Changing concepts in long-term central venous access: Catheter selection and cost savings

Background and objectives: Long-term central venous access is becoming an i ncreasingly important component of health care today. Long-term central ven ous access is important therapeutically for a multitude of reasons, includi ng the administration of chemotherapy, antibiotics, and total par enteral n utrition. Central Venous access can be established in a variety of ways var ying from catheters inserted at the bedside to surgically placed ports. Fur thermore, in an effort to control coals, many traditionally inpatient thera pies have moved to an outpatient setting. This raises many questions regard ing catheter selection. Which catheter will result in the best outcome at t he least cost? It has become apparent in our hospital that traditionally pl aced surgical catheters (ie, Hickmans and central venous ports) may no long er be the only options. The objective of this study was to explore the vari ous modalities for establishing central venous access comparing indications , costs, and complications to guide the clinician in choosing the appropria te catheter with the best outcome at the least cost. Methods: We evaluated our institution's central venous catheter use during a Li-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several de partments including surgery, radiology, nursing, anesthesia, pharmacy and t he hospital purchasing department. Results: During a 30-month period, 684 attempted central venous catheter in sertions were identified, including 126 surgically placed central venous ca theters, 264 peripherally inserted central catheters by the nursing service , and 294 radiologically inserted peripheral ports. Overall complications w ere rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally i nserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral pens and $3532 to $4296 for surgically pla ced catheters. Conclusions: Traditional surgically placed central catheters are increasing ly being replaced by peripherally inserted central venous access devices. S ignificant cost savings and fewer severe complications can be realized by p referential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologic ally placed versus surgically placed catheters. However, significant cost s avings and fewer severe complications are associated with peripheral centra l venous access versus the surgical or radiologic approach.