- Email: [email protected]
Vascular catheter-related infection claims to health insurance company: often preventable
RESEARCH NOTE
INFECTIOUS DISEASES
Vascular catheter-related infection claims to health insurance company: often preventable
A. Gagneux-Brunon1, J. F. Timsit2,3, A. Lepape4 and P. Berthelot1 1) Infectious Diseases Department, University Hospital of Saint-Etienne, Saint-Etienne, 2) Medical Polyvalent Intensive Care Unit, University Hospital Albert Michallon, Grenoble 1 University, Grenoble, 3) IAME UMR1137-Team 5, Decision Sciences in Infectious Disease Prevention, Control and Care, Paris Diderot University- Inserm, Sorbonne Paris Cite and 4) Intensive Care Unit, University Hospital of Lyon, Lyon, France
Abstract Using the main French health insurance company database over a 10-year period, the preventability of catheter-related infections of patients who claimed compensation after prosecution was reviewed by a panel expert. They occurred in 71 patients with few co-morbidities or risk factors for nosocomial infection and were mainly related to the use of a peripheral vascular catheter (42 cases) and due to Staphylococcus aureus (51 cases). Forty-two infections were considered to be preventable. Infections due to peripheral venous catheters were significantly more often preventable than those due to central ones (p < 0.05). We conclude that catheter-related infections perceived by patients and the justice system as not related to unforeseeable medical complications are mainly peripheral catheter infections due to S. aureus and might be an appropriate target for new preventive strategies. Keywords: insurance,
nosocomial
infection,
preventability,
Staphylococcus aureus, venous catheter Original Submission: 6 February 2014; Revised Submission:
Introduction Intravenous peripheral (PVC) and central (CVC) catheters, provide necessary vascular access, but put patients at risk of infectious complications (local or systemic). Twenty-five million PVCs and one million CVCs are estimated to be inserted each year in France (1). The recently published French national survey of hospital-associated infections described a prevalence of 0.3% and below 0.1% for CVCs and PVCs, respectively (http:// www.invs.sante.fr/Publications-et-outils/Rapports-et-syntheses /Maladies-infectieuses/2013/Enquete-nationale-de-prevalencedes-infections-nosocomiales-et-des-traitements-anti-infect ieux-en-etablissements-de-sante-France-mai-juin-2012). Nosocomial bacteraemias were predominantly due to venous catheters (33% CVC, 8.3% PVC). Incidence surveys aiming to describe the epidemiology of hospital-onset bacteraemia showed that the burden linked to these bacteraemias is underestimated by point prevalence studies (2). In France, it has been recently estimated that 12 400 patients died due to to healthcare-associated bacteraemia (3). The incidence of CVC-related infections and bacteraemia was, respectively, 0.84 and 0.66/1000 days in intensive care units (ICU) in the French network RAISIN (4). Assuming a stronger incidence of 1.23/1000 days in France, the additional costs for the healthcare system related to central catheter bloodstream infection (CRBSI) in ICUs was estimated to be 100 to 130 million Euros a year (5). Most often microorganisms responsible for CRBSI are coagulase-negative Staphylococcus (23% of cases) and Staphylococcus aureus (17%). None of these sources enable the evaluation of the preventable part of intravascular catheter-related infections (CRI). Another way to investigate this topic is to refer to health insurance data. To obtain this information in France, we asked SHAM, the main insurance company of French public and private hospitals, to investigate the claimed cases of CRI. The aim of the study was to describe vascular CRI claims to SHAM, and to evaluate the preventability of these healthcare-associated infections.
10 April 2014; Accepted: 15 May 2014
Editor: Didier Raoult Article published online: 20 May 2014
Methods
Clin Microbiol Infect 2014; 20: O1084–O1087 10.1111/1469-0691.12684
Corresponding author: P. Berthelot, Infectious Diseases Department, Infection Control Unit, University Hospital of Saint-Etienne, 42055 Saint-Etienne Cedex 02, France E-mail: [email protected]
Study population
This retrospective study was conducted using the database of SHAM, after approval by the local ethics committee of the University Hospital of Saint-Etienne, France. We searched the database of SHAM, during the period 2000–2010, with the following keywords: infections and catheters. A fellow,
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases
CMI
Gagneux-Brunon et al.
