An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial

BACKGROUND

Hickman-type tunnelled catheters (Hickman), peripherally inserted central catheters (PICCs), and totally implanted ports (PORTs) are used to deliver systemic anticancer treatment (SACT) via a central vein. We aimed to compare complication rates and costs of the three devices to establish acceptability, clinical effectiveness, and cost-effectiveness of the devices for patients receiving SACT.

METHODS

We did an open-label, multicentre, randomised controlled trial (Cancer and Venous Access [CAVA]) of three central venous access devices: PICCs versus Hickman (non-inferiority; 10% margin); PORTs versus Hickman (superiority; 15% margin); and PORTs versus PICCs (superiority; 15% margin). Adults (aged ≥18 years) receiving SACT (≥12 weeks) for solid or haematological malignancy from 18 oncology units in the UK were included. Four randomisation options were available: Hickman versus PICCs versus PORTs (2:2:1), PICCs versus Hickman (1:1), PORTs versus Hickman (1:1), and PORTs versus PICCs (1:1). Randomisation was done using a minimisation algorithm stratifying by centre, body-mass index, type of cancer, device history, and treatment mode. The primary outcome was complication rate (composite of infection, venous thrombosis, pulmonary embolus, inability to aspirate blood, mechanical failure, and other) assessed until device removal, withdrawal from study, or 1-year follow-up. This study is registered with ISRCTN, ISRCTN44504648.

FINDINGS

Between Nov 8, 2013, and Feb 28, 2018, of 2714 individuals screened for eligibility, 1061 were enrolled and randomly assigned, contributing to the relevant comparison or comparisons (PICC vs Hickman n=424, 212 [50%] on PICC and 212 [50%] on Hickman; PORT vs Hickman n=556, 253 [46%] on PORT and 303 [54%] on Hickman; and PORT vs PICC n=346, 147 [42%] on PORT and 199 [58%] on PICC). Similar complication rates were observed for PICCs (110 [52%] of 212) and Hickman (103 [49%] of 212). Although the observed difference was less than 10%, non-inferiority of PICCs was not confirmed (odds ratio [OR] 1·15 [95% CI 0·78-1·71]) potentially due to inadequate power. PORTs were superior to Hickman with a complication rate of 29% (73 of 253) versus 43% (131 of 303; OR 0·54 [95% CI 0·37-0·77]). PORTs were superior to PICCs with a complication rate of 32% (47 of 147) versus 47% (93 of 199; OR 0·52 [0·33-0·83]).

INTERPRETATION

For most patients receiving SACT, PORTs are more effective and safer than both Hickman and PICCs. Our findings suggest that most patients receiving SACT for solid tumours should receive a PORT within the UK National Health Service.

FUNDING

UK National Institute for Health Research Health Technology Assessment Programme.

Perioperative application of midline catheter and PICC in Patients with gastrointestinal tumors

PURPOSE

This study aimed to compare the application value of midline catheter and peripherally inserted central catheter (PICC) in patients with gastrointestinal tumors during the perioperative period.

METHODS

487 patients with gastrointestinal tumors admitted to Qingdao Municipal Hospital from August 2016 to September 2018 were selected and retrospectively analyzed. 279 patients treated with midline catheters during the treatment were regarded as the study group, and another 208 patients treated with PICC were regarded as the control group. The incidence of perioperative adverse reactions, the cost of daily catheter maintenance and the the total cost of catheter indwelling were compared between the two groups. Meanwhile, each patient was investigated for treatment satisfaction at the time of discharge.

RESULTS

The total incidence of adverse reactions in the study group was significantly lower than that in the control group (p=0.0001). The catheter indwelling duration in the study group was significantly shorter than that in the control group (p<0.001). The 24-h drainage volume in the study group was significantly higher than that in the control group (p<0.001). The average cost of daily maintenance and total cost of catheter indwelling in the study group were significantly lower than those in the control group (p<0.001). The satisfaction rate in the study group (69.53%) was significantly higher than that in the control group (51.92%) (p<0.001). The dissatisfaction rate in the study group (3.23%) was significantly lower than that in the control group (15.38%) (p<0.001).

CONCLUSION

Compared with PICC, the perioperative application of midline catheter in patients with gastrointestinal tumors can effectively reduce catheter-related adverse reactions, with higher medical economic benefits and satisfaction rate, and is worthy of clinical promotion and application.

Direct cost of maintenance of totally implanted central venous catheter patency

OBJECTIVE

to identify the average direct cost of maintaining the patency of totally implanted central venous catheter with heparin at a Day Hospital of a public hospital of high complexity specialized in the treatment of cancer patients, and estimate the average direct cost of replacing heparin with sodium chloride 0.9%.

METHOD

quantitative, exploratory-descriptive study, with a sample of 200 non-participant observations of the maintenance of totally implanted central venous catheters with heparin. The average direct cost was calculated by multiplying the (clocked) time spent by professionals to complete the procedure by the direct unit cost of workforce, added to the cost of materials and solutions.

RESULTS

the estimated total direct cost of catheter maintenance with heparin was US$ 9.71 (SD=1.35) on average, ranging from US$ 7.98 to US$ 23.28. The estimated total direct cost of maintenance with 0.9% sodium chloride in the place of heparin was US$ 8.81 (SD=1.29) on average, resulting in a reduction of US$ 0.90 per procedure.

CONCLUSION

the results contributed to propose strategies to assist in cost containment/minimization in this procedure. The replacement of heparin by 0.9% sodium chloride proved to be an option to reduce the total average direct cost.

The Self-Locating Catheter: Review and Cost Analysis

The self-locating catheter invented by Nicola Di Paolo has been increasingly used in Italy and elsewhere since 1994, with about a thousand patients currently implanted every year. Twelve grams of tungsten inserted in the tip of the conventional Tenckhoff catheter during extrusion do not significantly change its form, but suffice to keep the tip firmly in the Douglas cavity.

