Inpatient admissions are a major component of healthcare costs in the United States,[1] where the number of annual inpatient hospital admissions has increased by 15% from 34.3 million in 1993 to 39.5 million in 2006.² Studies performed predominantly in Europe have shown that inappropriate use of hospital beds exceeds 20% across various specialties.[3] A study by Campbell et al. showed that if given the choice, 60% of physicians would consider an alternative to admission for such patients, if such an option were available, and 70% of patients would prefer not to be admitted for workup.[4] Based on similar findings, various hospitals across the world have tried to make organizational changes to allocate healthcare resources more efficiently. The concept of quick and early diagnosis was first introduced in 1996 by Kendall et al., and it included a hospital unit in the United Kingdom managed by consultants receiving referrals from primary care doctors and led to early diagnostic workup without hospitalization.[5] A more refined version of this concept, a potentially cost‐saving and efficient alternative to inpatient hospitalization for diagnostic purposes, was described by Bosch et al., and named the quick diagnosis unit (QDU).[1]

The basic objectives of QDUs include early diagnosis of potentially severe diseases such as cancer, avoiding unnecessary hospitalization, minimizing hospital morbidity, reducing costs, and improving patient satisfaction. The first described QDU was managed by internists, where patients with specific symptoms such as undiagnosed lumps or masses, anemia, hematuria, or gastrointestinal symptoms could be referred for a diagnostic evaluation. Patients were required to be well enough to travel to the QDU on an outpatient basis, and patients unable to do so were thought to be better suited for hospitalization.[1]

In the present study, we conduct a systematic review, the first one on this subject to our knowledge, of studies that tested established QDUs or similar units in hospital settings. The majority of established units were tested and exist in Europe.[1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14] They have been studied in Spain, from where much of these data have been obtained.[1]

METHODS

RESULTS

Study Selection

Our literature search initially yielded 2047 publications, out of which 2034 were excluded after title and abstract screening. Thirteen studies were selected for full‐text review, out of which 5 were selected for detailed review based on our inclusion criteria (Figure 1). Three of the studies were in Spanish, and the results were analyzed with the help of a Spanish translator. The other 2 studies were in English.

Figure 1

DISCUSSION

Our systematic review evaluated the effectiveness of QDUs for the diagnostic evaluation of patients with potentially severe disease and showed that such units, where established, are cost‐effective, prevent unnecessary hospitalizations, and diagnose potentially severe diseases, particularly malignant conditions, in a timely manner.

QDUs can evaluate medically stable patients with a variety of complaints such as anemia, lymphadenopathy, undiagnosed lumps and masses, and gastrointestinal symptoms and accelerate the diagnostic evaluation without requiring inpatient hospitalization. Many times patients are admitted to the hospital for a diagnostic evaluation without actual treatment.[12] These patients may not be sick enough to warrant hospitalization and may be able to return to the clinic for an outpatient workup. The QDU approach can complete the evaluation in such patients with the added advantages of saving money and higher patient satisfaction, due to diminished disruption of the patient's daily life.[1, 12] As most primary care physicians are unlikely to provide regular and frequent access for unscheduled care and EDs are more likely to admit patients for diagnostic workup,[2] a QDU approach seems a reasonable alternative for making a quick diagnosis and at the same time avoiding unnecessary hospitalization. Bosch et al. have also evaluated the impact of the QDUs in the diagnosis of specific diseases such as cancer in 169 patients diagnosed at the QDU, and compared them to 53 patients who were diagnosed with cancer during an inpatient evaluation.[11] They found that although QDU patients were significantly younger than hospitalized patients, there was no difference in diagnoses established and the time to diagnosis at the QDU and length of stay in the hospital.

There is a significant cost saving associated with QDUs. The cost savings calculated by Bosch et al. and Capell et al. were for each patient enrolled in this protocol from index encounter to final diagnosis.[6, 7] These 2 studies describe primarily fixed costs saved per patient treated in the QDU versus an inpatient admission. Fixed costs in hospital care include personnel cost, buildings, and equipment, whereas variable costs include medication, test reagents, and disposable supplies.[15] In comparison with the US healthcare system, fixed costs in Europe are considerably lower, and certain variable costs (like medications and procedures) are significantly higher in the United States.[16] This suggests a greater opportunity for healthcare savings for carefully selected patients in the United States, where costs related to inpatient admissions are significantly higher.[16]

Another limitation of our analysis is the paucity of studies on this topic. Many of the publications are from Bosch et al.,[1, 6, 11, 12, 13, 14] a single group in Spain, and these show considerable cost savings, patient satisfaction, and patient safety. However, most of their data are either retrospective or from nonrandomized, prospective cohort studies. The only report describing a similar approach in the United States was by Paschal in the city of New Orleans.[17] After Charity Hospital and the Veterans Affairs Hospital in New Orleans were lost to hurricane Katrina, an urgent care clinic was set up where potentially severe diseases such as cancer, leukemia, and autoimmune and endocrine disorders were diagnosed efficiently, although safety data were not reported.

The reported studies used different study designs and evaluated different primary outcomes. These limitations can be overcome with a well‐designed prospective trial, which could also evaluate the actual impact on patient care, safety, and healthcare savings in the United States.

