Cindy Hamilton

Ethanol Lock Therapy in Reducing Catheter-Related Bloodstream Infections in Adult Home Parenteral Nutrition Patients Results of a Retrospective Study

BACKGROUND Equivocal data demonstrate the efficacy of ethanol lock therapy (ELT) in preventing catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition (HPN) patients, but it is not currently a standard of practice. The objective of this study is to investigate the efficacy of ELT in reducing the incidence of CRBSIs in HPN patients. METHODS Medical records from the Cleveland Clinic database of adult HPN patients with CRBSIs placed on prophylactic ELT were retrospectively studied from January 2006 to August 2009 (n = 31). Outcomes were compared pre- and post-ELT with the patients serving as their own controls. Medical-grade (70%) ethanol was instilled daily into each lumen of the central venous catheter (CVC) between PN infusion cycles. Comparative analysis was performed using McNemars test and Wilcoxon ranked tests. RESULTS Thirty-one patients had 273 CRBSI-related admissions prior to ELT in comparison to 47 CRBSI-related admissions post-ELT. Adjusted data for only tunneled CVC pre- and post-ELT showed a similar reduction of CRBSI-related admissions from 10.1 to 2.9 per 1000 catheter days (P < .001). There was also a statistically significant reduction in culture-positive CRBSIs and number of catheters changed pre- and post-ELT. There were no reported side effects or complications in any patient undergoing ELT. CONCLUSIONS This study supports the efficacy and safety of ELT in reducing CRBSI-related admissions in HPN patients and potentially helps reduce the burden of CRBSI-related healthcare costs. This novel technique shows great promise as a standard prophylaxis for CRBSI in HPN patients and must be incorporated in routine practice.

Identification and early treatment of dehydration in home parenteral nutrition and home intravenous fluid patients prevents hospital admissions.

BACKGROUND Early identification and treatment of dehydration is prudent in patients requiring home parenteral nutrition (HPN) or home intravenous fluids (HIVF) to prevent hospital admissions for dehydration. Our home nutrition support service (HNS) developed a protocol in 2010 to provide additional bags of HIVF to be kept on hand for immediate use in patients identified at risk of developing dehydration. METHODS A retrospective review was performed on all HPN and HIVF patients from a clinical database who received additional HIVF during 2010. Standard treatment for dehydration was 1 L HIVF daily for 3 days in addition to prescribed infusions. RESULTS Of 308 HNS patients in 2010, additional HIVF were ordered in 161 patients with malabsorption, fistula, or obstruction. Of the 161 patients, 63% (n = 102) required additional HIVF and had 201 episodes of dehydration recorded. Increased enterostomy output (P = .021), negative intake and output (I/O data) (P = .014), and age (P = .021) were predictors of multiple dehydration episodes. I/O data were consistent with signs and symptoms of dehydration 80% of the time. One hundred seventy episodes (84.5%) of dehydration were successfully treated at home compared with 9 emergency room (ER) admissions (4.5%) and 22 hospital admissions (11%) for dehydration. CONCLUSION We demonstrate 84.5% of episodes of dehydration successfully treated in the home in patients initially identified at risk by our protocol. Education of patients at risk of dehydration prior to discharge and providing additional HIVF on hand for immediate use may avoid ER treatment or hospitalization and potentially save healthcare costs.

The Association Between Home Parenteral Nutrition and Patients With FAP-Associated Intra-abdominal Desmoids A Retrospective Study

BACKGROUND Intra-abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life-saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP-IADTs. METHODS A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP-IADTs and 6-month follow up at CC. Exclusion criteria were <6-month follow-up, lack of 3-dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan-Meier curves were analyzed for HPN and non-HPN groups. RESULTS One hundred fifty-four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non-HPN (n = 113, 73.4%). The HPN group was more likely to have advanced-stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5-year survival HPN = 72% vs non-HPN = 95%), but duration of HPN did not affect mortality. CONCLUSION HPN, although a life-saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.

Treating Dehydration at Home Avoids Healthcare Costs Associated With Emergency Department Visits and Hospital Readmissions for Adult Patients Receiving Home Parenteral Support

Background: Administration of home parenteral support (HPS) has proven to be cost-effective over hospital care. Avoiding hospital readmissions became more of a focus for healthcare institutions in 2012 with the implementation of the Affordable Care Act. In 2010, our service developed a protocol to treat dehydration at home for HPS patients by ordering additional intravenous fluids to be kept on hand and to focus patient education on the symptoms of dehydration. Methods: A retrospective analysis was completed through a clinical management database to identify HPS patients with dehydration. The hospital finance department and homecare pharmacy were utilized to determine potential cost avoidance. Results: In 2009, 64 episodes (77%) of dehydration were successfully treated at home versus 6 emergency department (ED) visits (7.5%) and 13 readmissions (15.5%). In 2010, we successfully treated 170 episodes (84.5%) at home, with 9 episodes (4.5%) requiring ED visits and 22 hospital readmissions (11%). The number of dehydration episodes per patient was significantly higher in 2010 (P < .001) and may be attributed to a shift in the patient population, with more patients having malabsorption as the indication for therapy in 2010 (P = .003). Conclusion: There were more than twice as many episodes of dehydration identified and treated at home in 2010 versus 2009. Our protocol helped educate and provide the resources required to resolve dehydration at home when early signs were recognized. By reducing ED visits and hospital readmissions, healthcare costs were avoided by a factor of 29 when home treatment was successful.

Voiceover Interactive PowerPoint Catheter Care Education for Home Parenteral Nutrition

BACKGROUND In home infusions via tunneled catheter/peripherally inserted central catheter (TC/PICC) the risk of catheter-related bloodstream infection (CRBSI) and complications contribute to rehospitalization and costs. It is unknown if voiceover interactive PowerPoint (VOIPP) via digital video disc education improves clinical outcomes. MATERIALS AND METHODS In a quaternary care medical center and using a randomized, controlled, 2-group design, hospitalized patients with TC/PICC received usual care education or usual care (UC) plus VOIPP education prehospital discharge. A multiple-choice 6-item knowledge questionnaire was administered preeducation, immediately posteducation, and 7-10 days postdischarge. At 90 days, patients were assessed for CRBSI incidence rates per 1000 catheter-days, rehospitalization, CRBSI-related hospitalization, non-CRBSI complications and patient calls to the home parenteral nutrition (HPN) clinicians. Analysis of variance, Pearson χ(2), and Kruskal-Wallis test were used to compare results between groups. RESULTS Of 51 patients (UC, n = 27; UC+VOIPP, n = 24), mean ± SD age was 46.3 ± 14.3 years, 68.6% were female, HPN duration was 2.2 ± 1.01 months, and time to postdischarge test completion was 11.5 ± 5.2 days. There were no baseline differences between groups. Between-group knowledge and changes in knowledge were similar at preeducation, immediate posteducation, and postdischarge (P = .88, 0.30, and 0.37, respectively). There were no differences in CRBSI incidence, rehospitalization, CRBSI-related rehospitalization rates, and non-CRBSI complications between groups. The UC+VOIPP group had more patient calls than did the UC group (21.8 vs 7.7 calls/1000 catheter-days, P < .001). CONCLUSION Recorded education led to more patient calls to the HPN clinicians; however, there were no differences between groups in other outcomes.