Counting the cost: hospital versus home central venous catheter survival

Home intravenous therapy: Accessibility for Canadian children and youth

The administration of intravenous (IV) therapy at home is an alternative to hospitalization for treatment of infection and a number of other conditions, and has been demonstrated to be effective and safe, to reduce cost and to improve quality of life. While home IV therapy has many advantages for children, it is not uniformly available and access may be limited by age, geographical location and ability to pay. Physicians caring for children need to be aware of the indications for home IV therapy, its requirements and limitations, as well as whether this option is available for children in their care. Where access is limited, physicians should advocate for home IV therapy for children when it is medically indicated.

Options available for the infusion of lipid emulsion in home parenteral nutrition (HPN): a questionnaire survey for hospitals in Japan where HPN is practiced

OBJECTIVE

To understand the status of total parenteral nutritional (TPN) composition and the TPN line used for home parenteral nutrition (HPN) in Japan and to investigate how adequate nutritional support should be in HPN, we conducted a questionnaire survey.

METHODS

From February to March 2004, questionnaires were sent by mail to the members of the Japan Society for Home Therapy Research. With the content of the questionnaire, we surveyed 1) the types of medical staff who are involved in HPN, 2) the status of the preparation of TPN fluid and its place of preparation, 3) use of the TPN line and final filter, and 4) administration of lipid emulsion and All-in-One.

RESULTS

The major survey results from 66 respondents were that the 50% of the medical staff who are involved in HPN have more than 10 y of experience; however, the number of patients who used HPN and were treated by 78% of the medical staff was fewer than 50. With regard to TPN fluid, 50% was prepared in-house and 12% was prepared by home care service providers. In addition, 58% of institutions were infusing lipid emulsion from the side port of the TPN line or through a peripheral route because they used a final filter and closed system infusion line.

CONCLUSIONS

Because the final filter and closed system infusion line for HPN management is standard practice, lipid emulsion is not adequately used in Japan. Therefore, the All-in-One system including lipid emulsion is not used.

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Hospital in the home: constructions of the nursing role - a literature review

Acute medical and nursing treatment in the home is increasingly seen as an alternative to hospitalization. Models such as hospital in the home (HITH) or acute home care are said to provide a safe, comfortable environment for patients that is conducive to healing. A review of the literature reveals the embryonic nature of the research and discussion related to this alternative care delivery model. In general, the benefits of hospital in the home programmes are presented in an uncritical manner. Medical practitioners have embraced the move to home care as a means of expanding the use of advanced technologies and improved drug regimes beyond the hospital walls. The nursing response has been mechanistic and recipe-like while advancing the HITH nursing role as an opportunity for specialty practice by virtue of the increased autonomy and independence required. This review demonstrates the influence of a professional mandate for specialization, and the ideological and scientific interests that have influenced the role of the nurse.

A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000

BACKGROUND

Nosocomial infections (NIs) are a serious patient safety issue. Infection control personnel are responsible for implementing interventions to reduce this risk. The purpose of this systematic review was to audit the published economic evidence of the attributable cost of NIs and interventions conducted by infection control professionals and to evaluate the methods used. Economic evaluation methodology and recommendations for standardization are reviewed.

METHODS

A search of MEDLINE and HealthSTAR with medical subject headings or text words "nosocomial infections," "infection control," or "hospital acquired infections" cross-referenced with "costs," "cost analysis," "economics," or "cost-effectiveness analysis" was conducted. Published review articles were also searched. Inclusion criteria included articles published between 1990 and 2000 that contained an abstract and original cost estimate and were written in English. Results were standardized into a common currency.

RESULTS

Fifty-five studies were eligible. Approximately one quarter examined NIs in intensive care patients (n = 13). Most studies were conducted from the hospital perspective (n = 48). The costs attributable to bloodstream (mean = $38,703) and methicillin-resistant Staphylococcus aureus infections (mean = $35,367) were the largest.

CONCLUSIONS

Increased standardization and rigor are needed. Clinicians should partner with economists and policy analysts to expand and improve the economic evidence available to reduce hospital complications such as NI and other adverse patient/staff outcomes.

Catheter-related infection in patients on home parenteral nutrition: results of a prospective survey

BACKGROUND & AIMS

Central venous catheter (CVC) infection is the most frequent complication during home parenteral nutrition (HPN). We prospectively assessed incidence and catheter-related sepsis (CRS)-associated factors in the 42 adult patients enrolled in our HPN centre since its opening.