Safety data were reported in detail only in 1 study,[6] and the rates of admissions were reported by 2 other studies.[7, 8] These suggest that QDUs may be safe for a selected group of patients. Patients evaluated in these units preferred this approach as shown by the overwhelming majority of the patients who chose QDU care over inpatient admissions when patient surveys were performed.

CONCLUSION

In this era of healthcare reform and emphasis on value‐based care, we must optimize the efficiency of our care delivery systems and challenge our preexisting resource‐intensive healthcare models. One source of potential savings is avoiding hospitalizations for purely diagnostic purposes, utilizing quick diagnostic units for patients who are able to return for outpatient evaluations. Such units are established, have been studied in Europe, and our systematic review shows that they are cost‐effective, time‐ and resource‐efficient, and preferred by patients. In our healthcare system, with the high cost of inpatient care, the QDU can yield large savings of healthcare dollars while expediting diagnostic workup, increasing patient satisfaction, and preventing lost productivity from hospital stays. Further exploration and study of alternative care delivery models, such as quick diagnostic units, is required to achieve the goal of cost‐effective high‐quality care for all.

Inpatient admissions are a major component of healthcare costs in the United States,[1] where the number of annual inpatient hospital admissions has increased by 15% from 34.3 million in 1993 to 39.5 million in 2006.² Studies performed predominantly in Europe have shown that inappropriate use of hospital beds exceeds 20% across various specialties.[3] A study by Campbell et al. showed that if given the choice, 60% of physicians would consider an alternative to admission for such patients, if such an option were available, and 70% of patients would prefer not to be admitted for workup.[4] Based on similar findings, various hospitals across the world have tried to make organizational changes to allocate healthcare resources more efficiently. The concept of quick and early diagnosis was first introduced in 1996 by Kendall et al., and it included a hospital unit in the United Kingdom managed by consultants receiving referrals from primary care doctors and led to early diagnostic workup without hospitalization.[5] A more refined version of this concept, a potentially cost‐saving and efficient alternative to inpatient hospitalization for diagnostic purposes, was described by Bosch et al., and named the quick diagnosis unit (QDU).[1]

The basic objectives of QDUs include early diagnosis of potentially severe diseases such as cancer, avoiding unnecessary hospitalization, minimizing hospital morbidity, reducing costs, and improving patient satisfaction. The first described QDU was managed by internists, where patients with specific symptoms such as undiagnosed lumps or masses, anemia, hematuria, or gastrointestinal symptoms could be referred for a diagnostic evaluation. Patients were required to be well enough to travel to the QDU on an outpatient basis, and patients unable to do so were thought to be better suited for hospitalization.[1]

In the present study, we conduct a systematic review, the first one on this subject to our knowledge, of studies that tested established QDUs or similar units in hospital settings. The majority of established units were tested and exist in Europe.[1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14] They have been studied in Spain, from where much of these data have been obtained.[1]

METHODS

RESULTS

Study Selection

Our literature search initially yielded 2047 publications, out of which 2034 were excluded after title and abstract screening. Thirteen studies were selected for full‐text review, out of which 5 were selected for detailed review based on our inclusion criteria (Figure 1). Three of the studies were in Spanish, and the results were analyzed with the help of a Spanish translator. The other 2 studies were in English.

Figure 1

DISCUSSION

Our systematic review evaluated the effectiveness of QDUs for the diagnostic evaluation of patients with potentially severe disease and showed that such units, where established, are cost‐effective, prevent unnecessary hospitalizations, and diagnose potentially severe diseases, particularly malignant conditions, in a timely manner.

QDUs can evaluate medically stable patients with a variety of complaints such as anemia, lymphadenopathy, undiagnosed lumps and masses, and gastrointestinal symptoms and accelerate the diagnostic evaluation without requiring inpatient hospitalization. Many times patients are admitted to the hospital for a diagnostic evaluation without actual treatment.[12] These patients may not be sick enough to warrant hospitalization and may be able to return to the clinic for an outpatient workup. The QDU approach can complete the evaluation in such patients with the added advantages of saving money and higher patient satisfaction, due to diminished disruption of the patient's daily life.[1, 12] As most primary care physicians are unlikely to provide regular and frequent access for unscheduled care and EDs are more likely to admit patients for diagnostic workup,[2] a QDU approach seems a reasonable alternative for making a quick diagnosis and at the same time avoiding unnecessary hospitalization. Bosch et al. have also evaluated the impact of the QDUs in the diagnosis of specific diseases such as cancer in 169 patients diagnosed at the QDU, and compared them to 53 patients who were diagnosed with cancer during an inpatient evaluation.[11] They found that although QDU patients were significantly younger than hospitalized patients, there was no difference in diagnoses established and the time to diagnosis at the QDU and length of stay in the hospital.

