Cost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit

doi:10.1016/S0196-6553(97)90038-9

American Journal of Infection Control

Volume 25, Issue 2, April 1997, Pages 117-120

https://doi.org/10.1016/S0196-6553(97)90038-9 Get rights and content

Abstract

Background: The introduction of heated circuits and sealed, single-use humidifiers has prompted some investigators to question the traditional recommendations for changing vertilator circuits. We studied the clinical and cost impact of extending the circuit change interval from 72 hours to 7 days in our two intensive care units with 17 beds.

Methods: With standard surveillance definitions from the Centers for Disease Control and Prevention and the National Nosocomial Infections Surveillance System, baseline pneumonia rates were established for a 3-month period. After the institution of weekly circuit changes, daily surveillance of intubated patients was performed during 18 of 22 weeks from May through September 1993. Standard microbiologic methods were used for the identification of patient and environmental isolates.

Results: Ventilator-associated pneumonia for the 72-hour circuit change group was 9.1% or 1.29 per 100 ventilator days. After the institution of weekly changes, pneumonia occurred in 9 of 146 patients (6.2% or 0.74 per 100 ventilator days χ²= 0.33, p = 0.44). No common bacterial isolates were recovered as judged by phenotype, biochemical, or antimicrobial susceptibility patterns. Weekly changes reduced the number of circuits used from a predicted 469 to 214. Estimating $26.46 per circuit change, annualized cost savings were $20,246.90.

Conclusions: Weekly circuited changes in patients undergoing ventilation therapy in the intensive care unit are cost-effective and do not contribute to increased rates of nosocomial pneumonia.

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Cited by (28)

