Assignment 8
tushardeep05
Economic_impact_of_an_intraventeam.pdf
ECONOMIC IMPACT OF AN INTRAVENOUS TEAM IN REDUCING CENTRAL
LINE ASSOCIATED BLOODSTREAM INFECTIONS
Vivek Agnihotri
Dissertation Committee:
Dr. Daria Napierkowski (Chairperson)
Dr. Alma Ratcliffe (Expert)
Dr. Karen Phillips (Reader)
Approved by the Committee on the
Degree of Doctor of Nursing Practice
February 21 st , 2014
Submitted in partial fulfillment of the requirements for the
Degree of Doctor of Nursing Practice
William Paterson University of New Jersey
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Vivek Agnihotri
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ACKNOWLEDGEMENTS
I wish to acknowledge the support from William Paterson University and Saint Clare’s Hospital.
I would also like to acknowledge the following individuals for their support and advice:
Dr. Daria Napierkowski, Professor, Department of Nursing
Dr. Karen Phillips, Professor, Department of Nursing
Dr. Alma Ratcliffe, Executive Vice President of Medical Affairs
Dr. Brenda Marshall, Coordinator, DNP program
Dr. Cheryl Beers Director of Clinical Operations & Budget
Mr. King Law, Data Analyst, Quality Management
Ms. Laura Anderson, Nurse Epidemiologist
Dr. Philip Chase, Professor, Department of English
Dedication
This dissertation is dedicated to my wife Ngawang and our children Natasha and Akash
for their support and encouragement through this doctoral journey. Their support and
encouragement made this a smooth journey. What a Journey this has been.
iv
ABSTRACT
Objective: To determine the cost effectiveness of utilizing a hospital based nursing intravenous
team to lower central line associated blood stream infections (CLABSI).
Research Method: The research was conducted using the following key words and various
combinations of the key terminology, namely: central venous catheters; central lines; central line
associated bloodstream infections; hospital acquired infections; cost benefit analysis of CLABSI;
economics of HAI; hospital acquired conditions; IV team; CLABSI interventions; CLABSI
prevention.
Background: Annually approximately 250, 000 CLABSIs occur in the U.S. (Maki, 2006). The
cost of treating CLABSI is between $26,000 and $75,000 in the adult medical/surgical ICU
(Pittet, 1994, Shannon, 2006., Hollenbeak, 2011). These infections are a significant financial
burden to the hospitals, and the cost of managing CLABSI includes diagnosis and treatment,
prolonged hospital stay, and denial of reimbursement from third party payers (The Joint
Commission, 2012).
Study Design/Methodology: This was a retrospective, non-experimental, comparative study.
Eight years of already archived aggregated data for CLABSI (4 years of Pre and 4 years of post
IV team) was compared for the rates of CLABSI infection, cost of CLABSI, and cost of IV team.
The cost of CLABSI was determined based on various current literature and was compared with
the IV team member salaries and benefits.
Results: With the introduction of an IV team, there were 34 fewer CLABSIs over the four year
period with a 79.1% decrease in CLABSI. The overall cost saving for the institution was
$435,002 (31.3%), with 34 fewer central line associated bloodstream infections with the start of
the IV team. There was a consistent and sustained decrease in the CLABSI rate with the IV team.
Conclusion: The IV team provided a cost effective reduction in CLABSI by providing consistent
and standardized care for maintaining central lines post insertion. Healthcare costs continue to
rise. The reduction of hospital acquired infections lowers the overall hospital length of stay and
reduces the cost associated in treating these infections and hospitals’ risk management and legal
costs. Fewer infections will mean improving hospitals’ standing in their communities. Starting an
IV team to lower CLABSI is an important quality improvement initiative in hospitals with a
higher CLABSI rate.
v
Table of Contents
Chapter
1. Introduction ………………………………………………………………….. 1
2. Literature Review …………………………………………………………… 8
3. Methods ……………………………………………………………………… 14
4. Results ………………………………………………………………………... 18
5. Discussion ……………………………………………………………………. 24
References …………………………………………………………………………… 32
Appendices ………………………………………………………………………….. 38
A: Table 1- Pre IV team 1998 …………………………………………. 39
B: Table 2 – Pre IV team 1999 ………………………………………… 40
C: Table 3 – Pre IV team 2000 …………………………………………. 41
D: Table 4 – Pre IV team 2001 …………………………………………. 42
E: Chart 1 – Pre IV team 1998-2001 …………………………………… 43
F: Table 5 – Post IV team 2005 …………………………………………. 44
G: Table 6 – Post IV team 2006 …………………………………………. 45
H: Table 7 – Post IV team 2007 ………………………………………… 46
I: Table 8 – Post IV team 2008 ………………………………………… 47
J: Chart 2 – Post IV team 2005 – 2008 …………………………………… 48
K: Table 9 – Cost of IV team 2005-2008 ……………………………….. 49
L: Chart 3 – Pre and Post IV team ……………………………………… 50
M: Graph 1 ……………………………………………………………… 51
N: Graph 2 ………………………………………………………………. 52
1
CHAPTER 1
Introduction / Background
Central line associated bloodstream infections (CLABSI) are deadly hospital acquired
infections with a reported mortality rate of 12-25%. One out of every 20 hospitalized patients
develops a hospital acquired condition (Centers for Disease Control [CDC], 2011). The financial
burden of CLABSI includes the cost incurred related to diagnosis, treatment, prolonged hospital
stays, and lack of third party reimbursement for the cost of treating CLABSI. Ever increasing
costs are of a great concern for everyone involved in healthcare delivery. CLABSI increases the
hospital length of stay by up to three weeks (Edgeworth, 2009; Rosenthal, 2003) and
significantly increases the financial burden to hospitals, costing hospitals $25,155 to $75,000
(DiGiovine, 1999; Dimick, 2001; Hollenbeak, 2011; Kilgore, 2008; Laupland, 2006; Shannon,
2006; Warren, 2006; Zack, 2008). From the historical perspective, Pittet (1994) was the first to
study the cost of central line related bloodstream infections in critically ill patients and has been
subsequently cited in most recent published studies.
Patients admitted to the hospital in today’s healthcare institutions are subject to many
invasive procedures, such as central venous catheter insertion for management of fluids,
medication administration, total parenteral nutrition and blood work. The central venous
catheters are an important access that helps promote critically ill patients to wellness, yet at the
same time puts the patients at risk of unintended consequences, mainly central line associated
bloodstream infections. In 2001, the Institute of Medicine (IOM) in its report “Crossing the
Quality Chasm” wants hospitals and other acute care settings to improve the safety of their
patients and create a culture of safety. This study will examine the cost benefit of using a
2
dedicated team of nurses, often referred to as an intravenous therapy team (IV team), to prevent
infection resulting from central lines.
Central venous catheters are a necessity in the care of many critically and chronically ill
patients (Raad, 2007). The most commonly used access sites for central venous catheters
insertion are the subclavian vein, internal jugular vein, and the femoral vein. There are different
types of central venous catheters. Based on their design, central venous catheters can be any of
following: a) non tunneled catheter, b) tunneled central venous catheters, c) implantable ports,
and d) peripherally inserted central catheters (PICCs) (Maki, 2006; Raad, 2007). The non-
tunneled catheters are inserted into the subclavian, internal jugular or femoral vein over a guide
wire and advanced until they rest in the superior vena cava. These catheters are used for central
venous pressure monitoring, administration of intravenous fluids, total parenteral nutrition and
vasoactive medications (Joint Commission, 2012). The PICCS are inserted into a vein in the arm,
either the basilic vein, brachial vein or cephalic vein. The PICC lines are being increasingly used
for short term as well as long-term intravenous therapy. PICC lines used for long-term therapy
can remain in place up to a year, and the CDC recommends that PICCs be used instead of the
short peripheral catheters when the duration of therapy is likely to exceed more than six days
(Joint Commission, 2012). O’Grady (2011) recommends the use of PICC lines when the duration
of intravenous therapy will likely exceed six days. Associated with these central lines, central
line associated bloodstream infections (CLABSI) became a serious complication (Zingg, 2008).