The validity of the new catheter is confirmed by a multicentric controlled study in a large population of peritoneal dialysis patients. This trial showed that patients with the new catheter have fewer episodes of peritonitis, tunnel infection, cuff extrusion, catheter malfunction, obstruction and leakage.

This paper outlines the present situation and reports a comparative analysis of the costs of Tenckhoff and self-locating catheters.

Investigation into the causes of indwelling urethral catheter implementation and its effects on clinical outcomes and health care resources among dementia patients with pneumonia: A retrospective cohort study

There is a possibility that unnecessary treatments and low-quality medical care, such as inappropriate indwelling urethral catheter use, are being provided to older Japanese individuals.The aim of this study was to investigate contextual effects relating to indwelling urethral catheters in older people with dementia and to clarify the effects of indwelling urethral catheter use on patients' mortality, length of stay (LOS), and health care spending. This retrospective cohort study involved 4501 male and female Japanese participants. Those who were aged 75 or older with dementia and had a primary diagnosis of acute lower respiratory disease with antibiotics administered during hospitalization were eligible for inclusion. Patient mortality, LOS, and total charge during hospitalization were the main study outcomes. This study showed that indwelling urethral catheter use was significantly associated with higher mortality, longer LOS, and higher total charge for hospitalization. The pattern of indwelling urethral catheter use was clustered by care facility level. Physician density was significantly associated with indwelling urethral catheter use; the relationship was not linear but U-shaped, such that the approximate median had the lowest rate of urethral catheter use and this increased gradually toward both lower and higher physician densities. Our study found considerable variation in indwelling urethral catheter use between care facilities in older people with dementia. Additionally, indwelling urethral catheter use was related to poor outcomes. Based on these findings, we consider there to be an urgent need for constructing a framework to measure, report on, and promote the improvement of care quality for older individuals in Japan.

The Impact of Tunneled Catheters for Ascites and Peritoneal Carcinomatosis on Patient Rehospitalizations

PURPOSE

The aim of the study is to assess patient outcomes, complications, impact on rehospitalizations, and healthcare costs in patients with malignant ascites treated with tunneled catheters.

MATERIALS AND METHODS

A total of 84 patients with malignant ascites (mean age, 60 years) were treated with tunneled catheters. Patients with peritoneal carcinomatosis and malignant ascites treated with tunneled drain catheter placement over a 3-year period were studied. Overall survival from the time of ascites and catheter placement were stratified by primary cancer and analyzed using the Kaplan-Meier method. Complications were graded by the Common Terminology Criteria for Adverse Events v3.0 (CTCAE). The differences between pre- and post-catheter admissions, hospitalizations, and Emergency Department (ED) visits, as well as related inpatient expenses were compared using paired t tests.

RESULTS

There were no significant differences in gender, age, or race between different primary cancer subgroups. One patient (1%) developed bleeding (CTCAE-2). Four patients (5%) developed local cellulitis (CTCAE-2). Three patients (4%) had prolonged hospital stay (between 7 and 10 days) to manage ascites-related complications such as abdominal distention, discomfort, or pain. Comparison between pre- and post-catheter hospitalizations showed significantly lower admissions (-1.4/month, p < 0.001), hospital stays (-4.2/month, p = 0.003), and ED visits (-0.9/month, p = 0.002). The pre- and post-catheter treatment health care cost was estimated using MS-DRG IPPS payment system and it demonstrated significant cost savings from decreased inpatient admissions in post-treatment period (-$9535/month, p < 0.001).

CONCLUSIONS

Tunneled catheter treatment of malignant ascites is safe, feasible, well tolerated, and cost effective. Tunneled catheter treatment may play an important role in improving patients' quality of life and outcomes while controlling health care expenditures.

Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial

BACKGROUND

According to the 2011 Infusion Nursing Standards of Practice, the low pH of intravenous vancomycin requires that it be administered through a central line. However, a careful review of the literature and a retrospective analysis of the experience at New York Hospital Queens (NYHQ) did not support the position of the Standards.

PURPOSE

A prospective, controlled, randomized clinical trial was conducted to determine if intravenous vancomycin could be safely administered through a novel midline catheter (POWERWAND®, Access Scientific, San Diego, CA).

METHODS

Patients scheduled to receive short-term (<6 days) intravenous vancomycin were randomly assigned to receive treatment through either a peripherally inserted central catheter (PICC) or the midline study device. Complications and the costs of insertion were recorded.

RESULTS

The two groups did not differ significantly with respect to total complications (17.9% with PICCs vs. 19.9% with the midline), phlebitis (0% vs. 0%) or thrombosis (0% vs. 0%). One suspected catheter-associated bloodstream infection did occur in the PICC group. Insertion costs were $90.00 less per insertion in the midline group.

CONCLUSIONS

Short-term intravenous vancomycin can be safely and cost-efficiently administered in the deep vessels of the upper arm using the midline study device.

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters

BACKGROUND

Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative.

OBJECTIVES

To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters.

METHODS

A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed.

RESULTS

The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years.

CONCLUSION

The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.

PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites: a NICE Medical Technology Guidance