There is a significant cost saving associated with QDUs. The cost savings calculated by Bosch et al. and Capell et al. were for each patient enrolled in this protocol from index encounter to final diagnosis.[6, 7] These 2 studies describe primarily fixed costs saved per patient treated in the QDU versus an inpatient admission. Fixed costs in hospital care include personnel cost, buildings, and equipment, whereas variable costs include medication, test reagents, and disposable supplies.[15] In comparison with the US healthcare system, fixed costs in Europe are considerably lower, and certain variable costs (like medications and procedures) are significantly higher in the United States.[16] This suggests a greater opportunity for healthcare savings for carefully selected patients in the United States, where costs related to inpatient admissions are significantly higher.[16]

Another limitation of our analysis is the paucity of studies on this topic. Many of the publications are from Bosch et al.,[1, 6, 11, 12, 13, 14] a single group in Spain, and these show considerable cost savings, patient satisfaction, and patient safety. However, most of their data are either retrospective or from nonrandomized, prospective cohort studies. The only report describing a similar approach in the United States was by Paschal in the city of New Orleans.[17] After Charity Hospital and the Veterans Affairs Hospital in New Orleans were lost to hurricane Katrina, an urgent care clinic was set up where potentially severe diseases such as cancer, leukemia, and autoimmune and endocrine disorders were diagnosed efficiently, although safety data were not reported.

The reported studies used different study designs and evaluated different primary outcomes. These limitations can be overcome with a well‐designed prospective trial, which could also evaluate the actual impact on patient care, safety, and healthcare savings in the United States.

Safety data were reported in detail only in 1 study,[6] and the rates of admissions were reported by 2 other studies.[7, 8] These suggest that QDUs may be safe for a selected group of patients. Patients evaluated in these units preferred this approach as shown by the overwhelming majority of the patients who chose QDU care over inpatient admissions when patient surveys were performed.

CONCLUSION

In this era of healthcare reform and emphasis on value‐based care, we must optimize the efficiency of our care delivery systems and challenge our preexisting resource‐intensive healthcare models. One source of potential savings is avoiding hospitalizations for purely diagnostic purposes, utilizing quick diagnostic units for patients who are able to return for outpatient evaluations. Such units are established, have been studied in Europe, and our systematic review shows that they are cost‐effective, time‐ and resource‐efficient, and preferred by patients. In our healthcare system, with the high cost of inpatient care, the QDU can yield large savings of healthcare dollars while expediting diagnostic workup, increasing patient satisfaction, and preventing lost productivity from hospital stays. Further exploration and study of alternative care delivery models, such as quick diagnostic units, is required to achieve the goal of cost‐effective high‐quality care for all.

Inpatient admissions are a major component of healthcare costs in the United States,[1] where the number of annual inpatient hospital admissions has increased by 15% from 34.3 million in 1993 to 39.5 million in 2006.² Studies performed predominantly in Europe have shown that inappropriate use of hospital beds exceeds 20% across various specialties.[3] A study by Campbell et al. showed that if given the choice, 60% of physicians would consider an alternative to admission for such patients, if such an option were available, and 70% of patients would prefer not to be admitted for workup.[4] Based on similar findings, various hospitals across the world have tried to make organizational changes to allocate healthcare resources more efficiently. The concept of quick and early diagnosis was first introduced in 1996 by Kendall et al., and it included a hospital unit in the United Kingdom managed by consultants receiving referrals from primary care doctors and led to early diagnostic workup without hospitalization.[5] A more refined version of this concept, a potentially cost‐saving and efficient alternative to inpatient hospitalization for diagnostic purposes, was described by Bosch et al., and named the quick diagnosis unit (QDU).[1]

The basic objectives of QDUs include early diagnosis of potentially severe diseases such as cancer, avoiding unnecessary hospitalization, minimizing hospital morbidity, reducing costs, and improving patient satisfaction. The first described QDU was managed by internists, where patients with specific symptoms such as undiagnosed lumps or masses, anemia, hematuria, or gastrointestinal symptoms could be referred for a diagnostic evaluation. Patients were required to be well enough to travel to the QDU on an outpatient basis, and patients unable to do so were thought to be better suited for hospitalization.[1]

In the present study, we conduct a systematic review, the first one on this subject to our knowledge, of studies that tested established QDUs or similar units in hospital settings. The majority of established units were tested and exist in Europe.[1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14] They have been studied in Spain, from where much of these data have been obtained.[1]

METHODS

RESULTS

Study Selection

Our literature search initially yielded 2047 publications, out of which 2034 were excluded after title and abstract screening. Thirteen studies were selected for full‐text review, out of which 5 were selected for detailed review based on our inclusion criteria (Figure 1). Three of the studies were in Spanish, and the results were analyzed with the help of a Spanish translator. The other 2 studies were in English.

Figure 1

DISCUSSION

Our systematic review evaluated the effectiveness of QDUs for the diagnostic evaluation of patients with potentially severe disease and showed that such units, where established, are cost‐effective, prevent unnecessary hospitalizations, and diagnose potentially severe diseases, particularly malignant conditions, in a timely manner.