The central venous catheters that are inserted percutaneously are routinely used for short-term
access and are generally safe and inexpensive. The major disadvantages are the need for a
physician to insert the catheter, full barrier precautions, and need for an external dressing on the
site and line maintenance, which pose a greater risk for infection (Joint Commission, 2012).
3
These central venous catheters account for a majority of central line associated bloodstream
infections (O’Grady, 2011).
The risk factors for CLABSI include a patient’s age, especially neonates and the elderly.
Pre-existing underlying conditions -- especially hematological, immunologic deficiencies,
cardiovascular diseases, and gastrointestinal diseases (Molle, 2011) -- and male gender have
been identified as factors associated with increased risk (Zingg, 2009). Some of the other risk
factors include prolonged hospitalization prior to the central line insertion, prolonged use of the
central line, total parenteral therapy, multiple central venous catheters, and lack of sterile barrier
during insertion, femoral and jugular accesses (O’Grady, 2011; Safdar, 2004).
The insertion site acts as a portal of entry and is often an important source of colonization with
various microorganisms. These pathogens can then easily migrate from the site to the catheter
tip. Another potential source for the portal of entry is the colonization of the catheter hub or the
port whereby pathogens travel along the catheter lumen to the blood stream. This migration of
pathogens most often occurs due to manipulation of the intravenous system, the intravenous
fluids and the catheter port itself (Joint Commission, 2012).
A central line associated blood stream infection is a primary blood stream infection in the
presence of a central line at the time of or within 48 hours prior to the onset of infection with no
other source of infection evident other than the central line. There is no minimum period of time
that the central line must be in place in order for the blood stream infection to be considered
central line associated according to the National Health Safety Network. For a CLABSI, the
patient has to have a recognized pathogen cultured from one or more blood cultures, and the
organism cultured from the blood is not related to an infection at another site. The patient will
have at least one of the following signs or symptoms: fever (temperature greater than 38 degree
4
centigrade), chills, or hypotension; signs and symptoms and positive laboratory results are not
related to an infection at another site, and common commensal is cultured from two or more
blood cultures drawn on separate occasions (Joint Commission, 2012).
The CLABSI data are collected and voluntarily reported to the national database.
Surveillance by using standard definitions for CLABSI is an important first step in identifying
the magnitude of CLABSI in U.S. hospitals and helps monitor and compare CLABSI rates from
hospital to hospital, state to state and region to region. CLABSI surveillance involves systematic
collection of the data, analyzing the collected data, and interpreting and disseminating the data to
the leadership and other members of the health care facility.
It is important that outcome measures are performed using standard, universal and
consistent methodology over time. According to Nation Healthcare Safety Network protocol, the
CLABSI rate per 1000 central line days is calculated by dividing the number of CLABSIs by the
number of central line days and multiplying by 1000 (CDC, 2012). In this calculation the central
line days and not patient days are used because not all patients are at risk for CLABSIs, as only
patients with central lines are at risk for CLABSI. It is important to have standardized definitions
as all hospital in United States are required to report their CLABSI rates to the Centers for
Medicare and Medicaid Services (CMS) via the National Healthcare Safety Network beginning
in 2011. This data was used for reimbursement from CMS to US hospitals starting in 2013 (Joint
Commission, 2012).
Scope of the Problem
Healthcare associated infections affect 5% of patients hospitalized in the United States
each year. Central line associated blood stream infections (CLABSIs) are important and deadly
hospital acquired infections, with a reported mortality rate of 12%–25% (CDC, 2012). The
5
United States Department of Health and Human Services Centers for Medicare and Medicaid
Services (2009) reports 75% of hospital acquired infections in the United States are due to four
types of infections: urinary tract infection (UTI), surgical site infection (SSI), bloodstream
infection (BSI) and pneumonia. These hospital acquired infections increase morbidity and
mortality and the cost of health care (Burke, 2003). Laupland (2006) reported that ICU patients
are at increased risk for in-hospital death. The financial burden of CLABSI includes costs related
to diagnosis, treatment, prolonged hospital stays, and lack of third party reimbursement for the
cost of treating CLABSI. CLABSI increases the hospital length of stay by up to three weeks
(Edgeworth, 2009; Rosenthal, 2003; Pittet, 1994) and increases the financial burden to hospitals,
costing hospitals $25,155 to $75,000 (DiGiovine, 1999; Dimick, 2001; Hollenbeak, 2011;
Kilgore, 2008; Laupland, 2006; Pittet, 1994; Shannon, 2006; Warren, 2006; Zack, 2008).
There has been a decrease in CLABSIs in recent years, showing some success of
implementing CLABSI bundles. A CLABSI bundle is one of the important strategies in
preventing CLABSI wherein the interventions are grouped together based on evidence based
practices. According to the Institute for Healthcare Improvement (IHI, 2006), a central line
bundle consists of five key components: hand hygiene, maximum sterile barrier precautions
(which include use of cap, mask, sterile gown, gloves and full sterile body drape for insertion),
chlorhexidine skin antisepsis, optimal catheter insertion site selection and daily review of line
necessity with prompt removal of unnecessary lines. Despite implementing bundles, CLABSIs
persist as an important patient safety issue. Bundles provide a false sense of security of
decreasing CLABSI rates (Harnage, 2008).
Under the new guidelines from the Centers for Medicare and Medicaid Services (CMS),
there will be decreased or no reimbursement from CMS and/or third party payers (Joint
6
Commission, 2012) for central line associated bloodstream infections. Therefore, there is an
urgent need for zero tolerance for central line associated blood stream infections (Marra, 2010;
Zack, 2008). Central line associated bloodstream infections are not just a nursing issue, but a
problem associated with a care delivery process which will require a multidisciplinary
intervention.
These data support expenditure on intravenous therapy teams and infection prevention
and control programs (Brunelle, 2003; Harnage, 2008; Holzman, 2012; Royer, 2010). An
intravenous therapy team is an investment rather than an expense. A business case can be made
for implementing intravenous therapy teams to provide safe and cost effective care and achieve
zero central line associated blood stream infections (Yokoe, 2008).
Intended improvement or change
At a suburban community hospital in northern New Jersey, an intravenous therapy team
of dedicated nurses was implemented to provide central line maintenance to
decrease the central line associated blood stream infections. There is limited data on the
use of an IV team. The issue with the use of an IV team to prevent CLABSIs is unresolved
(Marschall, 2008; Pronovost, 2006). The study will look at the financial benefit of achieving a
reduction in or elimination of central line associated infection with the implementation of IV
team. This study will provide administrators, healthcare executives and practitioners in acute
care settings evidence that will help decrease central line associated blood stream infections and
improve patient safety and quality of care as well as promote a cost savings.
Study question – PICOT / hypothesis
Hospitalized patients are at increased risk of developing healthcare associated infections.
Patients with central venous catheters or a central line are susceptible to central line associated
7
bloodstream infection with 12-25% mortality (Joint Commission 2012). The purpose of this
project is to determine the financial implication of achieving zero central line associated blood
stream infections with implementation of an IV team. What is the cost benefit ratio of an IV team
that achieves zero central line associated blood stream infections?
The Null Hypothesis is that there is no financial benefit for a designated IV team relative
to central line associated blood stream infection rate.
Research question
Is an IV team cost effective in lowering CLABSI rates? The study will look at the cost of
central line associated blood stream infections over the eight-year period pre IV team and post
IV team. The data will also be collected on salaries and benefits of the IV team personnel over
four years.
