigned to receive either no routine in-line suction catheter changes (n = 258) or in-line suction catheter changes every 24 h (n = 263). The main outcome measure was the incidence of ventilator-associated pneumonia. Other outcomes evaluated included hospital mortality, acquired organ system derangements, duration of mechanical ventilation, lengths of intensive care and hospital stay, and the cost for in-line suction catheters. Ventilator-associated pneumonia was seen in 38 patients (14.7%) receiving no routine in-line suction catheter changes and in 39 patients (14.8%) receiving in-line suction catheter changes every 24 h (relative risk, 0.99; 95% CI, 0.66 to 1.50). No statistically significant differences for hospital mortality, lengths of stay, the number of acquired organ system derangements, death in patients with ventilator-associated pneumonia, or mortality directly attributed to ventilator-associated pneumonia were found between the two treatment groups. Patients receiving in-line suction catheter changes every 24 h had 1,224 catheter changes costing a total of $11,016; patients receiving no routine in-line suction catheter changes had a total of 93 catheter changes costing $837. Our findings suggest that the elimination of routine in-line suction catheter changes is safe and can reduce the costs associated with providing mechanical ventilation.

Standardized Trauma Admission Orders, a pilot project

The Standardized Trauma Admission Orders (STAOs) were developed in collaboration with the trauma team. Data supporting the development of the STAOs consisted of a retrospective chart review (group 1, n = 30) and a user satisfaction survey before the implementation of STAOs. A user satisfaction survey was administered before and after the STAOs were implemented. Both surveys showed a positive response to using the STAOs. STAOs were implemented in a surgical-trauma intensive care unit to reduce in-patient admission laboratory charges, the frequency of missed admission orders, and physician ordering variability. The difference between group 1 and group 2 (n = 30, STAOs) in-patient admission laboratory charges was significant. There was a $345 per patient reduction in the mean score between group 1 and group 2. Of the selected orders reviewed, completeness of orders was significantly improved in 5 of 21 orders. Survey results show that 11 (79%) of the staff surveyed were in favor of using the STAOs. The majority agreed that in-patient admission orders needs were being met. The STAOs are still being used in the surgical-trauma intensive care unit with some minor changes. Efforts are being directed toward the development of standardized admission orders for the neurosurgical intensive care unit and the trauma floor.