Articles
Changing concepts in long-term central venous access: Catheter selection and cost savings*

https://doi.org/10.1067/mic.2001.111536Get rights and content

Abstract

Background And Objectives: Long-term central venous access is becoming an increasingly important component of health care today. Long-term central venous access is important therapeutically for a multitude of reasons, including the administration of chemotherapy, antibiotics, and total parenteral nutrition. Central venous access can be established in a variety of ways varying from catheters inserted at the bedside to surgically placed ports. Furthermore, in an effort to control costs, many traditionally inpatient therapies have moved to an outpatient setting. This raises many questions regarding catheter selection. Which catheter will result in the best outcome at the least cost? It has become apparent in our hospital that traditionally placed surgical catheters (ie, Hickmans and central venous ports) may no longer be the only options. The objective of this study was to explore the various modalities for establishing central venous access comparing indications, costs, and complications to guide the clinician in choosing the appropriate catheter with the best outcome at the least cost. Methods: We evaluated our institution’s central venous catheter use during a 3-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several departments including surgery, radiology, nursing, anesthesia, pharmacy, and the hospital purchasing department. Results: During a 30-month period, 684 attempted central venous catheter insertions were identified, including 126 surgically placed central venous catheters, 264 peripherally inserted central catheters by the nursing service, and 294 radiologically inserted peripheral ports. Overall complications were rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally inserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral ports and $3532 to $4296 for surgically placed catheters. Conclusions: Traditional surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. Significant cost savings and fewer severe complications can be realized by preferential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologically placed versus surgically placed catheters. However, significant cost savings and fewer severe complications are associated with peripheral central venous access versus the surgical or radiologic approach. (AJIC Am J Infect Control 2001;29:32-40)

Section snippets

Methods

The setting for this study is Akron General Medical Center, which is a 511-bed hospital with 23,400 adult admissions per year, affiliated with Northeastern Ohio Universities College of Medicine. The medical records of patients requiring long-term venous access from 1995 through mid 1997 were evaluated, and patients were followed throughout this period. Complete registries were independently maintained by medical records for surgically placed lines, by the PICC team for all PICCs, and by the

Results

During a 30-month study period, 684 attempted long-term central venous catheter insertions were identified. There were 110 Hickman catheters, 11 subcutaneous ports, and 5 Groshong central catheters attempted. All but 1 Hickman catheter were successfully inserted. A total of 264 PICCs were attempted by the hospital PICC insertion team; 180 were successfully placed. Less than 10% of consults for PICC placement were not attempted as a result of apparently poor peripheral veins. There were 294

Discussion

Many factors need to be considered when selecting the appropriate modality for establishing venous access in a particular patient. Once the need for central venous access is established, a decision should be made regarding whether the need is short-term (generally <2-3 months) or long-term (generally >4 months). Catheter selection is primarily determined by physician preference, taking into account any input by the patient or other staff. Percutaneous subclavian central venous catheters are

Conclusion

Traditional, surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. When clinically feasible, use of PICCs instead of surgically or radiologically placed venous access devices results in fewer severe complications and a substantial cost savings.

Acknowledgements

We acknowledge Valerie Batten, RN, BSN, and Amy Gerber RN, OCN, for their substantial contributions in data collection, making this study possible.

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    *

    Reprint requests: Mark C. Horattas, MD, FACS, 400 Wabash Ave, Akron, OH 44307.

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