QDUs can evaluate medically stable patients with a variety of complaints such as anemia, lymphadenopathy, undiagnosed lumps and masses, and gastrointestinal symptoms and accelerate the diagnostic evaluation without requiring inpatient hospitalization. Many times patients are admitted to the hospital for a diagnostic evaluation without actual treatment.[12] These patients may not be sick enough to warrant hospitalization and may be able to return to the clinic for an outpatient workup. The QDU approach can complete the evaluation in such patients with the added advantages of saving money and higher patient satisfaction, due to diminished disruption of the patient's daily life.[1, 12] As most primary care physicians are unlikely to provide regular and frequent access for unscheduled care and EDs are more likely to admit patients for diagnostic workup,[2] a QDU approach seems a reasonable alternative for making a quick diagnosis and at the same time avoiding unnecessary hospitalization. Bosch et al. have also evaluated the impact of the QDUs in the diagnosis of specific diseases such as cancer in 169 patients diagnosed at the QDU, and compared them to 53 patients who were diagnosed with cancer during an inpatient evaluation.[11] They found that although QDU patients were significantly younger than hospitalized patients, there was no difference in diagnoses established and the time to diagnosis at the QDU and length of stay in the hospital.

There is a significant cost saving associated with QDUs. The cost savings calculated by Bosch et al. and Capell et al. were for each patient enrolled in this protocol from index encounter to final diagnosis.[6, 7] These 2 studies describe primarily fixed costs saved per patient treated in the QDU versus an inpatient admission. Fixed costs in hospital care include personnel cost, buildings, and equipment, whereas variable costs include medication, test reagents, and disposable supplies.[15] In comparison with the US healthcare system, fixed costs in Europe are considerably lower, and certain variable costs (like medications and procedures) are significantly higher in the United States.[16] This suggests a greater opportunity for healthcare savings for carefully selected patients in the United States, where costs related to inpatient admissions are significantly higher.[16]

Another limitation of our analysis is the paucity of studies on this topic. Many of the publications are from Bosch et al.,[1, 6, 11, 12, 13, 14] a single group in Spain, and these show considerable cost savings, patient satisfaction, and patient safety. However, most of their data are either retrospective or from nonrandomized, prospective cohort studies. The only report describing a similar approach in the United States was by Paschal in the city of New Orleans.[17] After Charity Hospital and the Veterans Affairs Hospital in New Orleans were lost to hurricane Katrina, an urgent care clinic was set up where potentially severe diseases such as cancer, leukemia, and autoimmune and endocrine disorders were diagnosed efficiently, although safety data were not reported.

The reported studies used different study designs and evaluated different primary outcomes. These limitations can be overcome with a well‐designed prospective trial, which could also evaluate the actual impact on patient care, safety, and healthcare savings in the United States.

Safety data were reported in detail only in 1 study,[6] and the rates of admissions were reported by 2 other studies.[7, 8] These suggest that QDUs may be safe for a selected group of patients. Patients evaluated in these units preferred this approach as shown by the overwhelming majority of the patients who chose QDU care over inpatient admissions when patient surveys were performed.

CONCLUSION

In this era of healthcare reform and emphasis on value‐based care, we must optimize the efficiency of our care delivery systems and challenge our preexisting resource‐intensive healthcare models. One source of potential savings is avoiding hospitalizations for purely diagnostic purposes, utilizing quick diagnostic units for patients who are able to return for outpatient evaluations. Such units are established, have been studied in Europe, and our systematic review shows that they are cost‐effective, time‐ and resource‐efficient, and preferred by patients. In our healthcare system, with the high cost of inpatient care, the QDU can yield large savings of healthcare dollars while expediting diagnostic workup, increasing patient satisfaction, and preventing lost productivity from hospital stays. Further exploration and study of alternative care delivery models, such as quick diagnostic units, is required to achieve the goal of cost‐effective high‐quality care for all.

Catheter‐related bloodstream infections (CRBSIs) are among the most common forms of hospital‐acquired infection and increase both length of stay and cost of hospitalization.[1, 2] Notable efforts are being devoted to reduce the rate of CRBSI, usually by implementing a bundle of measures.[3, 4, 5] One measure focuses on reducing to a minimum the exposure to vascular catheters.[3] In addition, various studies have shown that multilumen central venous catheters (CVCs) are associated with a higher risk of CRBSI than are single‐lumen catheters.[6, 7, 8, 9, 10] Accordingly, the Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline recommends that clinicians use a CVC with the minimum number of ports or lumens essential for the management of the patient.[3]

Despite the fact that most CRBSIs occur in conventional wards,[1, 11] only a few studies have been focused on the potential magnitude of reducing the number of unnecessary vascular catheters and catheter lumens in the noncritical‐care setting.[12, 13, 14, 15, 16] The adequacy of vascular‐catheter use has been predominantly assessed for nontunneled CVCs.[14, 16, 17, 18] An institutional program aimed at reducing the overall rate of CRBSI should also include other sources, such as conventional peripheral venous catheters (PVCs), peripherally inserted central catheters (PICCs), and arterial catheters (ACs).[3] The need to extend surveillance to other types of catheters has been identified by the Infectious Diseases Society of America (IDSA) as an unresolved issue.[19]

We sought to investigate the rate and appropriateness of use of vascular catheters in the entire population of inpatients at a tertiary‐care center on a single day, as well as the adequacy of the number of catheter lumens harbored by each patient, by using a set of preestablished objective criteria.