Preventability of catheter-related infection claims to insurance companies
specializing in infectious diseases, studied the medical reports of cases to confirm that each case was an intravascular CRI, and to collect the data necessary to evaluate preventability. Definitions used for CRI characterization were French ones edited by the National Technical Committee of Nosocomial Infection; they are in accordance with those described by Raad et al. (6).
O1085
occurred in the medical department, 21 (30%) in the surgical department and only seven (10%) in the ICU. Characteristics of the patients are depicted in Table 1. In 42 cases (60%), infections were related to PVCs. Eight cases occurred in paediatric patients (<15 years old), particularly in newborns. Microorganisms responsible for infection and complications associated with catheters
Data collection and statistical analysis
Collected data were characteristics of patients (age, sex, co-morbidities, and risk factors for infection such as diabetes mellitus, neutropenia, immunosuppressive agents, surgery and blood transfusion) and type of catheters (peripheral catheter, central venous catheter, arterial catheter, haemodialysis catheter or totally implantable catheter). Statistical analysis was performed using SPSS 20.0 (IBM, Chicago, IL, USA). We compared the proportion of preventable infections related to PVCs and CVCs using McNemar’s test. Preventability judgement
A medical committee composed of two practitioners working in ICU units and one working in an infection control unit examined the selected cases to evaluate the preventability of CRI. Adherence to guidelines for insertion, surveillance of intravascular catheters, diagnosis of intravascular-related infections and characteristics of patients were taken into account to determine the preventability of each case using a Lickert scale (7). Preventability was defined as an unintended CRI that was caused by medical management or a failure to meet the reasonably expected standard of care. The probability of preventability was graded using four categories: certainly or probably preventable, moderate preventability, not preventable, and undetermined probability. Preventable infections were those with moderate and strong probability of preventability.
A microorganism was identified in 93% of cases of infection. Staphylococcus aureus was the most frequent microorganism, recovered in 51 cases (72%); coagulase-negative staphylococci were responsible for three (4%) infections. In 10 (19%) S. aureus infections, a resistance to methicillin was identified. Other documented complications were: 13 patients with osteitis or arthritis, four with spondylodiscitis, one with toe amputation, two with infected arterial aneurysms, seven with endocarditis, two with mycotic aneurysms, one with pulmonary embolism, two with venous thrombophlebitis, one with infected haematoma and 14 with thrombosis of catheters. Ten osteo-articular infections and five cases of endocarditis were related to PVC infection. Outcomes
In 48 cases (68%), CRI induced sepsis: two (3%) were severe and 15 (21%) resulted in septic shock (five children). Surgery or an ICU stay was necessary in 23 (34%) and 22 (32%) cases, respectively. Death was attributable to CRI in eight cases (11%). When analyzing only the infections related to PVCs (42 cases), septic shock was observed in eight cases (19%). Surgery
TABLE 1. Characteristics of the patients who developed intravascular catheter-related infections (mean and SD for continuous variables, number and percentage for categorical variables) Characteristics (n, %)
Results
Age Sex ratio (M/F) Charlson Score at admission Presence of risk factors for infectiona Category on hospital admission Medicine Surgery Intensive care unit Others (rehabilitation, obstetrics, psychiatry. . .) Type of catheter Peripheral venous catheter Central venous catheter Otherb Bacteraemia Peripheral venous catheter Central venous catheter
Characteristics of cases
In France, more than sixty per cent of the hospital beds in medicine, surgery and obstetrics are insured by SHAM (75% public and 25% private). During the time period 2000–2010, 73 322 damages claims were made to SHAM. Five hundred and eighty-three (0.8%) were classified with the keywords infections and catheters and only 75 (0.1%) of these cases were effectively intravascular CRI. Four cases were excluded because too much information was missing from the medical files. Most of the cases (74%) occurred in patients admitted as an emergency to the hospital. Thirty-four cases (48%) of CRI
47 22 years 2.1/1 1 (1.9) 29 patients (41) 34 21 7 9
(48) (30) (10) (13)
42 26 3 49 31 18
(59) (37) (4) (69) (74) (70)
a
Septic shock, multiple organ failure, polytrauma, immunocompromised patient, cancer, major surgery, diabetes requiring insulin therapy, low birth weight (<1500 g), parenteral nutrition, prosthesis, blood transfusions. b Umbilical catheters.
