Abstract
Purpose
Patients at long-term acute care hospitals (LTACs) are medically complex with multiple comorbidities and high rates of antibiotic and device use. The objective of the study was to analyze the incidence and rate of central line-associated bloodstream infections (CLABSI) and the critical factors for patient care, management, placement and maintenance of the implanted central venous access device at this LTAC.
Methods
A 13-year retrospective chart review was performed comprising 191 medically complex patients with multiple comorbidities who had an implanted central line port. Information analyzed included (1) number of catheters; (2) number of patients; (3) number of catheter line days; (4) patient demographics; (5) port location; (6) admission diagnoses; (7) type, incidence and rate of catheter-related complications.
Results
The total number of catheter days was over 183,183 with a mean of 959 catheter days per patient. The mean rate of CLABSI was 0.087 per 1,000 days; incidence was less than 8% of patients with catheters.
Conclusions
The study found a markedly lower rate of CLABSI than reported for other LTACs as well as intensive care units, over 14- to 100-fold lower than other LTACs. The authors propose that standardized catheter placement with implementation of rigorous, prospective catheter care plans and a team approach to management were responsible for extremely low complication rates. These results can be extrapolated to different settings across the healthcare continuum.
Keywords
Introduction
Totally implantable central venous access devices play an indispensable role in the care of many patients, especially those with poor venous access. In addition, the subcutaneously implanted injection port provides patients with freedom of movement and the ability to engage in daily activities (1). However, in spite of the convenience that these access devices provide for the administration of intravenous fluids and medications, they can be a source of serious complications to the patient. These complications can include infection, bleeding, clot and thrombus formation, subcutaneous fluid extravasation, local skin necrosis and tip migration (2). The incidence and rate of complications, particularly central line-associated bloodstream infections (CLABSI) in the acute care setting, have been the subject of numerous published reports (3–10). The critical importance of reducing CLABSI has been emphasized by the Centers for Medicare & Medicaid Services (11).
The patient populations at long-term acute care hospitals (LTACs) are generally medically complex with multiple comorbidities and rates of antibiotic and device use comparable to intensive care units (ICUs). As a result, LTACs have been reported to be critical settings for CLABSI as well as other complications (12). The purpose of this study is to review the incidence of infectious complications of a subcutaneously implanted port for central venous access in a population of multiply medically complicated patients in an LTAC setting. We report a markedly lower rate of CLABSI than has been reported for other LTACs as well as for ICUs and discuss the possible reasons for this low rate.
Materials and Methods
Study objectives
The purpose of this retrospective review was to evaluate the types of patients who received Port-A-Caths™, at the Hospital for Special Care (HSC), a free-standing 228 bed LTAC, and to analyze the complications encountered with their use over a 13-year period.
Study design
An intravenous port access device was placed in a patient only after a recurring need for intravenous access was identified. One of the major indications for placement was a recurrent need for intravenous antibiotics over a 6-month time period with limited ongoing peripheral venous access options. A decision for subcutaneous port access placement was also made when intravenous access was felt to be needed due to various medical complications encountered over the course of a patient's hospitalization. All patients with Port-A-Caths™ were entered into a database that was updated regularly by an Advanced Practice Registered Nurse (APRN).
Inclusion criteria for entry of patients into the study protocol were the following:
Patients admitted to HSC from 1994 to 2007
Adult patients with a Port-A-Cath™
Information collected included the following:
Patient age and gender
Admission diagnoses with comorbidities
Port-A-Cath™ location
The number of catheters placed and followed during the review period
The total number of patients included during the review period
The number of catheter days per patient
Reason(s) for catheter placement
Type and incidence of catheter-related complications
Complications with catheter-related sepsis were evaluated. Catheter-related sepsis was defined as one or more positive blood cultures obtained via the central venous access and peripheral sites consistent with true bacteremia with the patient displaying clinical symptoms consistent with that diagnosis such as fever, hypotension or chills and laboratory results not related to an infection at another site.
The study protocol was reviewed by the hospital's Director of Medical Research and approved by the Center of Special Care's Institutional Review Board.
Analysis
Total catheter days for each patient were the number of days from Port-a-Cath™ device implantation until the date of device removal or date of death or last date of follow-up in the study, whichever came first. The rate of CLABSI per 1,000 catheter days was calculated by dividing the total number of CLABSI by the total number of catheter days and multiplying by 1,000. The incidence of CLABSI was calculated by dividing the total number of CLABSI by the total number of patients with catheters and multiplying by 100.
Results
One hundred ninety-one patients were included in the study (83 females and 108 males), with a mean age of 50 years and a total of 183,183 catheter days. The majority of the intravascular access lines were placed at the right subclavian vein site (117 patients, 61%). This site was followed in frequency by the left subclavian vein (21%), the right internal jugular vein (10%) and the left femoral vein (3%), with the remaining 5% in either the left internal jugular vein or the right femoral vein.
The primary admission diagnoses included respiratory failure (37%), neurologic diseases (23%) (e.g., multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy), spinal cord injury (21%) and anoxic brain injury (17%). Given the multiply medically complex nature of these patients, data were analyzed to assess the comorbidities found in the population studied. As shown in Table I, respiratory failure was the most frequent comorbidity followed by neurologic disease, renal calculi and/or kidney or bladder infection, neurogenic bladder and pressure ulcer. A very large proportion of the subjects had multiple comorbidities; greater than 90% had two or more while greater than 81% had three or more.