METHODS

RESULTS

Out of 1134 reviewed inpatient beds, 834 (73.5%) were occupied on the day of the survey. The mean age of the included patients was 64.518.8 years, and 415 (49.8%) were male. Of these patients, 575 (68.9%) had 1 vascular catheter in place. The proportion of patients with a vascular catheter was significantly higher in ICUs compared with conventional wards (100% vs 66.7%, P<0.0001; Table 2). The overall numbers of vascular catheters and catheter lumens analyzed were 703 and 1448, respectively. Regarding the type of device, 567 (80.6%) were PVCs, 111 (15.8%) were CVCs (including 65 nontunneled CVCs, 16 dialysis catheters, 15 PICCs, 7 skin‐tunneled CVCs, 5 totally implantable CVCs, and 3 Swan‐Ganz catheters), and 25 (3.5%) were ACs. The distribution according to hospital ward and anatomic site of insertion is detailed in Table 2. The use of CVCs and ACs was higher in ICUs (42.0% and 28.4% of all catheters in place, respectively) compared with conventional wards (12.0% and 0.0%, P<0.0001). The use of the subclavian vein insertion site was more common in medical wards (65.7% of all CVCs, excluding PICCs) than in surgical wards or ICUs (26.9%, P=0.0002). Most of the catheters had been inserted by nursing staff members (75.2%), followed by anesthesia physicians (13.4%) and critical‐care medicine physicians (4.8%). An opaque gauze or transparent polyurethane insertion‐site dressing was present in 378 (53.8%) and 319 (45.3%) catheters, respectively, with no significant differences according to the type of device or hospital ward.

After excluding ACs, we found an overall mean number of 2.060.82 lumens per catheter (1.860.45 per PVC and 3.091.39 per CVC), with significant differences between ICUs and conventional wards (P<0.0001; Table 2). There was a mean of 0.860.57 3‐way stopcocks per catheter. The mean number of concurrent IV medications per patient was 2.82.7 (ranging from 2.32.1 in those with a single catheter to 10.52.6 in those with 4 catheters). The most commonly administered medications were antimicrobials (46.6% of patients with a vascular catheter), fluid therapy (33.4%), chemotherapy (2.3%), and vasoactive and inotropic drugs (1.0%). According to the administration regimen, 455 (79.1%), 30 (5.2%), and 182 (31.6%) patients were receiving medications by rapid infusion, infusion over 124 hours, or continuous infusion over a 24‐hour period, respectively. In 57 patients (9.9%), the catheter was used only as preemptive vascular access. No apparent indication for the use of a vascular catheter was found in 63 patients (10.9%).

Based on our criteria, 126 out of 834 inpatients (15.1%, 95% CI: 12.817.7) had 1 inappropriate catheter, with significant differences between conventional wards and ICUs (13.2% vs 26.3%, P=0.014). This prevalence rate increases to 21.9% (95% CI: 18.725.5) when only patients with 1 vascular catheter in place were analyzed.

Focusing on the number of catheter lumens, 631 out of 1448 (43.6%, 95% CI: 41.046.1) were considered unnecessary. There was a nonsignificant trend toward a higher rate of unnecessary lumens in conventional wards compared with ICUs (44.8% vs 39.4%, P=0.086; Table 3). Because some centers have policies requiring all inpatients to harbor 1 PVC in place throughout the entire hospitalization period, we performed a first sensitivity analysis in which we assumed that having a single functional vascular lumen was appropriate in all cases, regardless of any other criteria. Under this assumption, only 248 lumens (17.1%, 95% CI: 15.319.2) could be regarded as unnecessary. We conducted a second sensitivity analysis by including in the rate denominator only those catheter lumens potentially removable (eg, PVCs, nontunneled CVCs, and noncoring needles inserted in Port‐A‐Cath catheters). By applying this method, 48.6% of lumens (631 out of 1298, 95% CI: 45.951.3) could be considered inappropriate.

DISCUSSION

In this cross‐sectional survey, we found that 1 out of every 5 (20%) adult inpatients with a vascular catheter in place in our tertiary‐care center had an inappropriate number of catheters. This figure increased to 43.6% when the number of catheter lumens was analyzed (or 17.1% if we assumed that all patients should have at least 1 vascular access during their hospitalization period solely on the basis of preemptive reasons). Such rates of unnecessary catheter use throughout an entire institution offer an opportunity for improvement in clinical practice and, eventually, for reducing catheter‐related morbidity.

Other authors have also assessed the adequacy of CVC use in either ICU[16, 17] or non‐ICU settings.[14, 15, 16, 18, 21] A recent hospital‐wide survey found that 4.8% of catheter‐days were unnecessary, with a higher proportion in conventional wards than in the ICU,[16] mirroring the results from previous studies.[14] Another prospective study, limited to conventional wards, reported that almost half of the patients had 1 day with inappropriate vascular‐device use; age, total number of catheters used, and duration of catheterization were significantly associated with this event.[21] On the contrary, compliance with the criteria drawn up by the HICPAC and the Infusion Nurses Society for PICC use was found to be high overall in a medium‐sized community hospital.[22] Interestingly, we found a differential pattern in the adequacy of catheter use between hospital areas in function of the variable analyzed: number of inappropriate vascular catheters (higher rate in ICUs) or number of unnecessary vascular lumens (higher rate in conventional wards). Although our assessment criteria may partially account for such differences (ie, drug infusions for >1 hour justified the use of an exclusive catheter lumen), this finding raises the question of whether future interventions should be aimed at modifying specific catheter practices according to the type of hospital ward.