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087
O1086
Clinical Microbiology and Infection, Volume 20 Number 12, December 2014
and an ICU stay were necessary in 12 (29%) and nine (21%) cases, respectively. The mean cost for SHAM of an intravascular CRI, using the data on 59 damages claims, for which the procedure was completed by the study date, was evaluated at 18 153 € (39 956, 0–231 700). Preventability
Forty-two infections (62%) were considered to be preventable by the expert committee: 31 (74%) for PVCs and 11 (38%) for CVCs. Identified contributing factors that could have influenced the occurrence of CRI are displayed in Table 2. Infections due to PVCs were significantly more often preventable than those due to CVCs (p < 0.05). According to guidelines (1), catheters should have been removed or replaced before the occurrence of the infection in 22 (52%) cases of PVC infection and in eight (28%) cases of CVC infection. Other contributing factors reported in the preventable infections were errors in hand hygiene, aseptic technique and skin preparation and absence of daily evaluation of the catheter insertion site. Overall, the money potentially saved by preventive measures was calculated to be 782 752 euros (57.5% of costs paid by SHAM).
Discussion To our knowledge, this is the first published study describing vascular catheter-related infection using the database of an insurance company. Additionally, this study brings new insights into the prevention of CRI. First, these infections occurred in patients with few co-morbidities or risk factors for nosocomial infections. Second, the most common microorganism isolated from these infections was Staphylococcus aureus, which is most of time susceptible to methicillin (81%). Third, most of the infections in claims made to SHAM
TABLE 2. Identified factors contributing to the 42 preventable CRIs (in two cases, two contributing factors were identified) Factors contributing to CRI Defects in hand hygiene and aseptic technique Defects in skin disinfection Catheters replaced after 72–96 h Catheters not removed despite local signs suggesting CRI Catheter not replaced when adherence to aseptic method was not ensured No indicated catheter use Defects in medical care after first local clinical signs of CRI
N (% of overall CRIs)
CMI
were preventable, particularly in the case of peripheral catheters. These results contrast with the observations in the French survey of prevalence of nosocomial infections, and the survey of the ICUs from RAISIN where methicillin resistance is frequent: 38.1% and 35%, respectively (1,7). We observed that CRIs are a minor cause of damage claims made to SHAM (11 423 claims overall in 2012, of which 7.2% were related to infection). In this database, the young age of patients, the absence of co-morbidity at admission and the small proportion of infections occurring in ICUs probably explained why patients made claims. It can also be hypothesized that only the patients who suffered the most severe infections have filed claims, which clearly underestimates the number of catheter-related infections. Additionally, a high number of complications related to PVC infection were observed, in accordance with a recent study (8) underlying the substantial burden due to these infections. One study already described a greater proportion of CRIs due to Staphylococcus aureus in peripheral venous catheter infections than in central venous catheter infections (9). Accordingly, the greater proportion of PVC infections in our study may, in part, explain the increased frequency of S. aureus infections. In the literature, the incidence of CRI associated with PVCs is low (0–0.2% bacteraemia), but there is considerable morbidity because of the frequency with which such catheters are used (10). Although this study is not representative of the epidemiology of vascular CRI (11), these results highlight that peripheral venous catheters could be a cause of severe hospital-associated infections. Catheters should have been removed or replaced before the occurrence of the infection in 71% of cases. A recent study showed that no more complications were observed when PVCs were removed as clinically indicated compared with routine replacement (12) but not all the catheter tips were cultured. French guidelines state that, in adults, it is recommended that PVCs should not be left in place for longer than 96 h, except in patients with a limited venous capital, provided the insertion site is carefully monitored and there are no complications (http://www.sf2 h.net/SF2H_english/SF2H_surveillance-and-pr evention-guidelines-2010.pdf). We believe that efforts must be made to not underestimate the infectious risk linked to PVCs and better prevent this type of infection.