The PleurX peritoneal drainage catheter for drainage of malignant ascites in a community setting has been evaluated by the NICE Medical Technologies Evaluation Programme. This article outlines the evidence included in the Sponsor's submission, the independent critique by the External Assessment Centre (EAC) and the recommendations made by the Medical Technologies Advisory Committee (MTAC). In accordance with the scope issued by NICE, the intervention technology was the indwelling PleurX peritoneal catheter drainage system, the comparator was large-volume paracentesis (LVP; inpatient or outpatient) and the population was patients with treatment-resistant, recurrent malignant ascites. Nine studies (ten papers) were identified with a total of 180 PleurX-treated patients; six were case series with more than four patients that, despite being low in the hierarchy of evidence, provided useful safety information. Technical success of the initial PleurX placement procedure was 100% across five studies which reported this outcome. One study reported equal complication rates between patients treated with indwelling PleurX catheters (40 patients and 40 catheters) and those receiving repeated LVPs (67 patients and 392 procedures), 7.5% (3/40; 95% CI 1.6, 20) and 7.5% (5/67; 95% CI 2.2, 15), respectively. All remaining studies were single-arm and reported complication rates of between 0% and 59%; this wide range was largely due to variation in the definition of complications and adverse events. Using validated tools, one case series reported improvements in several ascites-related symptoms after placement of the PleurX catheter; however, an overall quality-of-life improvement at 12 weeks was not demonstrated. Positive patient opinions relating to improved symptom control and convenience were reported in a qualitative study. Cost analysis demonstrated that PleurX offered savings to the NHS when compared with repeated LVPs performed in an inpatient setting. This saving of £679 per patient was driven primarily by reducing hospital bed days (year 2009-2010 values), but would require 23.5 additional community nurse visits. Advice from clinical experts was that additional home visits were overestimated as many patients would receive such visits regardless of whether a PleurX drain had been fitted. The model demonstrated that PleurX would be more expensive than LVP procedures performed in a setting where one or less hospital bed days were used (e.g. day case or outpatient). There was uncertainty surrounding the number of patients for whom insertion of a PleurX drain would be appropriate as well as the point in the care pathway at which such treatment should be administered. MTAC supported the case for adoption and considered that the available evidence showed PleurX was clinically effective, has low complication rates, can improve quality of life and is less costly than inpatient LVP. In Medical Technology Guidance 9 (MTG9), NICE recommended that PleurX peritoneal catheter drainage system be considered for use in patients with treatment-resistant, recurrent malignant ascites.

Eliminating hospital acquired infections: is it possible? Is it sustainable? Is it worth it?

An estimated 2 million hospital-acquired infections (HAI) are now reported annually in the US, and are associated with an estimated $5 billion in additional health care costs. With this, the growing incidence of HAI has become "ground zero" in the campaign to improve patient safety and eliminate waste in health care.We studied the characteristics of high-performing organizations and their leaders outside of health care to determine how such organizations become "best in class." We then sought to apply the principles that led to this status to eliminating HAI associated with central venous catheters.Observations of the current condition of health care revealed multiple defects in various processes, that were breeding grounds for error. Redesign of these processes by the people involved in them under the guidance of a leader resulted in an 86% reduction in infections in the blood. Overall, financial performance improved by $5.1 million over a 2-year period. Mortality in intensive care units declined by 29%.Using methods borrowed from highly reliable industries and engaging workers at the point of care can have profound and sustainable effects in nearly eliminating HAI, with significant clinical and financial benefits.

Nocturnal home hemodialysis: implementation, quality assurance and future challenges

Nocturnal home hemodialysis (NHHD) has been associated with several clinical benefits compared to conventional thrice-weekly in-center hemodialysis. However, the prevalence of NHHD remains low. To date, few studies have focused on the importance of training and education of a complex medical procedure such as NHHD. In the present review, we will describe guidelines for implementation of a NHHD program by focusing on 1) patients' selection, assessment and training; 2) challenges of adult education; 3) prescription and 4) barriers to adoption of home hemodialysis. Future challenges in research, the importance of quality assurance and innovations in clinical care delivery in NHHD will also be discussed.

Catheter-associated urinary tract infection and the Medicare rule changes

Catheter-associated urinary tract infection, a common and potentially preventable complication of hospitalization, is 1 of the hospital-acquired complications chosen by the Centers for Medicare & Medicaid Services (CMS) for which hospitals no longer receive additional payment. To help readers understand the potential consequences of the recent CMS rule changes, the authors examine the preventability of catheter-associated infection, review the CMS rule changes regarding catheter-associated urinary tract infection, offer an assessment of the possible consequences of these changes, and provide guidance for hospital-based administrators and clinicians. Although the CMS rule changes related to catheter-associated urinary tract infection are controversial, they may do more good than harm, because hospitals are likely to redouble their efforts to prevent catheter-associated urinary tract infection, which may minimize unnecessary placement of indwelling catheters and facilitate prompt removal. However, even if forcing hospitals to increase efforts to prevent complications stemming from hospital-acquired infection is commendable, these efforts will have opportunity costs and may have unintended consequences. Therefore, how hospitals and physicians respond to the CMS rule changes must be monitored closely.

Cost-effective central venous line for infants in the developing world

INTRODUCTION

The aim of the study was to look into the feasibility, safety, efficacy and cost-effectiveness of utilising the remains of central venous catheters in infants from a developing country.

METHODS

Between June 2005 and December 2006, 96 neonates and infants with various illnesses and required the insertion of central venous access, were divided into two groups; those who required it for a short to medium term (44 patients) received a piece of the remains of catheters, and those who required conventional catheter insertion intended for long-term use (52 patients) received a regular catheter. The same principle of insertion was used as for regular central venous access. The external jugular vein was used when possible or the internal jugular vein was used otherwise. After appropriate insertion, the catheter was mounted on an appropriately-sized cannula. A three-way stopcock connection was used to minimise manipulation of the cannula. Postoperative care was the same as for routine central venous lines. Complications encountered in the two groups were recorded and analysed.

RESULTS

Of the short- and medium-term catheters, 32 out of 44 patients (72.7 percent) completed the intended course of treatment successfully, and of the long-term catheters, 42 out of 52 patients (80.8 percent) completed the treatment successfully. Recorded complications were dislodgement, thrombosis and infection. These were, in the short-term group, as follows: five (11.4 percent), three (6.8 percent) and four (9.1 percent), respectively; and for the long-term group, two (3.8 percent), four (7.7 percent) and four (7.7 percent), respectively.

CONCLUSION

Utilisation of the remains of venous catheters in properly-selected patients for short- and medium-term treatment is feasible, cost-effective and safe, and the rates of complications are comparable to cases with conventional catheter insertion.