Effect of frequency of ventilator circuit changes (3 vs 7 days) on the rate of ventilator-associated pneumonia in PICU
2010, Journal of Critical Care
Citation Excerpt :
Our results demonstrated that the extension of the VC interval from a 3-day change to a 7-day change did not increase the occurrence rate of VAP and was associated with significant cost reduction. These findings were in agreement with several previous studies in adult patients and in only one trial in neonates [17,18]. Makhoul et al [16] reported that the rate of VAP was actually lower in the 72-hour VC change group compared with the 24-hour group (23.3 vs 37.7 per 1000 ventilator days, P < .05) in premature neonates.
Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality in pediatric intensive care unit (PICU). Our purpose was to evaluate the effects of ventilator circuit change on the rate of VAP in the PICU.
A prospective randomized controlled trial was conducted at a university hospital PICU. Children (younger than 18 years) who received mechanical ventilation from December 2006 to November 2007 were randomly assigned to receive ventilator circuit changes every 3 or 7 days.
Of 176 patients, 88 were assigned to receive ventilator circuit every 3 days and 88 patients had a change weekly. The rate of VAP was 13.9/1000 ventilator days for the 3-day circuit change (n = 12) vs 11.5/1000 ventilator days (n = 10) for the 7-day circuit change (odds ratio, 0.8; confidence interval, 0.3-1.9; P = .6). There was a trend toward decreased PICU stay and mortality rate in 7-day change group compared to 3-day change group but did not reach statistical significance. Furthermore, switching from a 3-day to a 7-day change policy could save costs up to US $22,000/y.
The 7-day ventilator circuit change did not contribute to increased rates of VAP in our PICU. Thus, it may be used as a guide to save workload and supply costs.
Infections Acquired in the Nursery: Epidemiology and Control
2006, Infectious Diseases of the Fetus and Newborn Infant
Infections Acquired in the Nursery: Epidemiology and Control
2005, Infectious Diseases of the Fetus and the Newborn Infant
Airway management for prevention of ventilator-associated pneumonia
2005, Medicina Intensiva
La neumonía asociada a la ventilación mecánica (NVM) sigue siendo una importante causa de morbilidad y mortalidad en los pacientes críticos a pesar del uso de medidas preventivas.
Esta revisión se centra en las medidas relacionadas con la vía aérea para la prevención de la NVM y se basa en una exposición de la literature más relevante, en el European Task Force de 2001 y en las recomendaciones de los Centers for Disease Control and Prevention (CDC) de 2003.
Las medidas de probada eficacia son: el uso de la intubación orotraqueal mejor que la nasotraqueal; mantener una presión óptima en el balón de neumotaponamiento del tubo endotraqueal; retirar el tubo endotraqueal lo antes posible, evitando retrasos innecesarios; evitar la reintubación cuando sea posible; no cambiar rutinariamente las tubuladuras, sólo cuando estén visiblemente contaminadas o malfuncionantes; esterilizar o desinfectar entre diferentes pacientes los equipos y dispositivos respiratorios reutilizables; no esterilizar o desinfectar rutinariamente la maquinaria interna del respirador y de la máquina de anestesia; lavado de manos y guantes cuando se realice el contacto con las secreciones y equipos respiratorios.
Las medidas de eficacia no probada son: el uso de un tubo endotraqueal con una luz para la aspiración continua de secreciones subglóticas; el uso de la ventilación mecánica no-invasiva para reducir la necesidad y la duración de la intubación endotraqueal; el uso de un intercambiador de calor y humedad o un humidificador de agua caliente; el uso de un sistema cerrado multiusos o de un sistema abierto de un solo uso para la aspiración de secreciones respiratorias.
Ventilator-associated pneumonia continues to be an important cause of morbidity and mortality in critical patients despite the use of preventive measures. This review deals mainly with measures relating to the airway in prevention of ventilator-associated pneumonia. It is based on an exhibition of the most pertinent literature, on the European Task Force of 2001 and on CDC recommendations of 2003.
Most proven effective measures are: use of orotracheal intubation rather than nasotracheal; maintenance of an optimal pressure in the pilot balloon of the endotracheal tube; avoiding unnecessary delay as assurance that the tube is removed as quickly as possible; avoiding reintubation whenever possible; replacing manifolds not routinely, but only when they are visibly contaminated or malfunctioning; sterilizing or disinfecting re-usable equipment and respiratory devices between patients; not routinely sterilizing or disinfecting the internal workings of the respiratorand anesthesia machine; washing hands and gloves when making contact with secretions and respiratory equipment. Measures of no proven effectiveness are: use of lighted endotracheal tubes for continuous subglottal suctioning of secretions; use of non-invasive mechanical ventilation to reduce the need for and duration of endotracheal intubation; use of heat moisture exchangers or hot water humidifiers; use of closed multi-use systems, or open single-use systems for aspiration of respiratory secretions.
A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000
2002, American Journal of Infection Control
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. (Am J Infect Control 2002;30:145-52.)
Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia: Potential economic implications
2001, Chest
Citation Excerpt :
Only literaturepublished since 1994 was used, as earlier articles may no longer beapplicable to present ICU practice. From these articles, we estimatedthe incidence of VAP as a function of the duration of, MV.111415161718192021222324252627282930313233343536373839 Rather than formally evaluate the quality ofeach of these studies, we relied on sensitivity analysis (see below) togauge the importance of uncertainty regarding these inputs.
To determine the cost-effectiveness ofcontinuous subglottic suctioning (CSS) as a strategy to decrease theincidence of ventilator-associated pneumonia (VAP).
Decision-model analysis of the cost and efficacy ofendotracheal tubes that allow CSS at preventing VAP. The primaryoutcome was cases of VAP averted. Model estimates were based on datafrom published prospective trials of CSS and other prospective studiesof the incidence of VAP. Setting andpatients: Hypothetical cohort of 100 patients requiringnonelective endotracheal intubation and management in an ICU.
In the model, patients were managed witheither traditional endotracheal tubes (ETs) or ETs capable of CSS.
The marginalcost-effectiveness of CSS was calculated as the savings resulting fromcases of VAP averted minus the additional costs of CSS-ETs, andexpressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on thecost-effectiveness was performed. The base case assumed that theincidence of VAP in patients requiring > 72 h of mechanicalventilation (MV) was 25%, that CSS-ETs had no impact on patientsrequiring MV for < 72 h, and that CSS-ETs resulted in a relative riskreduction of VAP of 30%. Despite the higher costs of ETs capable of, CSS, this tactic yielded a net savings of $4,992 per case of VAPprevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to beonly moderately sensitive to the calculated cost of VAP. With therelative risk reduction at 50% of the base-case estimate, CSS resultedin $1,924 saved per case of VAP prevented. When all variables wereskewed against CSS, total outlays were trivial (approximately $14 perpatient in the cohort).
CSS represents astrategy for the prevention of VAP that may result in savings. Furtherstudies are warranted to confirm the efficacy of, CSS.

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^☆: Presented in part of the 4th Meeting of the Society of Hospital Epidemiologists of America, New Orleans, La., March 20–22, 1994.

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Brief reportCost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit☆

Abstract

Chest

The potential role of inhalation therapy equipment in nosocomial pulmonary infection

J Clin Invest

An analysis of factors predisposing to gram negative bacillary necrotizing pneumonia

Am Rev Respir Dis

Contamination of mechanical ventilator with tubing changes every 24 or 48 hours

N Engl J Med

Brief report
Cost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit☆