Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections

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Summary

The cost of catheter-related bloodstream infection (CRBSI) is substantial in terms of morbidity, mortality and financial resources. Total parenteral nutrition (TPN) is a recognised risk factor for CRBSI. In 1997, an intravenous nutrition nurse was promoted to TPN surveillance clinical nurse manager (CNM) and quarterly infection audit meetings were introduced to monitor trends in CRBSI. Data were prospectively collected over a 15-year period using specific TPN records in a 535-bed tertiary acute university hospital. A total of 20 439 CVC-days and 307 CRBSIs were recorded. Mean number of infections before, and after, the introduction of a dedicated TPN surveillance CNM were compared. Mean CRBSI per 1000 catheter-days ±SD was 20.5 ± 6.34 prior to 1997 and 14.64 ± 7.81 after 1997, representing a mean reduction of 5.84 CRBSIs per 1000 catheter-days (95% CI: −4.92 to 16.60; P = 0.05). Mean number of CRBSIs per year ±SD was 28.3 ± 4.93 prior to 1997 and 18.5 ± 7.37 after 1997, representing a mean decrease of 9.8 infections per year (95% CI: 0.01 to 19.66; P < 0.05). The savings made by preventing 9.8 infections per year were calculated from data on bed-days obtained from the hospital finance office. The cost in hospital days saved per annum was €135,000. Introduction of a TPN surveillance CNM saved the hospital at least €78,300 per annum and led to a significant decrease in CRBSIs in TPN patients.

Introduction

The cost of catheter-related bloodstream infection (CRBSI) is substantial in terms of the morbidity, mortality and financial resources.1, 2, 3, 4 Numerous studies have demonstrated an increase in the length of ICU stay (8–22 days) and hospitalisation (7–24 days) in patients with CRBSIs.5, 6, 7 Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, not only CRBSIs but also local site infection, septic thrombophlebitis, endocarditis, and other metastatic infections.8, 9, 10 The estimated number of hospital-acquired infections was 1.7 million in a national study in the USA in 2002; more than 133 000 were bloodstream infections. The estimated number of deaths associated with hospital-acquired bloodstream infections was more than 30 000.11 The attributable mortality of CRBSI (if entire hospitals are assessed) is estimated at 12–25%.12 A 10-year retrospective pairwise-matched, risk-adjusted cohort study in Belgium reported the cost attributable to CRBSI as €13,585 per patient.

Guidelines recommend educational programmes to reduce the incidence of these infections.13, 14, 15 Well-organised educational programmes that enable the healthcare worker to provide, monitor and evaluate care and to continually increase their competence are critical to the success of any strategy designed to reduce the risk of infection.13, 14, 15, 16 In recent years there has been an introduction of campaigns to increase awareness of CRBSIs and their prevention such as the 5 Million Lives and the Saving Lives Campaign.14, 17 The concept of ‘central line care bundles’ was introduced in parallel with these campaigns. Central line care bundles are a group of evidence-based interventions for patients with intravascular catheters that, when implemented together, result in better outcomes than when implemented individually.14

Total parenteral nutrition (TPN) is a recognised risk factor for CRBSI.18, 19, 20 Wang et al. performed a two-year study on 1134 patients to evaluate the risk factors for CRBSIs in patients administered with TPN.18 There was an infection rate of 11.46%; however, the results were not expressed per 1000 catheter-days. Our study is the first large study in a TPN population which expresses the decline in the rate of CRBSI per 1000 catheter-days and quantifies the economic benefit of practice change. In our hospital, a TPN multidisciplinary committee meets on a quarterly basis. In 1996 an increasing incidence of CRBSI was noted and an infection audit TPN subcommittee was introduced in 1997 based on this increase. The main objective of our study was to measure the cost-effectiveness of the reduction in CRBSIs after the introduction of TPN surveillance clinical nurse manager (CNM) and analyse the net financial benefit to the hospital.

Section snippets

Methods

This study was performed in Mater Misericordiae University Hospital, Dublin, Ireland, a 535-bed tertiary acute university hospital with a large medical and surgical gastrointestinal unit. There is a hospital-wide TPN service based at the Department of Intensive Care Medicine. In 1994 an intravenous (IV) nutrition nurse was employed, and joined a TPN multidisciplinary committee that met on a quarterly basis. The aims of the TPN multidisciplinary committee were to ensure a high standard of

Results

A total of 1932 patients received TPN and 3307 CVCs were inserted over the 15-year period, with a total of more than 20 439 CVC-days during that period. A total of 307 CRBSIs were recorded.15 Mean number of patients per year ± SD receiving TPN was 129 ± 22.43. Fifty-nine percent of patients were located on the general ward/coronary care unit, 28% of patients on the intensive care unit (ICU) and 13% of patients were located on the high dependency unit.

We compared the mean number of infections prior

Discussion

This study demonstrates the reduction in CRBSIs in TPN patients with resultant savings after the employment of a dedicated TPN surveillance CNM over a 15-year period. The establishment of a surveillance programme highlighted high rates of CRBSIs, the need for intervention and the promotion of an IV nutrition nurse to a TPN surveillance CNM. As a result, in this high risk TPN population, rates of CRBSI were reduced to 5–7 per 1000 catheter-days in recent years of our surveillance. This is

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