A rehabilitation hospital's experience with ionic silver Foley catheters

A small rehabilitation hospital in northern Arkansas had a problem with catheter-associated urinary tract infections (CAUTI). A review of practices and policies provided no reason for the trend. The facility trialed an ionic silver Foley catheter finding that it dramatically reduced the incidence of CAUTI in their patient population.

Clinical and economic effects of central venous catheters on oncology patient care

Central Venous Catheters (CVC) and ports are essential devices to the medical care of cancer patients. Every year about one million CVCs are inserted in cancer patients. The field of oncohematology is making a great contribution to the development of new models of catheters and to the use of innovative materials. New therapeutic protocols, based on continuous administration and higher doses of anticancer drugs with relative phlebitis problems, have raised the issue of long CVC in situ permanence. Different complications are related to the intravascular catheters such as those associated with insertion (pneumothorax, damages to arteries and nerves), or with the duration of catheterization (thrombosis and infections). Furthermore, Catheter-Related Bloodstream Infections (CRBSI), in particular, cause significant mortality and excessive hospital costs. The aim of this prospective study was to analyze the costs related to the use of polyurethane (PU) CVC. 44 patients with a non tunneled double lumen PU CVC in place were followed for 6 months, and for each patient, time of permanence, possible antibiotic prophylaxis, blood parameters, adverse events and medical treatments were monitored. Our results suggest that physicians should pay greater attention to the correlation between new medical devices and the real benefit for the patient, and economic consequences.

Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis

Tunneled cuffed internal jugular vein catheters are widely used to provide short to medium-term vascular access for hemodialysis. The NKF-K/DOQI guidelines state that fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The KDOQI recommendation makes it difficult for Nephrologists to perform this procedure without access to fluoroscopy. This results in unnecessary waiting times and the inappropriate use of acute, non-tunneled catheters. The purpose of this study is: 1) to compare the outcomes of fluoroscopically guided vs modified traditional catheter placement technique, and 2) to perform a cost analysis of the two techniques. We performed a retrospective investigation of 202 tunneled hemodialysis catheters performed at our tertiary care hospital. Procedural data were obtained from the University of Wisconsin Department of Medicine, Nephrology Section Interventional Nephrology procedural database. Patient demographics, laboratory tests were obtained from the University of Wisconsin Hospital electronic medical record (EMR). Logistic regression was used to evaluate the effect of blind vs fluoro-guided placement on clinical outcomes, corrected for side of procedure, age, gender, previous history of catheter placement, diabetes mellitus (DM), and pre-procedural coagulation parameters. Baseline characteristics of 'blind' vs fluoro-guided groups differed with respect to side of procedure and DM (91.0% vs 79.6%, p = 0.02 and 43.30% vs 58.40%, p = 0.02, respectively). Non-fluoroscopic placement of catheters was associated with a decreased odds ratio of immediate success (OR = 0.1298, CI = 0.02 - 0.71). No difference in major or minor bleeding complications was discovered between the blind vs fluoro-guided group. Cost analysis revealed that performing the non-fluoroscopic technique as the preferred initial procedure would represent a substantial reduction in total bills submitted to third-party payers, including Medicare.

Economic evaluation and catheter-related bloodstream infections

Catheter-related bloodstream infections are a serious problem. Many interventions reduce risk, and some have been evaluated in cost-effectiveness studies. We review the usefulness and quality of these economic studies. Evidence is incomplete, and data required to inform a coherent policy are missing. The cost-effectiveness studies are characterized by a lack of transparency, short time-horizons, and narrow economic perspectives. Data quality is low for some important model parameters. Authors of future economic evaluations should aim to model the complete policy and not just single interventions. They should be rigorous in developing the structure of the economic model, include all relevant economic outcomes, use a systematic approach for selecting data sources for model parameters, and propagate the effect of uncertainty in model parameters on conclusions. This will inform future data collection and improve our understanding of the economics of preventing these infections.

A comparison of Hickman line- and Port-a-Cath-associated complications in patients with solid tumours undergoing chemotherapy

AIMS

To compare the complication rates of Hickman lines and Port-a-Caths in patients undergoing infusional chemotherapy for solid tumours.

MATERIALS AND METHODS

A single institution retrospective analysis comparing complication rates for 30 Hickman lines and 33 Port-a-Caths inserted for chemotherapy in adults with solid tumours was carried out.

RESULTS

Patients were well matched in terms of primary site and chemotherapy regimen. In both cases, over 85% were inserted radiologically under local anaesthetic. The total time in situ for Hickman lines and Port-a-Caths was 3539 days (median 83, range 6-585) and 5783 days (median 158, range 20-456), respectively. The complication rate for Hickman lines was 5.09/1000 catheter days, almost five times that for Port-a-Caths, with 1.04/1000 catheter days, a relative risk of 4.9 (confidence interval: 1.9-15.1, P=0.0003). Most (73%) complications occurred within 4 weeks of insertion. However, some arose much later: the range of time to complication was 1-304 days for Hickman lines and 1-132 days for Port-a-Caths. Infection was the most common complication, accounting for nine of 18 Hickman line complications and five of six Port-a-Cath complications, giving an overall infection rate of 2.54/1000 catheter days and 0.86/1000 catheter days, respectively. Additionally, Hickman lines had a 26% leakage rate or displacement rate, which did not occur at all in the Port-a-Cath group. Complications required the removal of 16 Hickman lines and five Port-a-Caths. The rate of removal was five times higher for Hickman lines (Hickman lines=4.52/1000 catheter days, Port-a-Caths=0.86/1000 catheter days, P=0.0027). Overall, the cost of Port-a-Caths was less than that of Hickman lines.

CONCLUSION

In this study, Port-a-Caths were shown to be both safer and cheaper than Hickman lines for patients requiring infusional chemotherapy.

