Bakke Christine K
Marshfield Clinic, Marshfield, WI, USA.
Nephrol Nurs J. 2010 Nov-Dec;37(6):601-15; quiz 616.
Sepsis is the second leading cause of death in patients with end stage renal disease (ESRD) on hemodialysis (HD). The average cost to the healthcare system for catheter-related infections (CRI) ranges from $4000 to $80,235 for each occurrence. CRI is a significant health problem leading to increased hospitalizations, morbidity, mortality, and a financial burden to the healthcare system. The purpose of this study was to evaluate the clinical and cost effectiveness of implementing published guidelines that pertain to patients on HD. Adult patients receiving long-term HD through a tunneled and cuffed HD catheter in an outpatient dialysis setting were studied. One-hundred and eighty-seven patients on HD were instituted on published guidelines (chlorhexidine to clean the exit site and HD catheters/hubs, hand washing, aseptic technique with site/dressing changes/placing patients on HD, setting up an infrastructure to support monitoring CRI) and prospectively followed from May 2009 to April 2010. Comparison was made to a retrospective cohort of 198 patients on HD from May 2008 to April 2009 in the same unit using standard care (sodium hypochlorite to clean the exit site; povidone iodine to clean the HD catheter hubs). A t-test analysis compared the two groups for differences. The number of infections decreased from 1.7 to 0.2 per 1000 catheter days during a 12-month period (p = 0.005). The number needed to prevent one adverse outcome of a CRI was 22 patients, with a relative risk of 0.11 and relative risk reduction of 89% in the treated group. The return on investment for implementing the program was 169% in one year, and the break-even point occurred within the first quarter. The projected annual savings in one dialysis unit was $141,606 using the project hospital's data and $179,010 using national data. CRI in patients on HD are preventable. The analysis revealed a significant reduction in CRI by implementing published guidelines with a significant cost savings to the healthcare system.
脓毒症是接受血液透析（HD）的终末期肾病（ESRD）患者的第二大死因。每次发生与导管相关的感染（CRI）给医疗系统带来的平均成本在4000美元至80235美元之间。CRI是一个严重的健康问题，会导致住院率、发病率、死亡率增加，并给医疗系统带来经济负担。本研究的目的是评估实施针对HD患者的已发表指南的临床效果和成本效益。研究对象为在门诊透析环境中通过带隧道涤纶套HD导管接受长期HD的成年患者。187例HD患者开始遵循已发表的指南（使用洗必泰清洁出口部位和HD导管/接头、洗手、在进行部位/敷料更换/让患者接受HD时采用无菌技术、建立支持CRI监测的基础设施），并于2009年5月至2010年4月进行前瞻性随访。将其与同一科室2008年5月至2009年4月采用标准护理（使用次氯酸钠清洁出口部位；使用聚维酮碘清洁HD导管接头）的198例HD患者的回顾性队列进行比较。采用t检验分析比较两组的差异。在12个月期间，每1000导管日的感染数从1.7降至0.2（p = 0.005）。预防一例CRI不良结局所需的患者数为22例，治疗组的相对风险为0.11，相对风险降低89%。实施该项目的投资回报率在一年内为169%，盈亏平衡点出现在第一季度。根据项目医院的数据，一个透析单元预计每年节省141606美元，根据全国数据则为179010美元。HD患者的CRI是可预防的。分析表明，实施已发表的指南可显著降低CRI，并为医疗系统节省大量成本。