8
CHAPTER 2
LITERATURE REVIEW
Electronic databases such as CINAHL, Cochrane library, Google Scholar, Medline, and
Up to Date were used to identify reports, publications and research related to the hospital costs
where central line associated bloodstream infections occur. In this review, literature search
technique, studies related to the cost of CLABSI and the impact of an IV team in reducing
hospitals’ cost will be presented.
Search Methods
For this chapter an extensive review was undertaken. The search was conducted using the
following Key words and various combinations of the key terminology, namely: central venous
catheters; central lines; central line associated bloodstream infections; hospital acquired
infections; cost benefit analysis of CLABSI; economics of HAI; hospital acquired conditions; IV
team; CLABSI interventions; CLABSI prevention;
Review
Hospital acquired infections affect hundreds of millions of patients annually worldwide
(World Health Organization, 2010). Healthcare associated infections affect 5% of hospitalized
individuals in the United States. Of these, over 80,000 are bloodstream infections (BSI) related
to the use of central venous catheters or the central lines (CDC, 2002) with the projected
CLABSI rate of 9.2 per 1000 device days according to the International Consortium on
Nosocomial Infection Control (Rosenthal, 2008). There are estimated to be 28,000 deaths per
year associated with these bloodstream infections (O’Grady, 2002), and the CDC (2012) reports
a 12-25% mortality in individuals with central line associated blood stream infections.
9
According to Centers for Medicare and Medicaid Services (2009), billions of dollars in
healthcare cost and many deaths are related to hospital-acquired conditions. The Hospital
Consumer Assessments of Healthcare Providers and Systems, commonly referred to as HCAPS,
is administered to hospital inpatients as a part of a patient satisfaction survey after discharge
from all hospitals. The survey reflects the care received during the hospital stay. According to
CMS, hospitals will no longer be reimbursed for additional cost to care for hospital-acquired
conditions (CMS, 2009). This new cut and reduction in reimbursement will have serious
consequences to the financial health of healthcare facilities. Use of central lines results in 80,000
CLABSIs per year, with $34,000 to $85,137 in additional healthcare cost (CDC, 2002;
Darouiche, 2001; DiGiovine, 1999; Hollenbeak, 2011; Laupland, 2006; Pittet, 1994; Shannon,
2006).
Hollenbeak (2011) reviewed seven published studies that reported on the cost of central
line associated bloodstream infections. The studies reviewed looked at the attributable cost that
directly relates to the infection. The attributable cost is calculated from the increased length of
stay and treatment. The Hollenbeak study looked at different populations and different study
designs and used different statistical methods. Hollenbeak (2011) found that the costs were
remarkably similar among the studies despite the different study populations and designs.
However, the surgical ICU patient costs were generally higher than the medical ICU, ranging
from $54,000 - $75,000.
Shannon (2006) looked at net operating margin for the patients whose care was
complicated with CLABSI, and compared the revenue expense and net operating margins of
patients with and without CLABSI. The authors compared costs before and after the patients
were diagnosed with CLABSI. The authors found that the actual cost due to CLABSI averaged
10
$40,179 (43.8%) of the total cost of hospitalization when compared to cases matched for age,
severity group and principle DRG but not complicated with CLABSI. In 54 patients that they
looked at whose care was complicated with CLABSI, the average payment for a case
complicated with CLABSI was $64,894, and the average expense was $91,733. The hospital
experienced on average a loss of $26,885 per patient. This negative impact of loss of revenue
was due to the treatment of CLABSI.
Kilgore and Brosette (2008) conducted a study from 2001-2006 involving 55 hospitals
participating in Cardinal Health/MEd mined in Birmingham, Alabama. They obtained the cost of
matching laboratory data with hospital accounting systems. In this study, the authors looked at
1,355,647 admissions in 55 participating hospitals. Of these, 12,578 (21%) were identified as
bloodstream infections that showed an associated attributable cost of $19,643. The significance
of this study was that they had a large sample size with 55 participating hospitals that provided
greater accuracy. The hospitals participating were not a representative sample for the country.
This study supports that the bloodstream infections involve additional cost for the care.
Therefore, preventing bloodstream infections will help boost the economic health for the
hospitals and healthcare facilities.
Warren (2006) conducted a prospective study at a nonteaching hospital in a medical and
surgical intensive care unit from January 19, 1998 to July 31, 2000 for occurrence of CLABSIs.
The objective of the study was to determine the attributable cost and length of stay of ICU from
CLABSI. They collected the data on the hospital costs from the accounting database. During this
study period there were 41 CLABSIs of the 1,132 patients, with the CLABSI rate of 3.6 per 1000
catheter days. Patients with CLABSI had a total hospital cost of $83,544 versus 23,803 with p <
0.001. Controlling for other factors, the attributable cost of CLABSI was $11,871.
11
Dimick (2001) in their prospective cohort study looked at increased resource use associated with
CLABSI in the surgical ICU. The authors estimate increases in total hospital cost, ICU cost,
hospital days, and ICU days attributable to CLABSI. The CLABSI rate was 3.6 per 1000 catheter
days, with an increase of $56,617 in total hospital cost and an increase of $71,443 in ICU cost, a
22 day increase hospital length of stay and 20 day increase in ICU stay. Based on this they
conclude, “For critically ill surgical patients, catheter related bloodstream infection is associated
with increased use of resources.”
The attributable cost of CLABSIs varies according to Stone (2002). In their systematic
review, they attribute CLABSI cost to be $9,969. Anderson (2007) differs in their estimates of
attributable cost. They gave a higher weight to estimates from the larger studies with an
estimated CLABSI cost of $25,072. Hu (2004) developed a range of estimates for CLABSI cost
of as low as $5,734 and as high as $22,939 based on the 2003-dollar figure.
Miller believes the recent decrease in CLABSI cases to be attributed to the
implementation of CLABSI bundles (Miller, 2012; Provonost, 2006). CLABSIs are a
preventable hospital acquired condition. Implementation of bundles and apart from the use of
antibiotic coated catheters, multimodal strategies to decrease central line associated bloodstream
infections is a successful strategy (Torres, 2007). There is limited data on the use of an
intravenous therapy (IV team) to decrease blood stream infections. The issue with the use of an
IV team to prevent CLABSI is unresolved (Marschall, 2008; Provonost, 2006).
Meier (1998) examined the benefits of a professional, dedicated intravenous therapy team
by comparing the trends in nosocomial bloodstream infections before and after such a team was
established. The study was done at a veterans’ administration medical center, a 198 bed federal
hospital that provided care for 6,300 veterans each year. In March 1992, a specialized IV team
12
was initiated with 11 registered nurses on the team and started to place peripheral IVs,
maintained IV catheters and replaced catheters regularly every 72 hours. In addition, the IV team
nurses also inserted PICC lines, performed central line dressing changes and provided staff
education on IV therapy. After the implementation of the IV team, the infection rate decreased
by 35% to 0.7 infections per 1000 patient days. Even though they had a decrease in infections,
the IV team was not cost effective. The excess cost of the IV team was $252,000 per year. The
limitations were that the use of the IV team was not randomly assigned, and was not adjusted to
severity of illness, which could have influenced the results. If the researcher used the cost figures
as Pettit (1994) reported in their study, the IV team would have resulted in a net cost saving for
the institution. If they had fewer RNs on their IV team, personnel cost would go down with
improved economic benefit.