A simple method to accurately position Port-A-Cath without the aid of intraoperative fluoroscopy or other localizing devices

BACKGROUND

To evaluate the efficacy and acceptability of the Port-A-Cath (PAC) insertion method with (conventional group as II) and without (modified group as I) the aid of intraoperative fluoroscopy or other localizing devices.

METHODS

A total of 158 women with various kinds of gynecological cancers warranting PAC insertion (n = 86 in group I and n = 72 in group II, respectively) were evaluated. Data for analyses included patient age, main disease, dislocation site, surgical time, complications, and catheter outcome.

RESULTS

There was no statistical difference between the two groups in terms of age, main disease, complications, and the experiencing of patent catheters. However, appropriate positioning (100% in group I, and 82% in group II) in the superior vena cava (SVC) showed statistical differences between the two groups (P = 0.001). In addition, the surgical time in group I was statistically shorter than that in group II (P < 0.001).

CONCLUSIONS

The modified method for inserting the PAC offered the following benefits: including avoiding X-ray exposure for both the operator and the patient, defining the appropriate position in the SVC, and less surgical time.

[National multicenter survey: the use of intravenous antimicrobial agents]

Infectious diseases are currently one of the major health problems worldwide. As a consequence, both nosocomial and community-acquired infections are responsible for a significant increase in workload and health costs for hospitals, particularly in Intensive Care Units (ICU), Internal Medicine and Surgery. The use of intravenous antimicrobial agents is common in hospitalized patients. In order to determine the use of antimicrobial agents and the most frequent procedures used for their administration in Spanish hospitals, a national multicenter survey was undertaken among ICU, Internal Medicine and Surgery health staff from 63 hospitals, in which data were collected on central and peripheral catheter manipulation and intravenous administration. Results showed that, in Spain, both catheter manipulation (insertion, maintenance and removal) and administration of antimicrobial agents are performed by the nursing staff following established protocols, particularly for central catheters. Moreover, the ICUs had the highest rates of catheter-bearing patients, as well as patients undergoing antimicrobial treatment, sometimes in combination. The use of intravenous antimicrobial agents in Spanish hospitals results in an increased workload for the nursing staff and higher health costs, not to mention the risk involved with the use of vascular catheters.

Associations between demographic factors and provider structures on cost and length of stay for hemodialysis patients with vascular access failure

Vascular access failure (VAF) is a major determinant of morbidity and cost for hemodialysis patients, but little is known about the care patterns and cost implications that are associated with VAF. A total of 952 episodes of VAF in 348 patients were identified using specific procedure codes. Demographic and care pattern characteristics were available as were detailed costs for each episode. The determinants of several important performance measures were evaluated: Cost per episode, inpatient versus outpatient treatment, and length of stay (LOS). Over 5 yr of study, the proportion of VAF episodes that were treated on an outpatient basis increased from 31 to 63%. Average costs of outpatient versus inpatient episodes were $1491 and $8265, respectively. Men were more likely to be treated as outpatients (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.17 to 2.08), but once admitted, their LOS was longer (difference LOS +1.3; 95% CI +0.32 to +2.28) and more costly (delta$ +2603; 95% CI +632 to +4573). Nonblack, nonwhite patients were more likely to be treated as outpatients than were white patients (OR 2.07; 95% CI 1.27 to 3.36) and had shorter LOS once admitted (deltaLOS -2.37; 95% CI -4.23 to -0.49). Compared with Medicare, non-Medicare case-managed insurance was associated with a higher likelihood of outpatient treatment (OR 1.40; 95% CI 1.01 to 1.94) for VAF and shorter LOS (deltaLOS -1.36; 95% CI -2.48 to -0.24) and lower costs (delta$ -2742; 95% CI -5012 to -472) for inpatient treatment. It is concluded that gender and racial factors may influence VAF care. Over time, more VAF episodes are being treated in outpatient settings. Case management may lead to more outpatient treatment and shorter inpatient treatment of VAF.

Chronic and acute consequences of a post-dialysis urokinase lock on permanent hemodialysis catheter function

BACKGROUND

To treat permanent hemodialysis (HD) catheter dysfunctions due to thrombosis, as an alternative to pre- and intradialytic instillations/infusions of fibrinolytic agents, for practical reasons, a post-dialysis urokinase lock is often preferred. This study aimed to analyze the consequences on catheter function and the cost/effectiveness of an intermittent post-dialysis urokinase lock.

METHODS

A prospective open experimental study enrolling 10 dialysis patients with a Tesio twin catheter locked with either heparin 5,000 IU/mL or escalating urokinase doses. Catheter function was monitored measuring the blood flow obtained with an aspiration pressure of -180 mmHg for 28 consecutive HD sessions.

RESULTS

No differences were noticed between the blood flow obtained before and after the lock of the catheter with 5000 U/lumen of urokinase (phase 1), but also with 10,000 U/lumen (phase 2) of urokinase. The incidence of catheter dysfunction episodes in the wash-out in the 1st and in the 2nd urokinase phases were, respectively: 13, 6 and 3% (p<0.05 for both 13 vs. 6% and 13 vs. 3%). 47,000 U of urokinase were necessary to avoid one dysfunction episode potentially treatable with an intradialytic urokinase lock of 10,000 U. Between the average blood flow measured in the initial wash out (230 +/- 27 ml/min) and in the 1st (236 +/- 32 ml/min) and also in the 2nd (247 +/- 34 ml/min) urokinase phases significant differences were noticed (p<0.01 and p<0.05, respectively).

CONCLUSIONS

The post-dialysis lock with urokinase is associated with an increase in the catheter blood flow and a re-duction in the occurrence of dysfunction episodes. However, the modest impact on dialysis quality and the apparent unfavorable cost/effectiveness of the prophylactic treatment, call for an investigation of its potential advantages in a larger study.

Get a hold on costs and safety with securement devices

Evidence shows that commercially available catheter securement devices both reduce accidental needlesticks to healthcare workers and prevent catheter-related bloodstream infections by limiting catheter movement.

