A retrospective, non-randomized analysis was completed on an average of 7385 patients/year receiving HPN from a single national specialty pharmaceutical provider from January 1, 2014 to December 31, 2017. The primary outcome measure was development of CRBSIs which is expressed as the number of CRBSIs per 1,000 catheter days of HPN use by patients in that year. PN use by patients in a given year. This data was compared year over year from 2014 through 2017. Data collected included demographic information, catheter type, number of catheter lumens and organisms responsible for the catheter infections when cultured.
As part of nutrition assessment, the Registered Dietitians completed a catheter history at the start of care, assessed compliance to catheter care as part of the ongoing nutrition assessment, and provided on-going education. The education provided reinforced catheter management techniques. On-going patient interactions with a nurse in the home, clinical support specialist or pharmacist provided additional opportunities for catheter assessment and/or potential to capture a catheter event. All confirmed catheter events were then documented in the pharmacy provider’s computer system.
Data was pulled from the pharmacy provider’s computer system using a specialized query tool. No individualized chart review was performed. Two or more reported catheter infections occurring in the same patient in a 12-month period were reported to a Clinical Manager or designee to determine alternative care strategies and recommended follow-up education on an as-needed basis based on catheter complication rates, unused supplies and demonstrated non-compliance.
All HPN patients who were not ordered an institution or clinician-specific catheter care protocol were provided with the CCB that consisted of 4 commercially available medical products which included:
1) 70% alcohol impregnated disinfection end cap
2) Foam disc impregnated with polyhexamethylene biguanide hydrochloride
3) Moisture barrier to help protect the intravenous dressing during showering.
4) Securement device for PICC.
All patients received standard CVC catheter maintenance care which included regular catheter flushing, regular timing for injection cap change out, appropriate use of catheter securement devices, appropriate use of extension sets, routine catheter dressing changes and safe catheter clamping techniques.
In conjunction with the CCB, an education program was initiated consisting of:
1. An internal education on the CCB to all home infusion nurses, pharmacists, dietitians and supporting nonclinical staff,
2. A letter outlining the CCB and its associated education program sent to the patients and their physicians
3. Specific patient education tools that addressed both catheter supply use and general guidelines for effective catheter care.
This education was provided in addition to the direct education provided to patients and caregiver(s) on how to effectively use the CCB. Patients were also provided with a laminated mat that was to be used as the location to prepare their prescribed PN. This mat contained instructions for maintaining aseptic technique and provided reminders about CVC maintenance strategies for avoiding CVC complications, including CRBSI. The mat could also be easily cleaned prior to use. Catheter locking of solutions for prevention of CRBSI was not a common practice and was not part of the intervention program.
Catheters were categorized as central catheters non-tunneled (CCNT), central catheters tunneled (CCT), peripherally-inserted catheters (PICC) and PORT. A catheter-related bloodstream infection was defined as when a patient exhibits the following symptoms: fever over 100.6F (38.1C) not attributable to other health issues; catheter exit-site redness, drainage or cord; and also has either blood/catheter culture or Gram stain confirmation of bacterial or fungal counts, or the prescriber determines that the catheter is the most likely source of infection, thus removing the catheter or treating the patient/catheter with anti-infectives. If the CRBSI symptoms develop less than 48 hours following hospital discharge, this would be considered a nosocomial infection, and not applicable to the home infusion setting. CRBSI symptoms developing 48 hours or more after central line insertion and care in the home infusion setting would be considered a nosohusial infection.(16) Patients admitted to the hospital for catheter infections were captured as part of the documentation process.
This was an observational study without patient randomization. Descriptive statistical reporting was performed on all collected data. Comparisons were made between independent variables using the Chi square (x)2. A p < .05 was considered statistically significant
All patient data was deidentified. CORAM/CVS internal clinical/ethics research committee reviewed the study and determined that it meets the criteria of 45 CFR 46101(b). Our research involved the “collection of existing data, documents, records” and “information is recorded by the investigator in such a manner that the subjects cannot be identified directly or through identifiers linked to the subjects”.