Holzmann (2012) came to a similar conclusion in their study of a line maintenance team
with reduction of CLABSI in a neonatal intensive care unit. In their study design, Holzmann
used National Healthcare Safety Network definitions. CLABSI rates were determined before and
after implementation of the line team. The data analysis was performed by two-portion t test. The
pre-intervention overall CLABSI rate was 11.6 per 1000 line days as compared to 4.0 per 1000
line days after intervention. Overall CLABSI decreased by 65% after the implementation of the
line team. This decreased infection rate was sustained over time. The dedicated team of nurses,
often referred to as an IV team or line maintenance, provided consistent care day in and day out
without compromising infection control practices, which led to a consistent and sustained
decrease in CLABSI (Holzman, 2012).
Brunelle (2003) in her prevalence research study on the impact of a dedicated infusion
therapy team on the reduction of catheter related nosocomial infection reported a decrease in
13
central line associated blood stream infection by instituting an IV team for maintenance of
central venous catheters, including dressing changes, assisting with infusion therapy and
educating the staff.
Other studies (Harnage, 2008; Royer, 2010) using an IV team/line maintenance
team/vascular access team have demonstrated a decrease in CLABSIs. Reduction in CLABSI
alone, which is one of the top 20 priorities for national action (Institute of Medicine, 2003),
justifies institution of these teams to manage all vascular access needs and IV therapy.
14
CHAPTER 3
METHODS
Research Design
A retrospective, non-experimental comparative study will be conducted in which
aggregated data using a quantitative evaluation of the number of CLABSIs will be collected from
the epidemiology department. The cost of CLABSI pre and post IV team will be determined
using available financial data from the finance department and the literature. The IV team
nurses’ salaries and benefits will be obtained from the nursing administration and human
resources.
Setting
The setting for this study is a 250-bed non-teaching community hospital located in
Denville, a suburban town of Morris County in northwest New Jersey. This hospital has one 22
bed medical surgical ICU, a 42 bed progressive care unit, a 42 bed acute care for the elderly
(medical floor), and a 40 bed surgical unit.
Sample
Aggregated data on number of CLABSI will be collected from the epidemiology
department.
Cost of CLABSI will be determined using the available literature
IV team salaries and benefits will be obtained from the Nursing Administration.
15
Data Collection
Definition
A central line associated blood stream infection is a primary blood stream infection in
the presence of a central line at the time of or within 48 hours prior to the onset of infection with
no other source of infection evident other than the central line. There is no minimum period of
time that the central line must be in place in order for the blood stream infection to be considered
central line associated. An infection must meet one of the following criteria:
Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures
and organism cultured from blood is not related to an infection at another site.
Criterion 2: Patient has at least one of the following signs or symptoms: fever
(temperature > than 38 degree centigrade), chills, or hypotension, and signs and symptoms and
positive laboratory results are not related to an infection at another site and common commensal
is cultured from two or more blood cultures drawn on separate occasions (Garner,1998).
When a patient developed a fever greater than 38.3 degree centigrade or suspected
bacteremia, and/or sepsis, blood samples were routinely obtained for cultures and other tests to
establish bacteremia and infection. The date of the first reported positive blood culture was
considered the date of CLABSI. CLABSI was considered nosocomial when the culture was first
reported positive, 48 hours after the hospitalization (Garner, 1998). An index case was defined as
a hospitalized patient with a central line and nosocomial bloodstream infection 48 hours after
hospitalization.
Case finding
The department of epidemiology did a prospective case finding surveillance. The Nurse
Epidemiologist from the department of Epidemiology performed a surveillance of positive blood
16
culture results from the microbiology laboratory. The nurse epidemiologist then reviewed the
patient’s chart to determine the clinical significance of the positive blood cultures to ascertain
whether the positive blood cultures were nosocomial or community acquired and the origin of
the infection and identified index cases of CLABSI. The retrospective aggregated data was
searched for all the hospitalized patients with confirmed nosocomial CLABSI.
It is important that outcome measures are performed using standard, universal and
consistent methodology over time. According to Nation Healthcare Safety Network protocol, the
CLABSI rate per 1,000 central line days is calculated by dividing the number of CLABSIs by the
number of central line days and multiplying by 1,000 (CDC, 2012). In this calculation the central
line days and not patient days are used because not all patients are at risk for CLABSIs, as only
patients with central lines are at risk for CLABSI. It is important to have standardized definitions
as all hospitals in the United States are required to report their CLABSI rates to the Centers for
Medicare and Medicaid Services (CMS) via National the Healthcare Safety Network beginning
in 2011. This is the standard method that all healthcare facilities use to calculate the infection
rate and report to various regulatory agencies.
The data on the number of CLABSIs were aggregated from the previously collected data
from the Department of Epidemiology for the all the years in the study before and after the start
of the IV team. This data of number of infections were used as a numerator for calculating the
rate. Numerator is the number of times the event has occurred during the specific time interval.
For the denominator, the data on device days were used. There are three important aspects to the
denominator: a) the denominator must reflect the same population from which the numerator is
derived. In this study, this means all the patients with central line; b) a person in the denominator
17
should have been at risk for the event occurrence. Here it is all the patients with a central line; c)
the number in the numerator and denominator should come from the same time period.
The data on central line days, often referred to as device days, were prospectively collected by
the night supervisors daily after midnight as the number of patients with a central line before the
implementation of the IV team. The data on patient days was generated daily as the number of
hospitalized patients per day based on midnight census. The IV team collected the data on central
line days following implementation of the team.
The CLABSI rate was calculated with standard formula as per National Nosocomial
Infection Surveillance
Rate = number of CLABSI X 1000
Device days
The Cost of CLABSI was determined based on the data from the available literature and from the
literature review. The salaries and the benefit package for the IV team was obtained from the
nursing administration for four of the years in the study.
18
Chapter 4
Results
This chapter will present the results of the review of the archived data collected on
central line associated bloodstream infections (CLABSI), and the cost of treating these infections
during the period of 1998-2001. Archived data were collected and analyzed for comparison for
the years 2005-2008 because the IV team was in effect at this time period. After this time
additional variables -- use of chlorhexidine sponges for dressing changes and use of the CLABSI
bundle -- were instituted and would not be equivalent years to compare and analyze. This chapter
will review the cost of CLABSI and the yearly salaries and benefits of the IV team nursing staff.
These data will answer the research question of cost effectiveness of the IV team in reducing
central line associated bloodstream infections. The associated cost of any healthcare associated
infections varies from one healthcare facility to another, from one region to another region and
from one country to another country. The healthcare facility specific data are not available. The
cost of CLABSI is estimated based on the region, size and designation of the hospital as teaching
or non-teaching hospital, and this information is compiled by institutions and used in the
statistical reference to CLABSI (Dunagan, 2002; Hollenbeak, 2012; Joint Commision, 2012;
Stone, 2005). The differences in the various financial institutions and systems in different
regions with no consistency in the methodology used by different researchers would make it very
difficult to quantify the actual cost of CLABSI.
For this study the cost of CLABSI was determined from the literature review
(Hollenbeak, 2012). Hollenbeak (2012), which looked at various hospitals by regions, teaching
and non-teaching, and size of the hospital: small, medium or large. Based on their study, the
19
average excess cost of treating CLABSI in a medium sized non-teaching hospital in the
Northeast region was identified as $32,199. This study was completed at a medium sized 250
bed, non-teaching hospital in northwest New Jersey. The cost identified by Hollenbeak (2012)
was applied. There were no patients identified in this study because it is an aggregate of data that
is compiled by the institution and individual patient information cannot be categorized; therefore,
patient confidentiality was not compromised.
The nurse epidemiologists collect information related to actual infection data. The nurses
use the data collection tool from the National Healthcare Safety Network (NHSN) which is
modified to the hospital needs. No data regarding length of stay are required to be collected or
reported to NHSN and or Centers for Medicare and Medicaid Services (CMS). CLABSIs are
acute events that happen in hospitalized patients who have central venous catheters or central
lines. With CLABSI being an acute event, there is a readmission issue as all triple lumen central
lines are removed before discharge.