Incidence of Comorbidities
The incidence, that is, number of subjects and percent of total study population experiencing specific complications, and the rate of complications per 1,000 catheter days were reviewed. Fifteen patients (8%) had an episode of CLABSI with a rate of 0.087 per 1,000 catheter days (Tab. II).
Incidence and Rate of Central Line-Associated Bloodstream Infections (Clabsi)
CI, confidence interval.
Discussion
In general, the infection rate of implantable central venous access devices is considered to be comparatively high. Indeed, in the National Healthcare Safety Network (NHSN) Report for 2010, the mean CLABSI rates for various categories of ICUs ranged from 0.6 to 3.5 per 1,000 catheter days (13). Since LTACs focus on medically complex patients with multiple comorbidities and often have high rates of antibiotic and device use, LTACs have been called the “perfect storm” for infections (12, 14). The results of the current LTAC study found a much lower rate of CLABSI complications than has been reported by others.
There are four reports that are most relevant to the LTAC subject population in this study. Wolfenden et al (15) evaluated the rate of CLABSI in a 93-subject cohort admitted with respiratory failure to two LTACs. They reported 33 sepsis events in the 93 patients with a rate of 16.44 per 1,000 catheter days. Two other published studies of CLABSIs in LTACs also report rates of infections that are much higher than those found in the study reported herein, ranging from 1.79 to 9.5 infections per 1,000 catheter days (16, 17). These rates are approximately 20- to over 100-fold higher than those found in the current study in which 8% of the patient population experienced a CLABSI with a rate of 0.087 per 1,000 catheter days. In the Centers for Disease Control and Prevention (CDC) NHSN report for 2010, the mean CLABSI rate for LTACs (from a total of over 517,000 catheter days from both free-standing LTACs and those within general acute care hospitals) was 1.3 per 1,000 catheter days (13). This rate is over 14-fold higher than that found in our study comprising over 183,000 catheter days.
We believe that a number of factors contributed to HSC's low complication rate over the 13-year time period of this study. The first critical factor was having a single surgeon responsible for the Port-A-Cath™ implantation and using a reproducible placement technique, standardized to a single Intravenous Access Device (IVAD) lumen; each line placed had a specific postoperative plan of care. Prior to surgery, the surgeon saw the patient at HSC to review medical history, need for placement and to explain the procedure to the patient and/or family member. At that visit and as part of the clinical review, anatomical placement points were reviewed with the subclavian area as the usual first choice, if possible. The importance of this process is emphasized by Koolen et al (6) who concluded that the high complication rate in their population may have been related to the large number of different surgeons as well as to the level of experience of the surgeons (who were surgical residents) placing the line.
The second set of critical factors was derived from the team approach to patient care and management and maintenance of these subcutaneously implanted ports (averaging from 45 to 50 Port-A-Caths™ per month). A standardized prospective care plan was developed which included workup and documentation of need prior to line placement, routine postoperative care and complication identification and management. The dedicated team consisted of the general surgeon, the LTAC full-time onsite infectious disease physician and an APRN who worked closely with the patient's primary physician and nurse to consistently evaluate the need for a subcutaneous central line port, possible site locations for placement of the port, the actual placement of the port access as well as pre-operative, postoperative and long-term management of the access device and skin entry site area. The team troubleshot potential issues prior to placement and worked to quickly resolve any identified postoperative issues. To further enhance the nursing educational process, materials and anatomically correct education models were purchased for nursing education staff to use. From among the nursing staff on each clinical nursing unit, nurse experts were chosen and educated on the unit to provide peer review and support to the nursing team members to facilitate management and use of the Port-a-Cath™ system (18).
This concept of a team approach in management to minimize the number of complications with central line use is supported by CDC guidelines that have summarized the impact of team management of central line access (19). The efficacy of implementing the CDC guidelines was demonstrated by Pronovost et al who confirmed the findings in a more recent study. Both studies found that adherence to the guidelines resulted in a significant decrease in median and mean CLABSI incidence (20, 21). Wenzel and Edmond in their editorial review sited this study as a testament to the ability of a quality-based effort coupled with the strength of a team-based process to achieve remarkable outcomes toward the goal of patient safety (22). The fiscal importance of using the team approach in implementing the CDC recommendations to reduce the rate of catheter-associated infections is emphasized by the report that CMS will stop paying hospitals for development of conditions that have evidence-based prevention guidelines such as catheter-associated infections (11). This is due to the economic impact of preventable CLABSI on the healthcare system; implementation of the guidelines is considered to result in considerable cost savings.
Regular monthly surveillance on the use of subcutaneously implanted central line ports has continued even after the completion of the study. The rate of CLABSI since the completion of the study is 0.084 per 1,000 catheter days. In summary, the catheter-related sepsis rate at our facility using Port-a-Caths™ comprising a total of 254,571 catheter days over a span of now 18 years is 0.086 per 1,000 catheter days.
In our experience as an LTAC, the use of Port-A-Caths™ was successful with an extremely low rate of infectious complications over an 18-year time period. Sustained success at our LTAC was due to standardized catheter placement and a postoperative care plan implemented by a team approach to patient care and Port-A-Cath™ management. An action plan to establish a program for effective IVAD placement and oversight based upon our approach is summarized in Table III. The authors believe that through implementation of a similar action plan the low rates of infectious complications and how they were achieved can be extrapolated to different settings across the healthcare continuum.
How to Establish an Effective Ivad Placement and Oversight Program