In contrast to the amount of literature on CVC, there is a scarcity of studies evaluating the appropriateness of PVC use in clinical practice. Lederle et al. reported that 17% of patients admitted in conventional wards of a university hospital had an idle PVC, with 20% of patient‐days of catheter exposure considered unnecessary.[12] The same authors subsequently demonstrated a significant decrease in these figures by implementing a multidisciplinary quality‐improvement intervention.[13] A previous cross‐sectional survey in our center revealed a PVC use rate as high as 46.2% among non‐critically ill adult inpatients.[23] Phlebitis is a common complication of PVC use, occurring in about 7% of inpatients and usually leading to catheter removal and replacement.[24] Although at a much lower incidence, peripheral catheterization also represents a non‐negligible source of CRBSI.[25] In our institution, in which a recently implemented specific bundle has resulted in a clear improvement in CVC care,[4, 20] about 60% of CRBSI occurring during the first 3 months of 2013 were due to PVCs (unpublished data). Therefore, this type of device should be routinely included in future surveys seeking to investigate the local epidemiology of catheter use at each institution. In that sense, it should be noted that a recent clinical trial showed no benefit of routine third‐day replacement vs clinically indicated replacement for phlebitis or CRBSI.[24]

Our study suggests that the daily review of the need for maintaining the vascular catheter should take into account the number of vascular lumens, as >40% of them were deemed unnecessary. To our knowledge, this area for potential intervention has not been addressed in previous surveys. Numerous studies have long demonstrated that the use of double‐lumen or triple‐lumen CVCs is associated with a higher rate of CRBSI than single‐lumen devices.[6, 7, 8] Even though a meta‐analysis concluded that this relationship diminishes when only high‐quality studies were included,[9] a more recent prospective study reported a hazard ratio for infection of 4.4 for each additional lumen.[10] However, it might be argued against our decision to count each inflow port in multiway stopcocks as a separate vascular lumen. Because the present survey was ultimately aimed at identifying opportunities to reduce the risk of CRBSI by decreasing catheter exposure, such an approach was chosen to properly capture and quantify every single potential source of infection in catheterized patients. We hypothesize that the use of 3‐lumen stopcocks could involve an increased number of manipulations, thus jeopardizing the integrity of the insertion‐site dressing and subsequently favoring the intraluminal bacterial colonization of the common catheter. Although the current guidelines do not provide specific recommendations regarding the number of lumens in devices other than CVCs,[3, 19] the potential benefit of reducing this figure to the minimum in PVCs and ACs should also be assumed. In our opinion, specific efforts have to be focused on improving the use of 3‐way stopcocks, as we found a mean of 1.86 lumens per PVC and >3 lumens per CVC in our study. Maybe the need for 3‐way stopcocks should be reassessed on a daily basis in a similar way as that recommended for temporary CVCs.[3, 19] By eliminating unnecessary vascular lumens, the risk of CRBSI could be diminished without compromising the availability of vascular access for preemptive purposes.

The present surveillance also provides an accurate insight into the real‐life vascular catheter practices in a hospital‐wide setting, in contrast with most of the previous studies, which have been conducted in specific wards or units.[13, 15, 17] One relevant finding was the relatively low use of the subclavian vein site for central venous access (only 40.8% of all CVCs inserted), with significant differences between medical wards and the remaining hospital areas. Various studies have shown that the subclavian site is associated with a lower risk of infectious and thrombotic complications.[4, 26, 27, 28] Therefore, the HICPAC and IDSA guidelines strongly recommend using a subclavian site, rather than a jugular or a femoral site, to minimize infection risk for nontunneled CVCs.[3, 19] Nevertheless, recent studies have suggested that internal jugular and femoral sites could be acceptable when a subclavian approach is not feasible, particularly if chlorhexidine‐impregnated dressings are used and catheters are left in place for <4 days.[29]

The current study has a number of inherent limitations; the most significant is its cross‐sectional design, which precludes direct comparison of the rates of catheter use with other prospective cohort surveys.[14, 16, 21] In addition, we were not able to assess the changing dynamics of catheter use over time. In other words, the lack of use of a given device on the day of the survey does not necessarily imply inappropriateness. The criteria used to determine appropriateness of vascular catheterization were consensus opinion and not evidence‐based, a weakness shared by previous studies,[21] as current guidelines only address the indications for certain devices (ie, HICPAC and Infusion Nurses Society recommendations for PICC use).[3, 30] Although we have attempted to be liberal in accepting indications for catheter use (ie, preemptive access in patients deemed at risk of hemodynamic instability), some misclassification bias cannot be ruled out. In evaluating the adequacy of catheter lumens, we did not take into account the simultaneous delivery of incompatible infusateswhich must be infused through separate linesor other relevant variables (eg, nursing availability). Because the aim of our study was simply to determine whether a patient had an appropriate number of vascular catheters and vascular lumens in overall terms, all vascular lumens in each subject were individually counted and added regardless of the nature of the device, and therefore we were not able to disaggregate the adequacy rate by specific catheter types. Finally, the generalizability of the results may be hampered by their single‐center nature, and this limitation applies particularly to institutions with different policies than ours regarding preemptive vascular catheterization (ie, those requiring that all inpatients have at least 1 vascular lumen at any time during hospitalization).