During the pre-IV team period, in the first quarter of 1998, there were two central line
associated bloodstream infections, zero infections in the second quarter and the third quarter, and
three in the last quarter for a total of five CLABSIs for the year of 1998. The total cost associated
with these five infections for the year was $160,995 at an average cost of $32,199 (see Table 1).
In 1999, in the first quarter there were four CLABSI infections, zero infections in the second and
the third quarter, and two in the last quarter for a total of six central line associated bloodstream
infections. With the mean cost of $32,199, the total cost of these infections was $193,194 (see
Table 2).
In the year 2000, in the first quarter there was one central line associated bloodstream
infection, two infections in the second quarter, three in the third quarter and two infections in the
20
last quarter for a total of eight central line associated bloodstream infections. The total cost for
these infections was $257,592 (see Table 3) at an average cost of $32,199. In the year 2001, the
first quarter had four central line associated blood stream infections. There were five infections
in the second quarter with six infections in the third quarter. The last quarter had nine infections
for a total of 24 central line associated bloodstream infections. The total cost for these infections
was $772,776 (see Table 4) at an average cost of $32,199. There were three times more
CLABSIs in the year 2001 than the previous year, and so 2001 accounted for 55.8% of the total
cost of CLABSIs in the four year period before the IV team.
During the pre-IV team period from 1998-2001, there were 43 documented central line
associated bloodstream infections. The total cost of CLABSIs pre-IV team was estimated to be
$1,388,457 as shown in Table 5.
In 1996, the institution merged with another community hospital, and following the
merger, the IV team was eliminated and the IV nurses were reassigned to other areas in the
hospital. The IV team was reinstituted in 2002. The IV nurses who were previously educated and
nationally certified as IV therapy nurses were reinstituted as the IV team. Following the
introduction of the IV team, the central line associated bloodstream infection data post IV team
was collected for the study periods of 2005-2008.
The IV team was the only variable difference at this time. In 2002, antibiotic coated
catheters were instituted for the insertion of central lines and the IV team was initiated to
maintain and to perform post insertion care for these central lines. In 2003 and 2004, due to lack
of support to utilized antibiotic coated catheters from general surgeons, they were discontinued
in the middle of 2004. The hospital reinstituted the use of the non-coated Arrow Guard catheters.
The dressing kits did not change during the study period. In 2009, the central line dressing kits
21
were changed to include chlorhexidine sponges to clean the catheter site. In 2010, the Institute of
Healthcare Initiative CLABSI bundle was initiated, and central line insertion kits were purchased
that were custom made for the hospital to include full barrier drape, sterile gown and gloves, and
a chlorhexidine sponge. These were the two other variables that were added later; hence the
years of 2009 to 2013 are not included in the study period.
The IV team was implemented in 2002. Other than the salaries and benefits of the two
RNs, there was no startup cost for the implementation of an IV team. The two nurses who
worked previously in the IV team were reassigned to the IV team, with an average salary and
benefits of $82,958. The nurses were previously educated and employed as IV therapy nurses
before the IV team was eliminated. Both nurses are nationally certified in infusion therapy. There
was no cost involved for education and training.
After starting the IV team, in the year 2005, there were zero CLABSIs in the first quarter
and one infection in each of the next three quarters for a total of three infections in 2005. At an
average cost of $32,199 per CLABSI, the total cost of these three infections was $96,597 (see
Table 5). The cost of the IV team for the year 2005 was $168,896 (see Table 9).
In the year 2006, the first, second and the third quarters had zero CLABSIs, while the two
infections were recorded for the last quarter for a total of 2 infections for the year 2006. The total
cost for these two infections was $64,398 at an average cost of $32,199 (see Table 6). The total
cost of the IV team for the year 2006 was $149,408 (see Table 9). The average cost of the IV
team was $74,704. The annual cost of the IV team for 2006 was lower than any of the four years
in the study. For 12 weeks, there was only one IV team nurse; hence the total cost was less than
the previous year.
22
For the year 2007, in the first quarter there were no infections, while the second, third and
the last quarter had one infection each respectively for a total of 3 CLABSIs. The total cost of
these three infections was $96,597 (see Table 7) at an average cost of $32,199. The cost of the
IV team for the year 2007 was $172,266 (see table 9) with average salary and benefit of $86,133.
For the year 2008, the first, second and the third quarters had zero infections while the fourth
quarter had one CLABSI for a total of one infection. The total cost for the one CLABSI infection
was $32,199 (see Table 8). The cost of the IV team for the year 2008 was $173,094 (see Table 9)
with an average cost of $86, 547. There were a total of nine CLABSIs during the time period
from 2005-2008. The cost associated with the nine CLABSIs was $289,791 (see chart 2) at an
average cost of $32,199. The cost of the IV team itself was $663,664 (see Table 9) with an
average yearly cost for two IV therapy nurses at $165,916. The number of infections decreased
by 79.1%, and the decrease in the cost associated with CLABSIs was 79.1% (see Chart3).
Cost Analysis:
The hospital IV team consisted of two full-time registered nurses as their staff. The nurses
in the IV team worked 40 hours a week with no overtime. The registered nurses were
experienced nurses who previously worked as IV nurses and were nationally certified in IV
therapy. The responsibilities of the IV team nurses included maintenance of the central line post
insertion. The post insertion care involved dressing changes, blood draws, and starting total
parenteral nutrition. The dressings were changed within 48 hours post insertion and weekly
thereafter. Other roles for the IV team included collection of data on central line days and
starting peripheral venous sites. Central line days, also commonly referred to as device days,
included all the patients with a central line on any given day. As an example, if there were 14
patients with central lines on a particular day, then the line days for that day are 14.
23
The first graph (appendix M) is a mixed line/bar graph for total cost and the number of
CLABSIs by years. Looking at the data, pre-IV team, the number of CLABSIs increased each
year, with 24 CLABSIs in 2001 alone, which was a threefold increase from the year 2000. Cost
was driven by the year 2001. The 24 CLABSIs in 2001 with the associated cost of $772,776 was
55.8% of the total cost of CLABSIs pre-IV team.
In the post-IV team years, the central line associated bloodstream infections decreased by
79.1% from 43 to 9 with the difference of 34 (see Chart 3). The cost of CLABSIs also decreased
by 79.1% from $1,388,457 to $289,791 with the difference of $1,098,660 (see Chart 3). The cost
of having two fulltime equivalent RN positions on the IV team, including their salaries and
benefits, was $663,664 over the four year period. The average cost of the IV team per year was
$165,916 for the two RNs. The overall cost saving for the institution was $435,002 (31.3%) with
34 fewer central line associated bloodstream infections (see Chart 3, Graph 1 and Graph 2).
24
Chapter 5
This chapter provides a discussion on the interpretation of the results of this project in
relation to the impact of an IV team on the clinical practice environment in providing fiscally
competent care. The purpose of this study was to evaluate the effectiveness of the IV team in
decreasing the central line associated bloodstream infections (CLABSI), thereby decreasing the
cost associated with the treatment of CLABSI. This chapter will address the Doctor of Nursing
Practice (DNP) essentials that are met by the study, implications, study limitations, future
research and conclusions of the study.
The research question was: “Is an IV team cost effective in decreasing central line
associated blood stream infections?”
Review of the project
This retrospective, non-experimental, comparative study assessed the financial
implications of a nursing IV team on reducing the number of central line associated bloodstream
infections in a suburban medical center. The data analysis was done using an evaluation of the
cost of central line associated bloodstream infections pre- and post-IV team implementation and
an evaluation of IV team salaries and benefits packages. Aggregated data on the number of
central line associated bloodstream infections and cost of central line associated bloodstream
infections pre-IV team between the years 1998-2001 were evaluated. The post-IV team data
between the years of 2005 and 2008 were analyzed for the number of central line associated
bloodstream infections and the cost of central line associated bloodstream infections and the cost
of IV team nurses, which included the salaries and benefits for the two nurses on the IV team.