Infection control issues in central venous catheter care

Central venous catheters (CVCs) are now a routine part of patient management in the intensive care unit (ICU). Over time, a vast amount of literature associated with the use and care of CVCs has accumulated. The purpose of this article is to discuss the literature associated with the care of these devices in a narrative format. Although particular attention is paid to infection control issues, other fundamental areas such as catheter design, dressings, line changing and post insertion management are also discussed. The article goes on to look at the future of CVC design and concludes with an analysis of future developments related to CVCs.

Health Economic Analysis of Fluoropyrimidine-Based Therapies of Colorectal Cancer from the Perspective of Statutory Sickness Funds

AIMS

1) to identify the treatment costs of different standard fluoropyrimidine-based therapies, i. e., the Mayo-Clinic and AIO/Ardalan regimens, under real-life conditions in settings routinely used for chemotherapy administration in Germany (inpatient, day-clinic or office-based oncologists) and 2) to investigate the cost implications of the routine use of capecitabine, an oral alternative for the treatment of metastatic colorectal cancer.

METHODS

We analysed the actual fee-listings of office based oncologists and projected the results to several hospital-based treatment settings and to oral treatment with capecitabine from the perspective of statutory sickness funds.

RESULTS

Office-based setting: the highest quarterly treatment costs of 9.874 were found for the AIO/Ardalan-regimen, followed by the Mayo-Clinic regimen, which incurred costs of 2.497. The cheapest treatment option was capecitabine with quarterly costs of 1.610. Day-clinic setting: the costs of the Mayo-Clinic protocol amounted to 2.036 in a municipal hospital and 8.455 in a university hospital. The respective costs for the AIO/Ardalan regime were 1.294 and 5.374. In-patient setting: the Mayo-Clinic protocol costs were 3.143 in a municipal hospital and 10.5609 in a university hospital. The respective costs found for the AIO/Ardalan-regimen were 1.998 and 6.717.

CONCLUSION

From a health economic perspective, substantial cost savings for health insurance may be realised if patients with colorectal carcinoma were treated in the office-based setting with capecitabine instead of a hospital-based treatment. Economic consequences would be positive for municipal hospitals (avoided losses) and negative for university hospitals. Further savings could be realised if drug prices in hospital and retail pharmacies were harmonized.

The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management

BACKGROUND

Some investigators have shown that the initial placement of a catheter or graft, instead of the timely construction of an arteriovenous fistula (AVF), late referral to nephrology services and unplanned dialysis increase morbidity and mortality in chronic haemodialysis (CHD) patients. Furthermore, a delay in providing an adequate AVF entails significant increases in treatment-related costs. This study was limited to the analysis of the effects of the lack of an adequate vascular access for CHD on morbidity and mortality.

METHODS

According to the vascular access they had in the first 3 months of CHD treatment 96 patients were divided into three groups (VA group): Group 1 (G1), having an adequate AVF in the first 3 months; Group 2 (G2), starting with a catheter but finishing with an AVF; and Group 3 (G3) starting and finishing with a catheter. Time-dependent Cox regression analysis was performed to identify variables associated with survival, and the standardized mortality index (SMI) was calculated. Finally, we studied cost-effectiveness.

RESULTS

Time-dependent Cox regression and logistic regression analyses showed the statistically significant variable to be the VA group. To ensure that mortality was comparable between VA groups, eliminating age bias, the findings were adjusted applying SMI. G1 patients appear to have a lesser risk of death (relative risk, 0.39) than G2 and G3 patients, as do G2 relative to G3 patients. Also, after adjustment with SMI, patients over 65 years, presumably at greater risk of death, have a lower mortality than the <or=65 age group. Patients with an adequate and functioning AVF lived longer than the others, and the cost of each 'death prevented' was lower (3318/patient).

CONCLUSIONS

The lack of an adequate AVF at the start of haemodialysis decreases survival significantly-even if patients are not diabetic, are referred to a nephrologist early and planned haemodialysis is initiated. It also increases the cost of each prevented death.

Controlling antimicrobial use and decreasing microbiological laboratory tests for urinary tract infections in spinal-cord-injury patients with chronic indwelling catheters

PURPOSE

The effect of replacing the indwelling catheter of patients suspected of having a urinary tract infection (UTI) before collecting a urine sample on the number of organisms isolated in cultures and on drug and microbiology laboratory costs was studied.

METHODS

Data were collected for all patients hospitalized in two spinal cord injury (SCI) units between October 2001 and March 2002 who had an indwelling catheter or suprapubic catheter and were suspected of having a UTI. Urine samples were obtained through a port of the indwelling catheter in one SCI unit, while the indwelling catheter was replaced immediately before each urine sample was obtained in the second SCI unit. Patient demographics, history of antimicrobial use, bacterial isolate sensitivity data, and current antimicrobial treatment were recorded.

RESULTS

A total of 85 patients, 41 in the control group and 44 in the intervention group, were enrolled during the six-month study period. In the control and intervention groups, 93 and 79 organisms were isolated, respectively, with an average of 2 isolates per patient in the control group and 1 per patient in the intervention group. Patients in the control group had significantly more multidrug-resistant organisms in their urine, with 34 isolated from 26 patients (63%) (p < 0.001). Changing the indwelling catheter decreased antimicrobial and microbiology laboratory costs, resulting in a cost saving of $15.64 per patient.

CONCLUSION

Replacement of the indwelling catheter before collecting a urine sample for culture and conducting susceptibility testing reduced the pathogens identified, the number of toxic antimicrobials prescribed to treat the infection, and the costs of antimicrobials and microbiology laboratory technician time.

Changing practice in the subcutaneous infusion of fluids to improve safety

Many nurses administer subcutaneous infusion therapy; it is seen as an alternative to intravenous therapy. But how sharp-safe is the equipment they use? An evaluation of a clinical trial on a catheter to replace metal butterfly needles is outlined, together with details of how this was introduced into clinical areas.