On the other hand, some strengths of this survey merit consideration, namely its comprehensive design, capturing the entire population of adult inpatients in different hospital areas and every type of vascular catheter. Moreover, we addressed the adequacy of maintaining catheterization not only in terms of idle catheters in place, but also in terms of unnecessary lumens. In conclusion, there remains room for improvement in daily practice regarding the prompt removal of vascular catheters and vascular lumens that are no longer medically necessary. Further educational efforts among physicians and nursing staff should be targeted toward achieving this simple but effective measure to reduce the incidence of CRBSI.

Catheter‐related bloodstream infections (CRBSIs) are among the most common forms of hospital‐acquired infection and increase both length of stay and cost of hospitalization.[1, 2] Notable efforts are being devoted to reduce the rate of CRBSI, usually by implementing a bundle of measures.[3, 4, 5] One measure focuses on reducing to a minimum the exposure to vascular catheters.[3] In addition, various studies have shown that multilumen central venous catheters (CVCs) are associated with a higher risk of CRBSI than are single‐lumen catheters.[6, 7, 8, 9, 10] Accordingly, the Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline recommends that clinicians use a CVC with the minimum number of ports or lumens essential for the management of the patient.[3]

Despite the fact that most CRBSIs occur in conventional wards,[1, 11] only a few studies have been focused on the potential magnitude of reducing the number of unnecessary vascular catheters and catheter lumens in the noncritical‐care setting.[12, 13, 14, 15, 16] The adequacy of vascular‐catheter use has been predominantly assessed for nontunneled CVCs.[14, 16, 17, 18] An institutional program aimed at reducing the overall rate of CRBSI should also include other sources, such as conventional peripheral venous catheters (PVCs), peripherally inserted central catheters (PICCs), and arterial catheters (ACs).[3] The need to extend surveillance to other types of catheters has been identified by the Infectious Diseases Society of America (IDSA) as an unresolved issue.[19]

We sought to investigate the rate and appropriateness of use of vascular catheters in the entire population of inpatients at a tertiary‐care center on a single day, as well as the adequacy of the number of catheter lumens harbored by each patient, by using a set of preestablished objective criteria.

METHODS

RESULTS

Out of 1134 reviewed inpatient beds, 834 (73.5%) were occupied on the day of the survey. The mean age of the included patients was 64.518.8 years, and 415 (49.8%) were male. Of these patients, 575 (68.9%) had 1 vascular catheter in place. The proportion of patients with a vascular catheter was significantly higher in ICUs compared with conventional wards (100% vs 66.7%, P<0.0001; Table 2). The overall numbers of vascular catheters and catheter lumens analyzed were 703 and 1448, respectively. Regarding the type of device, 567 (80.6%) were PVCs, 111 (15.8%) were CVCs (including 65 nontunneled CVCs, 16 dialysis catheters, 15 PICCs, 7 skin‐tunneled CVCs, 5 totally implantable CVCs, and 3 Swan‐Ganz catheters), and 25 (3.5%) were ACs. The distribution according to hospital ward and anatomic site of insertion is detailed in Table 2. The use of CVCs and ACs was higher in ICUs (42.0% and 28.4% of all catheters in place, respectively) compared with conventional wards (12.0% and 0.0%, P<0.0001). The use of the subclavian vein insertion site was more common in medical wards (65.7% of all CVCs, excluding PICCs) than in surgical wards or ICUs (26.9%, P=0.0002). Most of the catheters had been inserted by nursing staff members (75.2%), followed by anesthesia physicians (13.4%) and critical‐care medicine physicians (4.8%). An opaque gauze or transparent polyurethane insertion‐site dressing was present in 378 (53.8%) and 319 (45.3%) catheters, respectively, with no significant differences according to the type of device or hospital ward.

After excluding ACs, we found an overall mean number of 2.060.82 lumens per catheter (1.860.45 per PVC and 3.091.39 per CVC), with significant differences between ICUs and conventional wards (P<0.0001; Table 2). There was a mean of 0.860.57 3‐way stopcocks per catheter. The mean number of concurrent IV medications per patient was 2.82.7 (ranging from 2.32.1 in those with a single catheter to 10.52.6 in those with 4 catheters). The most commonly administered medications were antimicrobials (46.6% of patients with a vascular catheter), fluid therapy (33.4%), chemotherapy (2.3%), and vasoactive and inotropic drugs (1.0%). According to the administration regimen, 455 (79.1%), 30 (5.2%), and 182 (31.6%) patients were receiving medications by rapid infusion, infusion over 124 hours, or continuous infusion over a 24‐hour period, respectively. In 57 patients (9.9%), the catheter was used only as preemptive vascular access. No apparent indication for the use of a vascular catheter was found in 63 patients (10.9%).

Based on our criteria, 126 out of 834 inpatients (15.1%, 95% CI: 12.817.7) had 1 inappropriate catheter, with significant differences between conventional wards and ICUs (13.2% vs 26.3%, P=0.014). This prevalence rate increases to 21.9% (95% CI: 18.725.5) when only patients with 1 vascular catheter in place were analyzed.

