Category: Federal Forum Posters
Purpose: Catheter locking solutions, namely heparin, sodium citrate, and tissue plasminogen activator (tPA), are used to minimize catheter-related thrombosis and bacteremia in hemodialysis (HD) patients using chronic central venous catheters (CVC). Studies show no significant difference between heparin and sodium citrate in catheter-related complications. A significant reduction in complications was seen in heparin versus tPA, however, with a significant cost increase. The primary objective was to evaluate the incidence of catheter-related thrombosis and bacteremia after protocol conversion from tPA three times per week to heparin twice weekly and tPA weekly. The secondary objective was to determine cost avoidance after protocol conversion.
Methods: This is an institutional review board approved, quality assessment study. The study period is from November 1, 2015 to October 31, 2017. The index date is the date of implementation of the change to the individual patients, and closest to November 1, 2016. All patients 18 years or greater undergoing chronic hemodialysis using a CVC at least one month before (period 1) and after (period 2) the proposed change was included. Patients were excluded if undergoing acute dialysis, receiving dialysis during a hospital admission, but receives chronic dialysis at an outside facility, or using an arteriovenous fistula or arteriovenous graft for HD. Thrombosis was defined as tPA protocol violation (greater than 4mg of tPA catheter lock solution used per HD session during period 1 and greater than 4mg of tPA catheter lock solution used per week during period 2) or catheter exchanges due to clot as documented by renal attending. The primary objective measures were the number of incidences of catheter malfunction due to thrombosis as defined in the study, and the number of incidences of catheter-related bacteremia. Secondary objective included calculation of cost savings before and after the protocol conversion. Descriptive statistics and paired t-test were applied as appropriate.
Results: Among the 314 patients receiving HD during the study period, 19 patients met the inclusion and exclusion criteria. When compared between period 1 and period 2, there was no difference in primary outcomes of number of tPA protocol violations (20 versus 18, p-value equals 0.94), number of catheter exchanges due to clot (1 versus 0, p-value equals 0.33), and number of catheter-related bacteremia (3 versus 2, p-value equals 0.58). Of the 19 patients, 8 versus 7 patients had a tPA protocol violation, 1 versus 0 patients had a catheter exchange due to clot, and 3 versus 1 patients had a catheter-related bacteremia between period 1 and period 2, respectively. For the secondary outcome, the realized cost savings for the study population was approximately $223,000 and the estimated cost savings after the protocol conversion for the study period reached $370,000.
Conclusion: The findings suggest the protocol conversion did not affect the number of catheter thrombosis or catheter-related bacteremia in patients undergoing chronic HD using a central venous catheter. In addition, replacing tPA with heparin was more cost-effective, generating significant cost-savings.
Mustafa Lee– Clinical Pharmacist, Veterans Affairs Long Beach Healthcare System, Fullerton, CA