METHODS

Age, frequency of infusions, CVC type, autonomy or nurse/family aid, underlying disease, involved infectious organism(s), hospital stay, efficacy of antibiotic-lock and other infectious complications, were studied.

RESULTS

CRS occurred 39 times (3/1000 days of HPN). In 37/39 cases, it was proven by both peripheral and central blood cultures. In 56% of patients, clinical signs were discrete, delaying diagnosis. Individual factors like learning potency, underlying disease (especially chronic intestinal obstruction with bacterial overgrowth), and length of remaining colon and small intestine, were slightly associated with higher CRS incidence. Usually, one organism (S. epidermidis; 51%) was detected. A total of 14 CVC were immediately removed. In the others, antibiotic-lock was more effective in patients having tunnelled catheters (TC, 50%) than implanted devices (25%; P<0.05). Mean hospital stay was 22+/-15 days, which was influenced by 3 patients presenting associated osteomyelitis.

CONCLUSIONS

CRS incidence was 3/1000 days of HPN. Clinical symptoms were often discrete, suggesting importance of rigorous survey. Individual apprenticeship and risk for higher bacterial translocation seem associated to higher CRS incidence. CVC sterilization was more frequent in patients with TC.

Central venous catheter-related infections in children on long-term home parenteral nutrition: incidence and risk factors

BACKGROUND AND AIMS

This study aimed to assess the incidence and etiology of central venous catheter (CVC) infections in children on home parenteral nutrition (HPN).

METHODS

207 CVC-years were studied retrospectively in 47 children on HPN, aged 8.1+/-5.0 years.

RESULTS

125 CVC were used (means: 2.6 CVC/patient and 21 months utilization/CVC). Half of the hospitalizations (162) were due to proven CVC-related infections. The mean infection incidence was 2. 1/1000 HPN days. The total population divided in two groups below and above this value: group one including 24 children, incidence < or = 2.1 per 1000 days (mean: 0.83) and group two including 23 children, incidence >2.1 per 1000 days (mean: 4.3). No differences were found between the two groups in terms of underlying disease, presence of ostomies, age at the time of HPN onset, or micro-organisms responsible. The only differences (p<0.05) were the mean duration of HPN (longer in group one) and the delay between HPN onset and the first infection (longer in group one).

CONCLUSIONS

This study does not highlight any risk factors for CVC infection. However, early CVC infections after HPN onset appear to predict a bad prognosis.

Nutrition

The use of nutrition for the medical patient, in the inpatient setting and at home, will likely continue to increase in the future. Each patient should be evaluated in an individualized but systematic fashion. Each patient in whom malnourishment is suspected should undergo a thorough assessment for the presence and degree of malnutrition with an accurate calculation of nutritional requirements. It is important to choose the correct method of delivery of nutrition, to monitor and recognize any complications or problems that may arise, and to tailor the nutritional therapy to the unique diseases that are encountered in medicine. Although increasingly new advances and changes are occurring in the field of nutrition, nutritional support and therapy are best delivered and supplied to the patient with a network of health care workers, including the physician, the nurse, the dietitian, the social worker, and pharmacist.

Economic aspects of paediatric home parenteral nutrition

Children account for 15-20% of home parenteral nutrition programmes. Underlying irreversible intestinal diseases lead to potential indications for intestinal transplantation. Therefore, new controversial issues are timing for referring children for transplantation, and comparison between home parenteral nutrition and transplantation in terms of costs and quality of life.

Home enteral and parenteral nutrition in children

The prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world, in children as in adults. Home artificial nutrition, especially parenteral nutrition, is an expensive technology but is life-saving for many patients. The only possible alternative to home treatment is keeping patients in hospital, and cost-benefit studies have demonstrated that home nutrition is about 70% more cost-effective than hospital-based therapy. Although home nutrition is usually considered by children and families to lead to an improvement in their quality of life, the complications of these techniques, including psychological consequences, have to be carefully assessed and prevented.

Home artificial nutritional support in gastrointestinal disease

Recent studies in the area of home artificial nutrition have shown that the prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world. Other features of the past few years are the shift from non-malignant towards malignant indications and the increasing number of geriatric patients.