3 (4.2) 6 (8.4) 13 (18.3) 12 (16.9)
Acknowledgements
1 (1.4) 4 (5.6) 5 (7.1)
Dr Frederic Fuz, SHAM, is acknowledged for help in researching the SHAM database. Lyon Biopole, Sepsis Program, is acknowledged for help in setting up this study.
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087
CMI
Gagneux-Brunon et al.
Preventability of catheter-related infection claims to insurance companies
Transparency Declaration 3.
Nothing to declare.
4.
Funding
5.
SHAM supported the funding of the collection and of the statistical analysis performed by the authors. The analysis of the study was conducted by an independent medical committee without any contribution from SHAM. The descriptive part of this work was presented at the Annual Congress of the French Society for Hospital Hygiene and the analysis of the preventability of the infections was presented at the Annual Congress of the French Infectious Diseases Society.
6.
7.
8.
9.
References
10.
1. Societe francßaise d’hygiene hospitaliere. Prevention des infections liees aux catheters veineux peripheriques- Prevention of peripheral catheters related infections. Guidelines for clinical pratice. [Internet]. 2005. Available from: http://www.sf2h.net/publications-sf2h.html 2. Laupland KB, Lyytik€ainen O, Søgaard M et al.; International Bacteremia Surveillance Collaborative. The changing epidemiology of
11. 12.
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Staphylococcus aureus bloodstream infection: a multinational population-based surveillance study. Clin Microbiol Infect 2013; 19: 465–471. Richet H, Carrieri P, Loffeier V et al. Health-care-associated bloodstream infections in France. Lancet Infect Dis 2013; 13: 656. Timsit JF, L’Heriteau F, Lepape A et al. A multicentre analysis of catheter-related infection based on a hierarchical model. Intensive Care Med 2012; 38: 1662–1672. Tacconelli E, Smith G, Hieke K, Lafuma A, Bastide P. Epidemiology, medical outcomes and costs of catheter-related bloodstream infections in intensive care units of four European countries: literature- and registry-based estimates. J Hosp Infect 2009; 72: 97–103. Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis 2007; 7: 645–657. Michel P, Quenon JL, Djihoud A et al. French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Health Care 2007; 16: 369e77. Trinh TT, Chan PA, Edwards O et al. Peripheral venous catheter-related Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol 2011; 32: 579–583. Pujol M, Hornero A, Saballs M et al. Clinical epidemiology and outcomes of peripheral venous catheter-related bloodstream infections at a university-affiliated hospital. J Hosp Infect 2007; 67: 22–29. O’Grady NP, Alexander M, Burns LA et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52: e162–e193. Timsit JF. Diagnosis and prevention of catheter-related infections. Curr Opin Crit Care 2007; 13: 563–571. Rickard CM, Webster J, Wallis MC et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380(9847): 1066–1074.
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087
INFECTIOUS DISEASES
Vascular catheter-related infection claims to health insurance company: often preventable
A. Gagneux-Brunon1, J. F. Timsit2,3, A. Lepape4 and P. Berthelot1 1) Infectious Diseases Department, University Hospital of Saint-Etienne, Saint-Etienne, 2) Medical Polyvalent Intensive Care Unit, University Hospital Albert Michallon, Grenoble 1 University, Grenoble, 3) IAME UMR1137-Team 5, Decision Sciences in Infectious Disease Prevention, Control and Care, Paris Diderot University- Inserm, Sorbonne Paris Cite and 4) Intensive Care Unit, University Hospital of Lyon, Lyon, France
Abstract Using the main French health insurance company database over a 10-year period, the preventability of catheter-related infections of patients who claimed compensation after prosecution was reviewed by a panel expert. They occurred in 71 patients with few co-morbidities or risk factors for nosocomial infection and were mainly related to the use of a peripheral vascular catheter (42 cases) and due to Staphylococcus aureus (51 cases). Forty-two infections were considered to be preventable. Infections due to peripheral venous catheters were significantly more often preventable than those due to central ones (p < 0.05). We conclude that catheter-related infections perceived by patients and the justice system as not related to unforeseeable medical complications are mainly peripheral catheter infections due to S. aureus and might be an appropriate target for new preventive strategies. Keywords: insurance,
nosocomial
infection,
preventability,
Staphylococcus aureus, venous catheter Original Submission: 6 February 2014; Revised Submission:
Introduction Intravenous peripheral (PVC) and central (CVC) catheters, provide necessary vascular access, but put patients at risk of infectious complications (local or systemic). Twenty-five million PVCs and one million CVCs are estimated to be inserted each year in France (1). The recently published French national survey of hospital-associated infections described a prevalence of 0.3% and below 0.1% for CVCs and PVCs, respectively (http:// www.invs.sante.fr/Publications-et-outils/Rapports-et-syntheses /Maladies-infectieuses/2013/Enquete-nationale-de-prevalencedes-infections-nosocomiales-et-des-traitements-anti-infect ieux-en-etablissements-de-sante-France-mai-juin-2012). Nosocomial bacteraemias were predominantly due to venous catheters (33% CVC, 8.3% PVC). Incidence surveys aiming to describe the epidemiology of hospital-onset bacteraemia showed that the burden linked to these bacteraemias is underestimated by point prevalence studies (2). In France, it has been recently estimated that 12 400 patients died due to to healthcare-associated bacteraemia (3). The incidence of CVC-related infections and bacteraemia was, respectively, 0.84 and 0.66/1000 days in intensive care units (ICU) in the French network RAISIN (4). Assuming a stronger incidence of 1.23/1000 days in France, the additional costs for the healthcare system related to central catheter bloodstream infection (CRBSI) in ICUs was estimated to be 100 to 130 million Euros a year (5). Most often microorganisms responsible for CRBSI are coagulase-negative Staphylococcus (23% of cases) and Staphylococcus aureus (17%). None of these sources enable the evaluation of the preventable part of intravascular catheter-related infections (CRI). Another way to investigate this topic is to refer to health insurance data. To obtain this information in France, we asked SHAM, the main insurance company of French public and private hospitals, to investigate the claimed cases of CRI. The aim of the study was to describe vascular CRI claims to SHAM, and to evaluate the preventability of these healthcare-associated infections.
10 April 2014; Accepted: 15 May 2014
Editor: Didier Raoult Article published online: 20 May 2014
Methods
Clin Microbiol Infect 2014; 20: O1084–O1087 10.1111/1469-0691.12684
Corresponding author: P. Berthelot, Infectious Diseases Department, Infection Control Unit, University Hospital of Saint-Etienne, 42055 Saint-Etienne Cedex 02, France E-mail: [email protected]
Study population
This retrospective study was conducted using the database of SHAM, after approval by the local ethics committee of the University Hospital of Saint-Etienne, France. We searched the database of SHAM, during the period 2000–2010, with the following keywords: infections and catheters. A fellow,
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases
CMI
Gagneux-Brunon et al.
Preventability of catheter-related infection claims to insurance companies
specializing in infectious diseases, studied the medical reports of cases to confirm that each case was an intravascular CRI, and to collect the data necessary to evaluate preventability. Definitions used for CRI characterization were French ones edited by the National Technical Committee of Nosocomial Infection; they are in accordance with those described by Raad et al. (6).
O1085
occurred in the medical department, 21 (30%) in the surgical department and only seven (10%) in the ICU. Characteristics of the patients are depicted in Table 1. In 42 cases (60%), infections were related to PVCs. Eight cases occurred in paediatric patients (<15 years old), particularly in newborns. Microorganisms responsible for infection and complications associated with catheters
Data collection and statistical analysis
Collected data were characteristics of patients (age, sex, co-morbidities, and risk factors for infection such as diabetes mellitus, neutropenia, immunosuppressive agents, surgery and blood transfusion) and type of catheters (peripheral catheter, central venous catheter, arterial catheter, haemodialysis catheter or totally implantable catheter). Statistical analysis was performed using SPSS 20.0 (IBM, Chicago, IL, USA). We compared the proportion of preventable infections related to PVCs and CVCs using McNemar’s test. Preventability judgement
A medical committee composed of two practitioners working in ICU units and one working in an infection control unit examined the selected cases to evaluate the preventability of CRI. Adherence to guidelines for insertion, surveillance of intravascular catheters, diagnosis of intravascular-related infections and characteristics of patients were taken into account to determine the preventability of each case using a Lickert scale (7). Preventability was defined as an unintended CRI that was caused by medical management or a failure to meet the reasonably expected standard of care. The probability of preventability was graded using four categories: certainly or probably preventable, moderate preventability, not preventable, and undetermined probability. Preventable infections were those with moderate and strong probability of preventability.