Midline Catheters

Evangelical Community Hospital at Lewisburg, Pennsylvania, is a small community hospital with 110 beds. This organization sought a device to bridge between the short peripheral catheter and the peripherally inserted central catheter. The midline catheter provided an answer to this dilemma. However, a literature search for midline catheters yielded only four published articles, and only one of these was related to outcomes. The drugs used and the type of patients treated at Evangelical Community Hospital provided a challenge for the infusion therapist. This article examines the management of the patients who fell into a midlength of stay, and for whom both the short peripheral catheter and the peripherally inserted central catheter were inappropriate.

Catheters: a review of the selection, utilisation and complications of catheters for peripheral venous access

Intravenous catheters are used for the administration of medications and fluids and are an integral part of veterinary practice. The aim of catheter use is to optimise administration of medication and minimise complications such as thrombus formation, thrombophlebitis and sepsis. Catheters made from teflon are less flexible, less durable and stimulate more tissue reaction than polyurethane or silicon. However silicon catheters are more expensive and complicated to insert. Generally, for veterinary practice, the biostability and cost of polyurethane catheters make them preferable for short and long-term use. The smallest diameter catheter should be selected to minimise internal vessel wall contact and irritation without compromising medication delivery. The site of insertion varies with individual preference, vessel access and patient compliance. The jugular, cephalic, saphenous, ear, lateral thoracic and subcutaneous abdominal veins are accessible. Hair removal and a thorough aseptic skin preparation should be performed prior to catheter insertion. Daily maintenance is required to detect complications and maximise catheter longevity. Potential complications include thrombus formation, thromboembolism, bacterial colonisation and septicaemia, blood loss and air embolism. Permanent or transient skin dwelling bacteria are commonly isolated if sepsis occurs. The development of novel antiseptic and antibiotic impregnated catheters may reduce the complications associated with catheter infection in the future.

Are Antimicrobial-Impregnated Catheters Effective? Don't Throw Out the Baby with the Bathwater

The antimicrobial-impregnated central venous catheter (CVC) has been the most intensively studied technology for the prevention of CVC-related bloodstream infections (BSIs) over the past 30 years. Although more than a dozen randomized trials have shown significant benefit, authors of an analysis published in a recent issue of Clinical Infectious Diseases have raised questions about the efficacy of antimicrobial-impregnated CVCs because of perceived defects in the experimental design of the studies and statistical analyses of the data. They have further argued that even if this technology might be effective in preventing CVC-related BSI, its cost-effectiveness is questionable. Although most of the studies scrutinized by the authors of this analysis indeed had shortcomings, we believe that their analysis unjustifiably downplays a large body of research that has demonstrated a consistent reduction in CVC-related BSI and a clear-cut cost-effectiveness associated with the use of antimicrobial-impregnated CVCs.

Using bladder instillations to manage indwelling catheters

Indwelling urinary catheters are commonly used in both acute and primary care settings but patients often experience problems with blockage of the catheter as a result of encrustation. Bladder instillations of differing solutions are used in an attempt to prevent and treat this problem of encrustation. This article looks at some of the issues surrounding the use and methods of these solutions. Based on an audit performed by a group of continence clinical nurse specialists in five areas of the UK, results of a questionnaire sent to acute and primary care nursing staff in 2003 are presented and discussed. The questionnaire covered a variety of clinical issues involved in performing bladder instillations and the results show that there is a wide variation of practice across the UK. The authors conclude that there are issues pertaining to bladder instillations which warrant further work.

Improving vascular access outcomes: a systems approach to eliminating structural barriers

Maximizing AV fistula creation, regular access monitoring, prompt outpatient interventions and minimizing catheter use are well-accepted approaches for vascular access management. Systemic barriers impede the application of these strategies. A misaligned reimbursement system coupled with educational deficits and a lack of accountability has contributed to the institutionalization of substandard vascular access care. The hallmark of performance management is to create systems in which incentives are aligned to produce desired behaviors. Realigning reimbursement through a combination of pre-ESRD funding, enhancements to the composite rate to reward outcomes and cover vascular access monitoring and updated reimbursement for outpatient vascular access procedures would improve care and decrease unnecessary hospitalizations. This should be coupled with clearly defined outcome standards and accountability incorporated into hospital accreditation and credentialing. Capitation may provide alternative solutions. A two-phased approach including reimbursement reform while exploring capitation represents a prudent course with the best likelihood of success.

Integrated vascular access management

Nephrologists need to deal with the problem of vascular access management in the same manner as the other major problems that affect our dialysis patients. We need to become experts in vascular access and we need to occupy a pivotal position in directing the decisions that are made that affect dialysis patient welfare. An integrated vascular access management strategy is required. Optimally, there should be four components to this strategy - evidence-based policies and procedures, a dedicated vascular access facility, committed vascular access surgeons and the availability of committed vascular access interventionalists. In many respects this is the approach that offers the best in quality of patient care and is also the most economic to deliver.

Outpatient implantation of a central venous access system in gynecologic oncology patients

OBJECTIVE

To determine the feasibility, accuracy, complications and cost of implantation of the PORT-A-CATH II Fluoro-Free venous access system (SIMS Deltec Inc., St. Paul, Minnesota) in the procedure room setting.

STUDY DESIGN

A prospective study of 49 consecutive gynecologic oncology patients who underwent 53 PORT-A-CATH II System implantations was conducted. Local anesthesia and conscious sedation were used for the procedure. To localize and position the catheter tip, the CATH-FINDER (SIMS Deltec) electronic catheter sensing device was utilized. Demographic characteristics, operative data, complication rates, failure rates and itemized costs were collected and analyzed.

RESULTS

For the 53 ports implanted, the mean operative time was 54 minutes (range, 39-74) and mean estimated blood loss was 17 mL (range, 7-50). Immediate complications included failure to thread the catheter or guidewire past the left subclavian vein (4 patients), pneumothorax (1) and electronic wire fracture (1). All catheter tips were positioned accurately, as confirmed by chest radiography. The procedural charge ranged from $1,946 to $2,042. The CATH-FINDER obviated the need for, and expenses of, fluoroscopy, operating room and anesthesia services, resulting in savings of approximately $2,000 per procedure.

