Impregnated catheters show cost-saving promise

Policy changes critical for maximum efficacy

Antiseptic-impregnated central venous catheters may reduce nosocomial infection rates while dramatically lowering associated hospital costs, researchers are finding.

Presented recently in New Orleans at the annual symposium of the Society of Critical Care Medicine, two unrelated studies documented favorable results with commercially available catheters impregnated with silver sulfadiazine and chlorhexidine. The catheter appears to yield the greatest efficacy when used in conjunction with policy revisions on changing the catheter guide wires, explains Joseph M. Sivetta, MD, professor of medicine at the University of Miami School of Medicine and director of surgical critical care at Jackson Memorial Medical Center.

The traditional practice has been to change out catheters if the patient spikes a fever, but only a small percentage of even non-antiseptic catheters are actually infected in such situations, he notes.

"The number of times you changed the catheter and the patients fever went away was also very low, but it became an ingrained practice because of that low percent that was positive," he tells Hospital Infection Control.

Since the antiseptic-impregnated, or "protected," catheters have shown an association with reduced rates of catheter colonization and bacteremia in previous studies, the next step was to reduce the frequency of catheter guide wire changes, he says. In the study, suspected catheter sepsis (SCS) was substituted for fever as an indication for guide wire exchange. SCS was defined as a fever of more than 2° F over the patient's prior maximum -- without any alternative explanation for the fever, he says. Even then, the "safe period" before guide wire changes for SCS were considered was extended from two days to four days.

"[Protective catheters] really afford you that liberty," he says. "We shouldn't change it just because there is a fever spike."

The protected catheters were used in conjunction with the policy changes and application of a chlorhexidine skin preparation, which was used during the catheter insertion and during subsequent guide wire exchanges. The study included 156 patients with protected catheters in a trauma intensive care unit and compared them to a similar group of patients with unprotected catheters. The number of catheter-related infections dropped 83% -- from 23 patients to four.

New rules a must

"That will of course improve the quality of care because now only four instead of 23 patients were at risk of device-related bloodstream infection," Sivetta says. "The number of catheters changed for fevers dropped by 100, and yet the incidence of positive cultures dropped from 15% to 6%. Because the catheter exerted a protective effect, it decreased the number of positives that occurred. But the second part of it, to make it cost-effective, is that you have to change the rules. There are a lot of hospitals in this country that still abide by the rule that after a couple days of patient fever, you automatically [change] the catheter."

The protected catheter cost approximately $21 more than an unprotected catheter, but the savings are realized in the reduction of guide wire changes -- which were estimated to cost $264 per change in materials and labor. The resulting savings of using the protective catheters and reducing guide wire changes was $4,750 a month for the trauma ICU, he says, noting that the catheters also are being used in another ICU at the hospital.

"If we round it off, we are saving about $10,000 a month in just two ICUs in our hospital -- that's $120,000 a year," Sivetta says.

Another study presented at the conference also reported impressive cost savings when 363 protected catheters were compared to 362 non-protected devices in terms of hospital charges over a four-month period. Catheters were tracked for patient outcome, catheter dwell time, pharmacy charges, and overall charges. Blood cultures and catheter tip cultures were performed according to the orders of the physician of record, with no attempt made by the investigative team to influence physician practice, reports Frank Booth, MD, chief of the division of surgical critical care at the State University of New York Hospital in Buffalo.

$8,000 per patient in savings

In all, 42 protected catheters were cultured on withdrawal. Of those, 14 grew organisms, eight of which were judged to be clinically significant. In contrast, 54 non-protected catheters were cultured, and 31 grew organisms, of which 25 were judged clinically significant. When hospital charges were compared between the two groups, overall charges were significantly different. Overall, the use of a protected catheter was associated with a reduction in pharmacy charges of $1,221 per patient and a reduction in overall charges of $8,000 per patient.

"[There was] a decrease in the charges, for which it is reasonable to assume there was a reduction in costs," Booth tells Hospital Infection Control. "But like the majority of health care institutions, we have only the vaguest idea of what our costs are. Therefore, as a surrogate, we are obliged -- like the majority of researchers in this area -- to fall back on charges. The difference in charges was quite dramatic -- just a penny or two over $8,000 per patient."

Projecting the findings over a year, Booth calculated that an expenditure of an additional $50,000 for the more expensive protected catheters could create a potential annual savings in the range of $8 million.

"Our infection control people are enthusiastic about this data," he says. "I'm disappointed that I've had a near total lack of response from my finance department."

Indeed, proponents of such devices may find it difficult to convince budget officers that spending more upfront can reap dramatic savings down the road, Sivetta adds, noting that he has presented the data to managed care officials to try and raise consciousness on the issue.

"When physicians have taken our data and gone to the purchasing department, they say, 'Nope -- that's going to cost $20 more. We are in a managed care environment -- we can't do that.' The individuals in materials management have to look beyond the borders of their own budget." *