A microorganism was identified in 93% of cases of infection. Staphylococcus aureus was the most frequent microorganism, recovered in 51 cases (72%); coagulase-negative staphylococci were responsible for three (4%) infections. In 10 (19%) S. aureus infections, a resistance to methicillin was identified. Other documented complications were: 13 patients with osteitis or arthritis, four with spondylodiscitis, one with toe amputation, two with infected arterial aneurysms, seven with endocarditis, two with mycotic aneurysms, one with pulmonary embolism, two with venous thrombophlebitis, one with infected haematoma and 14 with thrombosis of catheters. Ten osteo-articular infections and five cases of endocarditis were related to PVC infection. Outcomes
In 48 cases (68%), CRI induced sepsis: two (3%) were severe and 15 (21%) resulted in septic shock (five children). Surgery or an ICU stay was necessary in 23 (34%) and 22 (32%) cases, respectively. Death was attributable to CRI in eight cases (11%). When analyzing only the infections related to PVCs (42 cases), septic shock was observed in eight cases (19%). Surgery
TABLE 1. Characteristics of the patients who developed intravascular catheter-related infections (mean and SD for continuous variables, number and percentage for categorical variables) Characteristics (n, %)
Results
Age Sex ratio (M/F) Charlson Score at admission Presence of risk factors for infectiona Category on hospital admission Medicine Surgery Intensive care unit Others (rehabilitation, obstetrics, psychiatry. . .) Type of catheter Peripheral venous catheter Central venous catheter Otherb Bacteraemia Peripheral venous catheter Central venous catheter
Characteristics of cases
In France, more than sixty per cent of the hospital beds in medicine, surgery and obstetrics are insured by SHAM (75% public and 25% private). During the time period 2000–2010, 73 322 damages claims were made to SHAM. Five hundred and eighty-three (0.8%) were classified with the keywords infections and catheters and only 75 (0.1%) of these cases were effectively intravascular CRI. Four cases were excluded because too much information was missing from the medical files. Most of the cases (74%) occurred in patients admitted as an emergency to the hospital. Thirty-four cases (48%) of CRI
47 22 years 2.1/1 1 (1.9) 29 patients (41) 34 21 7 9
(48) (30) (10) (13)
42 26 3 49 31 18
(59) (37) (4) (69) (74) (70)
a
Septic shock, multiple organ failure, polytrauma, immunocompromised patient, cancer, major surgery, diabetes requiring insulin therapy, low birth weight (<1500 g), parenteral nutrition, prosthesis, blood transfusions. b Umbilical catheters.
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087
O1086
Clinical Microbiology and Infection, Volume 20 Number 12, December 2014
and an ICU stay were necessary in 12 (29%) and nine (21%) cases, respectively. The mean cost for SHAM of an intravascular CRI, using the data on 59 damages claims, for which the procedure was completed by the study date, was evaluated at 18 153 € (39 956, 0–231 700). Preventability
Forty-two infections (62%) were considered to be preventable by the expert committee: 31 (74%) for PVCs and 11 (38%) for CVCs. Identified contributing factors that could have influenced the occurrence of CRI are displayed in Table 2. Infections due to PVCs were significantly more often preventable than those due to CVCs (p < 0.05). According to guidelines (1), catheters should have been removed or replaced before the occurrence of the infection in 22 (52%) cases of PVC infection and in eight (28%) cases of CVC infection. Other contributing factors reported in the preventable infections were errors in hand hygiene, aseptic technique and skin preparation and absence of daily evaluation of the catheter insertion site. Overall, the money potentially saved by preventive measures was calculated to be 782 752 euros (57.5% of costs paid by SHAM).