CONCLUSION

Implantation of the PORT-A-CATH II System was performed safely, accurately and cost effectively in the procedure room setting. The advantages of functional longevity, low complication rates and reduced cost of this port system offer an excellent option for long-term central venous access.

Polyurethane II catheter as long-indwelling intravenous catheter in patients with cancer

BACKGROUND

Silicone has been the standard material for indwelling devices to date. Polyurethane II exhibits properties that makes it suitable as a component of long-indwelling vascular access, with the added advantage of low cost.

OBJECTIVE

To describe the experience of an intravenous therapy team with 206 polyurethane II catheters used as long-indwelling vascular access in patients with cancer.

MATERIALS AND METHODS

All polyurethane II single- and double-lumen catheters implanted between January 1, 1994, and March 15, 1995, were analyzed, including time of stay and type and rate of infectious and noninfectious complications.

RESULTS

A total of 206 catheters were placed--164 single-lumen and 42 double-lumen catheters--in 190 patients; average stay was 101 days (range, 1-445 days). The infection incidence rate was 0.66 per 1000 catheter-days for single-lumen catheters and 1.6 per 1000 catheter-days for double-lumen catheters. Noninfectious complications included 1 thrombosis (incidence rate, 0.06 per 1000 catheter-days for single-lumen and none for double-lumen catheters), 5 catheter ruptures (2.4%), and 1 pneumothorax (0.48%). Twelve catheters (8.3%) were removed because of complications; only 1 was infectious. The remaining 17 infectious episodes (94.4%) were resolved without catheter removal. Our complication rate with single-lumen catheters in this series was similar to our previous experience with a nontunneled silicone catheter.

CONCLUSIONS

Our findings indicate that polyurethane II catheters have proven useful and safe as long-indwelling vascular access in patients with cancer at our hospital at a considerably lower cost.

Preventing vascular access dysfunction: which policy to follow

In the USA, three Clinical Performance Measures are currently in place: increasing the number of autologous arteriovenous fistulas (AVFs) among incident hemodialysis patients to 50% and to 40% in prevalent hemodialysis patients; to foster the surveillance of accesses with preemptive correction of problems before accesses thrombose or fail, and to reduce the use of catheters in prevalent patients to less than 10%. Reduction of catheters will automatically result from initiatives that increase the construction of AVFs and preemptive monitoring and surveillance of accesses for dysfunction. Therefore, policies that promote the latter two vascular access aspects are most important to develop and follow. Of these two, however, the most impact will be made by promoting a policy to increase AVF creation in the timeliest manner possible. Strategies and resources needed to achieve these policies are presented. The need for a team approach is emphasized.

Comparison of effectiveness of two urinary drainage systems in intensive care unit: a prospective, randomized clinical trial

OBJECTIVE

In a previous non-randomized study, we demonstrated that no difference occurred in the rate of acquisition of bacteriuria between a complex closed drainage system (CCDS) and a two-chamber drainage system (TCDS) in patients in an intensive care unit (ICU). To confirm this result, we performed a randomized, prospective, and powerful study assessing the effectiveness of the CCDS and the TCDS in ICU patients.

DESIGN

Randomized, prospective, and controlled study.

SETTING

Medico-surgical intensive care unit (16 beds) in a teaching hospital.

PATIENTS AND INTERVENTIONS

Three hundred and eleven patients requiring an indwelling urinary catheter for longer than 48 h were assigned individuals to the TCDS group or CCDS group to compare the rate of acquisition of bacteriuria.

MEASUREMENTS AND RESULTS

Patients did not receive prophylactic antibiotics during placement management or catheter withdrawal. Urine samples were obtained weekly for the duration of catheterization and within 24 h after catheter removal, and each time symptoms of urinary infection were suspected. There was no statistical difference in the rate of bacteriuria between the two groups. Bacteriuria occurred in 8% and 8.5% of patients for TCDS and CCDS, respectively. Rates of urinary tract infection were 12.1 and 12.8 episodes per 1,000 days of catheter.

CONCLUSION

This randomized study, that compares the effectiveness of a TCDS and a CCDS in ICU patients, confirms the results of our previous study. No differences were noted between the two systems (a =0.05). The higher cost of CCDS is not justified for ICU patients.

Comparison of effectiveness of two urinary drainage systems in intensive care unit: a prospective, randomized clinical trial

OBJECTIVE

In a previous nonrandomized study we observed no difference in the rate of acquisition of bacteriuria between a complex closed drainage system (CCDS) and a two-chamber drainage system (TCDS) in ICU patients. To confirm this result we performed a statistically powerful study assessing the effectiveness of the CCDS and the TCDS in ICU patients.

DESIGN AND SETTING

Randomized, prospective, and controlled study in the medicosurgical intensive care unit (16 beds) in a teaching hospital.

PATIENTS AND INTERVENTIONS

We assigned 311 patients requiring indwelling urinary catheter for longer than 48 h to TCDS or CCDS to compare the rate of acquisition of bacteriuria.

MEASUREMENTS AND RESULTS

Patients did not receive prophylactic antibiotics during placement management or catheter withdrawal. Urine samples were obtained weekly for the duration of catheterization and within 24 h after catheter removal, and each time symptoms of urinary infection were suspected. There was no statistical difference in the rate of bacteriuria between the two groups: 8% with TCDS and 8.5% with CCDS. Rates of urinary tract infection were 12.1 episodes with TCDS and 12.8 episodes with CCDS per 1000 days of catheter.

CONCLUSIONS

This randomized study on the effectiveness of TCDS and CCDS in ICU patients confirms the findings of our previous study. No differences were noted between the two systems. The higher cost of CCDS is not justified for ICU patients.