25
Discussion
The results of this project demonstrated that the implementation of the IV team
effectively reduced yearly occurrence of central line associated bloodstream infections by 79.1
%. In 1998, there were 838 central line days, and this number fluctuated over the ten years of the
data collection. There were a total of 3558 central line days pre-IV team from 1998-2001, and
3772 days from 2005-2008 post-IV team. Despite the increased use of central lines in the post IV
team period, the number of central line infections decreased from 43 to 9. In 1998, a hospital was
reimbursed for hospital acquired infections and increased patient length of stay without any
penalties. In 2009, Centers for Medicare and Medicaid Services (CMS) indicated that if a patient
developed a hospital acquired infection, namely central line associated bloodstream infection,
there would be no reimbursement going forward (CMS, 2009). Hospital acquired infections
(HAI’s) affect one out of every twenty hospitalized patients (CDC, 2011), and central line
associated bloodstream infections are one of the hospital acquired infections that commonly
occur and are highly associated with increased morbidity and mortality (CDC, 2011). Beginning
in 2011, all hospitals in the United States are required to report their central line associated
bloodstream infection rates to the National Healthcare Safety Network. These data are being
used for reimbursement from Centers for Medicare and Medicaid Services to US hospitals
starting in 2013 (Joint Commission, 2012).
Based upon the results of the evaluation of the data collected in this study, the focus was
on the role of the IV team in reducing cost associated with central line associated bloodstream
infections. The results show that the dedicated team of nurses whose sole responsibility was to
maintain care for the central lines post insertion achieved a decrease in the central line associated
26
bloodstream infection rate there and decreased the cost for caring for patients with central line
associated bloodstream infections.
Post insertion maintenance care for central lines requires meticulous details. The care is
complex and needs a great deal of time and effort. Providing consistent care post insertion is the
key. The IV team nurses provided that consistency on a daily basis, which untrained registered
nurses could not provide due to multiple patient responsibilities. The success of the IV team in
reducing the central line associated bloodstream infection rate, and thereby cost, is multifactorial.
Many previous studies (Brunelle 2003; Holzmann 2012) have demonstrated the role of an IV
team in reducing bloodstream infections. Brunelle (2003) reported a decrease in central line
associated bloodstream infections by instituting an IV team for maintenance of central venous
catheters, including dressing changes, assisting with infusion therapy and educating the staff.
Holzman (2012) came to a similar conclusion with reduction of central line associated
bloodstream infections in a neonatal intensive care unit. Overall, the central line related
bloodstream infections decreased by 65%, and thus the cost associated with the infections also
decreased. They demonstrated a consistent and sustained decrease in central line associated
bloodstream infections. This study also is consistent with their findings. The reduction in the
central line associated bloodstream infection rate has been consistently maintained and is below
the national level throughout the post-IV team period and continues to be low.
DNP essentials:
In this practice focused doctoral education there is a scholarly approach and commitment
to the profession for its future, advancement and standing in the arena of today’s health care
delivery. The Doctor of Nursing Practice (DNP) curriculum as visualized by the American
Association of Colleges of Nursing (AACN) has two components, one of which is the eight
27
essentials that look at foundational outcome competencies that are necessary for the all graduates
of a Doctor of Nursing Practice program regardless of specialization or focus. This study met
five of the eight essentials established by AACN for DNP education. These five essentials were
1) Scientific underpinnings for practice, 2) Organizational and systems leadership for quality
improvement and systems thinking, 3) Clinical scholarship and analytical methods for evidence
based practice, 6) Inter-professional collaboration for improving patient and population health
outcomes, and 7) Clinical prevention and population health for improving the nation’s health
(AACN, 2006).
Essential 1: The nursing actions and processes through scientific underpinning for practice
affecting positive changes. The study found that the process change, a new practice approach by
instituting dedicated team of nurses (IV team) and nursing actions by an IV team had a positive
effect on the central line associated bloodstream infections.
Essential II: Organizational and systems leadership to improve patient and healthcare
outcomes. This study demonstrated that when a dedicated team of nurses provides care of central
lines, there is a decrease in central line associated bloodstream infections, leading to improved
patient and healthcare outcomes and patient safety.
Essential III: Clinical scholarship and analytical methods for evidence based practice. One of
the top twenty priorities for United States health is to prevent central line associated bloodstream
infections. This study has demonstrated that an IV team can decrease the central line associated
bloodstream infection rate and be cost effective. The data from the study will be presented to the
Research Evaluation Committee, Executive Leadership and the Board of Directors.
28
Essential VI: Interprofessional collaboration for improving patient and population health
outcomes. Today’s healthcare delivery is multimodal and complex. Hospitals depend upon
highly skilled and knowledgeable healthcare professionals to provide safe, efficient and patient-
centered care. This study demonstrated that highly skilled and knowledgeable IV team nurses
improved patient outcomes for the patient population with central lines.
Essential VII: Clinical prevention and population health for improving the nation’s health.
The clinical prevention activities are central to achieving the national goal of improving the
health status of the population of the country. Prevention of central line associated bloodstream
infections was identified as one of the top 20 national priorities in Institute of Medicine report
(2003). The implementation of an IV team was instrumental in decreasing central line infections
and thereby preventing deadly hospital acquired infections in a specific population at risk for
central line associated bloodstream infections (AACN, 2006).
Implications of the study
The purpose of this study was to look at cost effective ways of preventing central line
associated infections. Hospitalized patients who are critically ill are at a higher risk for
developing hospital acquired infections. The cost associated with central line associated
bloodstream infections includes those related to diagnosis and management, increased length of
stay and moving forward, and lack of third party payment for the cost of treating central line
associated blood stream infections. Quantifying the cost of central line associated bloodstream
infection is complex. The cost of central line associated bloodstream infections varies from
region to region and from different types and sizes of hospitals (Hollenbeak, 2012). It is
important to have a good and reliable surveillance to understand the costs associated with central
29
line associated bloodstream infection. There is increasing demand for infection prevention and
control programs that are cost effective. A business case for prevention of central line associated
bloodstream infection is made to the leadership of the organization who make economic
decisions. Most administrators and executive leadership at the highest level are involved in
containing the cost of healthcare and weigh the benefits of additional investments in infection
prevention. “It is easier to quantify the cost of intervention than their benefits or cost savings as a
result of hospital acquired infections avoided” (The Joint Commission, 2012 page 106).
It is advantageous for the hospital to lower the hospital acquired infections, including
central line associated bloodstream infections as they can be and are life threatening. Lowering
central line associated bloodstream infections might help in lowering the hospitals’ risk
management and legal costs (The Joint Commission, 2012). The Centers for Disease Control and
the Society for Healthcare Epidemiology of America in their practice recommendation for
prevention of central line associated bloodstream infections recommend implementation of a
central line insertion checklist, use of chlorhexidine, dressing changes and daily assessment of
the need for central line use and prompt removal of the central lines when not required. These
evidence based central line insertion and maintenance bundles have decreased central line
associated bloodstream infections, although central line associated bloodstream infections still
occur. Using these bundles and instituting IV teams to maintain lines post insertion will further
help lower central line associated bloodstream infections. The use of an IV team as demonstrated
in this study is cost effective in lowering central line associated bloodstream infections.
30
Limitations
There were limitations to this study. This study used a single, midsize, non-teaching
community hospital. This study was a retrospective study; the study used already existing
archived data that did not identify a patient’s admitting diagnosis. The study could not identify
other contributing factors that may have had an impact on central line associated bloodstream
infection rates, the associated cost as well as any mortality, co-morbid conditions and the impact
of the severity of illness. The data of this study cannot be generalized; in order to generalize the
findings, additional prospective multi-centric studies are needed.