Discussion To our knowledge, this is the first published study describing vascular catheter-related infection using the database of an insurance company. Additionally, this study brings new insights into the prevention of CRI. First, these infections occurred in patients with few co-morbidities or risk factors for nosocomial infections. Second, the most common microorganism isolated from these infections was Staphylococcus aureus, which is most of time susceptible to methicillin (81%). Third, most of the infections in claims made to SHAM
TABLE 2. Identified factors contributing to the 42 preventable CRIs (in two cases, two contributing factors were identified) Factors contributing to CRI Defects in hand hygiene and aseptic technique Defects in skin disinfection Catheters replaced after 72–96 h Catheters not removed despite local signs suggesting CRI Catheter not replaced when adherence to aseptic method was not ensured No indicated catheter use Defects in medical care after first local clinical signs of CRI
N (% of overall CRIs)
CMI
were preventable, particularly in the case of peripheral catheters. These results contrast with the observations in the French survey of prevalence of nosocomial infections, and the survey of the ICUs from RAISIN where methicillin resistance is frequent: 38.1% and 35%, respectively (1,7). We observed that CRIs are a minor cause of damage claims made to SHAM (11 423 claims overall in 2012, of which 7.2% were related to infection). In this database, the young age of patients, the absence of co-morbidity at admission and the small proportion of infections occurring in ICUs probably explained why patients made claims. It can also be hypothesized that only the patients who suffered the most severe infections have filed claims, which clearly underestimates the number of catheter-related infections. Additionally, a high number of complications related to PVC infection were observed, in accordance with a recent study (8) underlying the substantial burden due to these infections. One study already described a greater proportion of CRIs due to Staphylococcus aureus in peripheral venous catheter infections than in central venous catheter infections (9). Accordingly, the greater proportion of PVC infections in our study may, in part, explain the increased frequency of S. aureus infections. In the literature, the incidence of CRI associated with PVCs is low (0–0.2% bacteraemia), but there is considerable morbidity because of the frequency with which such catheters are used (10). Although this study is not representative of the epidemiology of vascular CRI (11), these results highlight that peripheral venous catheters could be a cause of severe hospital-associated infections. Catheters should have been removed or replaced before the occurrence of the infection in 71% of cases. A recent study showed that no more complications were observed when PVCs were removed as clinically indicated compared with routine replacement (12) but not all the catheter tips were cultured. French guidelines state that, in adults, it is recommended that PVCs should not be left in place for longer than 96 h, except in patients with a limited venous capital, provided the insertion site is carefully monitored and there are no complications (http://www.sf2 h.net/SF2H_english/SF2H_surveillance-and-pr evention-guidelines-2010.pdf). We believe that efforts must be made to not underestimate the infectious risk linked to PVCs and better prevent this type of infection.
3 (4.2) 6 (8.4) 13 (18.3) 12 (16.9)
Acknowledgements
1 (1.4) 4 (5.6) 5 (7.1)
Dr Frederic Fuz, SHAM, is acknowledged for help in researching the SHAM database. Lyon Biopole, Sepsis Program, is acknowledged for help in setting up this study.
ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087
CMI
Gagneux-Brunon et al.
Preventability of catheter-related infection claims to insurance companies
Transparency Declaration 3.
Nothing to declare.
4.
Funding
5.
SHAM supported the funding of the collection and of the statistical analysis performed by the authors. The analysis of the study was conducted by an independent medical committee without any contribution from SHAM. The descriptive part of this work was presented at the Annual Congress of the French Society for Hospital Hygiene and the analysis of the preventability of the infections was presented at the Annual Congress of the French Infectious Diseases Society.
6.
7.
8.
9.
References
10.
1. Societe francßaise d’hygiene hospitaliere. Prevention des infections liees aux catheters veineux peripheriques- Prevention of peripheral catheters related infections. Guidelines for clinical pratice. [Internet]. 2005. Available from: http://www.sf2h.net/publications-sf2h.html 2. Laupland KB, Lyytik€ainen O, Søgaard M et al.; International Bacteremia Surveillance Collaborative. The changing epidemiology of
11. 12.
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ª2014 The Authors Clinical Microbiology and Infection ª2014 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O1084–O1087