Recommendation for Research in the future
In this retrospective study, the data collection was limited. A prospective multi-centric
study with a defined standardized role for an IV team would be beneficial where patient data
regarding admitting diagnosis, comorbidities and length of stay and actual cost and outcome data
would be collected.
Conclusion
Healthcare costs continue to rise, with nurses functioning as the first line of defense for
the identification of patients at risk for hospital acquired infections. This study of a two nurse IV
team in a 250 bed suburban hospital demonstrated the efficacy of this IV team to decrease central
line associated bloodstream infections in hospitalized patients with central lines. The reduction
of hospital acquired infections lowers the overall hospital length of stay and reduces the cost
associated in treating these infections and hospitals’ risk management and legal costs. Fewer
infections will mean happier patients and healthier families, thereby improving hospitals’
standing in their communities. Utilization of nurses in specific roles that are focused on reducing
31
healthcare associated infections while continuing to provide patient centered holistic and fiscally
competent care can benefit the patient and the healthcare facility. Evaluating each of the
outcomes of nursing interventions and comparing them to regional and national averages will
allow each facility to reach its highest level of patient care.
32
References
American Association of Colleges of Nursing (2006). The Essentials of Doctoral Education for
Advanced Nursing Practice. www.aacn.nche.org
Anderson, D.J., Kirkland, K.B., Kaye, K.S., Thacker, P.A., Kanafani, Z.A., & Sexton, D.J
(2007). Under resourced hospital infection control and prevention programs: Penny wise,
pound foolish? Infection Control and Hospital Epidemiology 28:767-773.
Brunelle, D. (2003). Impact of dedicated infusion therapy team on the reduction of catheter
related nosocomial infections. Journal Infusion Nursing, 26: 362-366.
Burke, J.P. (2003). Infection control: A problem of patient safety. New England Journal
Of Medicine, 348 (7) 651-66.
Centers for Disease Control and Prevention (2011) Vital signs: Central line associated
bloodstream infections- United States, 2001, 2008, 2009. MMWR 4; 60 (8):243-248.
Centers for Disease Control and Prevention (2012) Health care associated infections
(HAI). The Burden. Retrieved from www.cdc.gov/HAI/Burden
Centers for Disease Control (2002). Guidelines for the prevention of intravascular catheter
related infections. Morbidity and Mortality Weekly Report, 51(2) 11.
Centers for Medicare and Medicaid Services (2009a). Hospital Acquired conditions. Retrieved
from http://www.cms.hhs.gov/HospAcqCond/06
Centers for Medicare and Medicaid Services (2009b). HCAPS Hospital Survey. Retrieved from
http://www.hcapsonline.org
Darouiche, R (2001). Device associated infections: A macro problem that starts with
microadherence. Clinical Infectious Disease 33; 1567-1572.
33
DiGiovine, B., Chenoweth, C., Watts, C., & Higgins, M (1999). The attributable mortality and
cost of primary nosocomial bloodstream infections in the intensive care unit. American
Journal of Respiratory Critical Care Medicine 160, 976-981.
Dimick, J.B., Pelz, R.K., Consunji, R., Swoboda, S.M., Hendrix, C.W., & Lipsett, P.A (2001).
Increased resource use associated with catheter related bloodstream infection in the
surgical intensive care unit. Archives of Surgery 136:229-234.
Dunagan, W.C., Murphy, D.M., & Hollenbeak, C.S (2002). Making the business case for
infection control: pitfalls and opportunities. AJIC 30 (2): 86-92.
Edgeworth, J. (2009). Intravascular catheter infections. Journal of Hospital Infections.
73 (4) 323-330.
Garner, J., Jarvis, W., & Emori, T. (1988). CDC definitions for nosocomial infections. American
Journal of Infection Control 16: 128-140.
Harnage, S (2008). A PICC team ends CRBSIs. RN 71(5), 35-39
Hollenbeak, C.S. (2011) The Cost of Catheter-Related Bloodstream Infections: Implications for
the Value of Prevention. Journal of Infusion Nursing. 34(5), 309-313.
Hollenbeak, C.S., Grossbart, R.S., Guilloteau, R.F., & Denham, C.R (2012). A calculator to
estimate the cost of healthcare associated infections in various institutional settings.
Journal of Patient Safety, 8 (2):1-9
Holzmann, G., Kubanda, A., Davis, K., Khan, A.M., Brumley, K., & Denson, S.E (2012).
Utilizing a line maintenance team to reduce central line associated bloodstream infections
in a neonatal intensive care unit. Journal of Perinatology. 32:281-286
34
Hu, K.K., Veenstra, D.L., Lipsky, B.A., & Saint, S (2004). Use of maximal sterile barriers
during central venous catheter insertion: clinical and economic outcomes. Clin Infect Dis
39:1441-1445.
Institute of Healthcare Improvement (2006). Central line bundle. Retrieved from
http://www.ihi.org/IHI/topics
Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st
century Washington, DC: National Academy Press.
Institute of Medicine (2003). Priority area for national action: Transforming health care quality.
Washington, DC: National Academy Press.
Joint Commission (2012). Preventing central line – associated bloodstream infections: A global
challenge, a global perspective. Oak Brook, IL: Joint Commission Resources,
www.PreventingCLABSIs.pdf
Kilgore, M., & Brossette, S (2008). Cost of bloodstream infections. American Journal of
Infection Control, 36(10):s172 e1-3.
Laupland, K.B., Lee, H., Gregson, D.B., & Manns, B.J. (2006). Cost of intensive care unit
acquired blood stream infection. Journal of Hospital Infections, 63(2) 124- 132.
Maki, D.G., Kluger, D.M., & Crnich, C.J (2006). The risk of bloodstream infection in adults
With different intravascular devices: A systematic review of 200 published
prospective studies. Mayo Clinic Proceedings, 81(9), 1159-1171.
Marschall, J., Mermel, I.A., Classen, D., Arias, K.M., & Anderson, D.J. (2008). Strategies to
prevent central line associated blood stream infections in acute care hospitals. Infection
Control and Hospital Epidemiology, 29, 522-530
35
Marra, A.R., Rodrigues, R.G., Durao, M.S., Correa, L., Guastelli, L.R., Moura, F.D., &
Edmond, M.B. (2010). Impact of a program to prevent central line associated
bloodstream infection in the zero tolerance era. American Journal of Infection control.38,
434-439.
Meier, P.A., Frederickson, M., Catney, M., & Nettleman, M.D (1998). Impact of dedicated
intravenous therapy team on nosocomial bloodstream infection rates. American Journal
of Infection Control 26:388-92
Miller, S.E., & Maragakis, L.L (2012). Central line associated blood stream infection.
Current opinion. Infectious Disease 25(4): 412-422.
Molle, P., Jones, M., Stackelroth, J., Van Kuilenburg, R., & Joubert, W (2011). Catheter
associated bloodstream infection incidence and risk factors in adults with cancer. A
prospective study. Journal of Hospital Infection 78(1), 26-30.
O’Grady, N.P., Alexander, M., Dellinger, E.P., Gerberding, J.L., Heard, S.O., & Maki, D.G.
(2002). Guidelines for the prevention of intravascular catheter related infection.
Morbidity and Mortality Weekly Report 5; 1-29.
O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland J., Heard, S.O., Lipsett,
P.A., Masur, H., & Mermel, L.A (2011). Healthcare infection control practices advisory
committee (HICPAC). Guidelines for the prevention of intravascular catheter related
infections. Clinics in Infectious Diseases. 52 (9): 162-193.
Pittet, D., Tarara, D., & Wenzel, R. (1994) Nosocomial bloodstream infection in critically ill
patients. Journal of American Medical Association, 271(20):1598-1600
36
Provonost, P., Needham, D., Bernholtz, S., Sinopoli, D., Chu, H., & Cosgrove, S. (2006).
An intervention to decrease catheter related blood stream infection in the ICU. New
England Journal of Medicine 355(26): 2725-2732.
Radd, I., Hanna, H., & Maki, D. (2007). Intravascular catheter related infections.
Advances in diagnosis, prevention and management. Lancet 7(10): 645-657
Rosenthal, V.D., Guzman, S., Migone, O., & Crnich, C.J. (2003). The attributable cost, length of hospital
stay, and mortality of central line associated BSI in ICUs. A prospective, matched analysis.
American Journal of Infection Control. Dec 31 (8): 475-480.
Rosenthal, V.D., Maki, D.G., Mehta, A., Alvarez-Moreno, C., Higuera, F., & Pratesi, R.D.
(2008). International nosocomial infection control consortium report 2002-2007.
American Journal of Infection Control 36:627-637.
Royer, T (2010). Implementing a better bundle to achieve and sustain a zero central line
associated bloodstream infection rate. Journal of Infusion Nursing 33; 398-406.
Safdar, N., & Maki, D.G (2004). The pathogenesis of catheter related bloodstream infection with
non-cuffed short term central venous catheter. Intensive care Medicine 30(1): 62-67.
Shannon, R.P., Patel, B., Cummins, D., Shannon, A.H., Ganguli, G., & Lu, Y. (2006).
Economics of central line associated bloodstream infections. American Journal of
Medical Quality 21(6): Suppl: 7S-16S.
Stone, P.W., Larson, E., & Kawar, L.N (2002). A systematic audit of economic evidence linking
nosocomial infection control interventions: 1990-2000. American Journal of Infection
Control 30: 145-152.
Stone, P.W., Braccia, D., & Larson, E. (2005). Systematic review of economic analysis of health
care associated infections. AJIC 33 (9): 501-509.
37
Torres, A.J., & Harbarth, S (2007). Prevention of primary bacteremia. International Journal of
Antimicrobial Agents 30, S80-S87.
Warren, D.K., Quadir, W.W., Hollenbeak, C.S., Elward, A.M., Cox, M.J., & Fraser, V.J (2006).
Attributable cost of catheter associated bloodstream infections among intensive care
patients in a nonteaching hospital. Critical Care Medicine 34(8):2084-2089.
World Health Organization (2010). The burden of health care associated
infections worldwide. A summary. www.who.int/publications
Yokoe, D.S., & Classen, D (2008). Improving patient safety through infection control. A new
healthcare imperative. Infect Control and Hospital Epidemiology 29 Suppl 1:S3-11.
Zack, J (2008). Zeroing on zero tolerance for central line associated bacteremia.
American Journal of Infection Control. 36: s176e1-s176e2.
Zingg, W., Cartier-Fassler, V., & Walder, B (2008). CVC associated infections. Best
Practice and Research Clinical Anesthesiology 22(3): 407-421
Zingg, W., Imhof, A., Maggiorini, M., Stocker, R., & Keller, E. (2009). Impact of prevention
strategy targeting hand hygiene and catheter care on the incidence of catheter related
blood stream infection. Critical Care Medicine, 37(7): 2167-2173.
38
Appendices
39
Appendix A: Table 1 Pre IV team 1998
Year 1998 Number of CLABSI Cost of CLABSI in $
Quarter 1 2 64,398
Quarter 2 0 0
Quarter 3 0 0
Quarter 4 3 96,597
Total 5 162,995
________________________________________________________________________
40
Appendix B: Table 2 Pre IV team 1999
Year 1999 Number of CLABSI Cost of CLABSI in $
Quarter 1 4 128, 796
Quarter 2 0 0
Quarter 3 0 0
Quarter 4 2 64,398
Total 6 195,094
________________________________________________________________________
41
Appendix C: Table 3 Pre IV team 2000
Year 2000 Number of CLABSI Cost of CLABSI in $
Quarter 1 1 32,199
Quarter 2 2 64,398
Quarter 3 3 96,597
Quarter 4 2 64,398
Total 8 257,602
42
Appendix D: Table 4 Pre IV team 2001
Year 2001 Number of CLABSI Cost of CLABSI in $
Quarter 1 4 32,199
Quarter 2 5 162,995
Quarter 3 6 195,094
Quarter 4 9 289,791
Total 24 772,776
________________________________________________________________________
43
Appendix E: Chart 1 Pre IV team 1998 - 2001
Year Number of CLABSI Cost of CLABSI in $
________________________________________________________________________
1998 5 160,995
1999 6 193,194
2000 8 257,592
2001 24 772,796
Total 43 1,384,557
________________________________________________________________________
44
Appendix F: Table 5 Post IV team 2005
Year 20006 Number of CLABSI Cost of CLABSI in $
Quarter 1 0 0
Quarter 2 1 32,199
Quarter 3 1 32,199
Quarter 4 1 32,199
Total 3 96,597
________________________________________________________________________
45
Appendix G: Table 6 Post IV team 2006
Year 2006 Number of CLABSI Cost of CLABSI in $
Quarter 1 0 0
Quarter 2 0 0
Quarter 3 0 0
Quarter 4 2 64,398
Total 2 64,398
________________________________________________________________________
46
Appendix H: Table 7 Post IV team 2007
Year 2007 Number of CLABSI Cost of CLABSI in $
________________________________________________________________________
Quarter 1 0 0
Quarter 2 1 32,199
Quarter 3 1 32,199
Quarter 4 1 32,199
Total 3 95,597
________________________________________________________________________
47
Appendix I: Table 8 Post IV team 2008
Year 2008 Number of CLABSI Cost of CLABSI in $
Quarter 1 0 0
Quarter 2 0 0
Quarter 3 0 0
Quarter 4 1 32,199
Total 1 32,199
________________________________________________________________________
48
Appendix J: Chart 2 Post IV team 2005-2008
Year Number of CLABSI Cost of CLABSI in $
________________________________________________________________________
2005 3 96,597
2006 2 64,398
2007 3 96,597
2008 1 32,199
Total 9 287,791
________________________________________________________________________
49
Appendix K: Table 9 Cost of IV team 2005-2008
Year Cost of IV team
_______________________________________________
2005 $168,896
2006 $149,408
2007 $172,266
2008 $173,099
_____________________________________________
Total $663,664
______________________________________________
50
Appendix L: Chart 3: Pre and Post IV team
Pre IV team Post IV team Difference Percent
_____________________________________________________________________
# CLABSI 43 9 34 79.1
Cost of CLABSI 1,384,557 289,791 1,074,996 79.1
Cost of IV team NA 663,664 663,664 NA
Total Cost 1,384,557 953,455 431,102 31.1
51
Appendix M: Graph 1
$160,995 $193,194
$257,592
$772,776
$265,493 $213,806
$268,863 $205,293
5 6 8
24
3 2 3 1 $-
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
0
5
10
15
20
25
30
1998 1999 2000 2001 2005 2006 2007 2008
Pre - IV team Post IV Team
# B
S I
Pre - IV Team (1998 - 2001) & Post - IV Team (2005 - 2008)
Total Cost and Number of BSI By Years
Total Cost
# BSI
52
Appendix N: Graph 2
$1,384,557
$953,455 43
9
$- $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000
0
10
20
30
40
50
Pre - IV team (1998-2001)
Post IV Team (2005-2008)
# o
f B
S I
Pre - IV Team (1998 - 2001) & Post - IV Team (2005 - 2008)
Total Cost and Number of BSI
Total Cost
Total # of BSI