Focusing on the number of catheter lumens, 631 out of 1448 (43.6%, 95% CI: 41.046.1) were considered unnecessary. There was a nonsignificant trend toward a higher rate of unnecessary lumens in conventional wards compared with ICUs (44.8% vs 39.4%, P=0.086; Table 3). Because some centers have policies requiring all inpatients to harbor 1 PVC in place throughout the entire hospitalization period, we performed a first sensitivity analysis in which we assumed that having a single functional vascular lumen was appropriate in all cases, regardless of any other criteria. Under this assumption, only 248 lumens (17.1%, 95% CI: 15.319.2) could be regarded as unnecessary. We conducted a second sensitivity analysis by including in the rate denominator only those catheter lumens potentially removable (eg, PVCs, nontunneled CVCs, and noncoring needles inserted in Port‐A‐Cath catheters). By applying this method, 48.6% of lumens (631 out of 1298, 95% CI: 45.951.3) could be considered inappropriate.

DISCUSSION

In this cross‐sectional survey, we found that 1 out of every 5 (20%) adult inpatients with a vascular catheter in place in our tertiary‐care center had an inappropriate number of catheters. This figure increased to 43.6% when the number of catheter lumens was analyzed (or 17.1% if we assumed that all patients should have at least 1 vascular access during their hospitalization period solely on the basis of preemptive reasons). Such rates of unnecessary catheter use throughout an entire institution offer an opportunity for improvement in clinical practice and, eventually, for reducing catheter‐related morbidity.

Other authors have also assessed the adequacy of CVC use in either ICU[16, 17] or non‐ICU settings.[14, 15, 16, 18, 21] A recent hospital‐wide survey found that 4.8% of catheter‐days were unnecessary, with a higher proportion in conventional wards than in the ICU,[16] mirroring the results from previous studies.[14] Another prospective study, limited to conventional wards, reported that almost half of the patients had 1 day with inappropriate vascular‐device use; age, total number of catheters used, and duration of catheterization were significantly associated with this event.[21] On the contrary, compliance with the criteria drawn up by the HICPAC and the Infusion Nurses Society for PICC use was found to be high overall in a medium‐sized community hospital.[22] Interestingly, we found a differential pattern in the adequacy of catheter use between hospital areas in function of the variable analyzed: number of inappropriate vascular catheters (higher rate in ICUs) or number of unnecessary vascular lumens (higher rate in conventional wards). Although our assessment criteria may partially account for such differences (ie, drug infusions for >1 hour justified the use of an exclusive catheter lumen), this finding raises the question of whether future interventions should be aimed at modifying specific catheter practices according to the type of hospital ward.

In contrast to the amount of literature on CVC, there is a scarcity of studies evaluating the appropriateness of PVC use in clinical practice. Lederle et al. reported that 17% of patients admitted in conventional wards of a university hospital had an idle PVC, with 20% of patient‐days of catheter exposure considered unnecessary.[12] The same authors subsequently demonstrated a significant decrease in these figures by implementing a multidisciplinary quality‐improvement intervention.[13] A previous cross‐sectional survey in our center revealed a PVC use rate as high as 46.2% among non‐critically ill adult inpatients.[23] Phlebitis is a common complication of PVC use, occurring in about 7% of inpatients and usually leading to catheter removal and replacement.[24] Although at a much lower incidence, peripheral catheterization also represents a non‐negligible source of CRBSI.[25] In our institution, in which a recently implemented specific bundle has resulted in a clear improvement in CVC care,[4, 20] about 60% of CRBSI occurring during the first 3 months of 2013 were due to PVCs (unpublished data). Therefore, this type of device should be routinely included in future surveys seeking to investigate the local epidemiology of catheter use at each institution. In that sense, it should be noted that a recent clinical trial showed no benefit of routine third‐day replacement vs clinically indicated replacement for phlebitis or CRBSI.[24]

Our study suggests that the daily review of the need for maintaining the vascular catheter should take into account the number of vascular lumens, as >40% of them were deemed unnecessary. To our knowledge, this area for potential intervention has not been addressed in previous surveys. Numerous studies have long demonstrated that the use of double‐lumen or triple‐lumen CVCs is associated with a higher rate of CRBSI than single‐lumen devices.[6, 7, 8] Even though a meta‐analysis concluded that this relationship diminishes when only high‐quality studies were included,[9] a more recent prospective study reported a hazard ratio for infection of 4.4 for each additional lumen.[10] However, it might be argued against our decision to count each inflow port in multiway stopcocks as a separate vascular lumen. Because the present survey was ultimately aimed at identifying opportunities to reduce the risk of CRBSI by decreasing catheter exposure, such an approach was chosen to properly capture and quantify every single potential source of infection in catheterized patients. We hypothesize that the use of 3‐lumen stopcocks could involve an increased number of manipulations, thus jeopardizing the integrity of the insertion‐site dressing and subsequently favoring the intraluminal bacterial colonization of the common catheter. Although the current guidelines do not provide specific recommendations regarding the number of lumens in devices other than CVCs,[3, 19] the potential benefit of reducing this figure to the minimum in PVCs and ACs should also be assumed. In our opinion, specific efforts have to be focused on improving the use of 3‐way stopcocks, as we found a mean of 1.86 lumens per PVC and >3 lumens per CVC in our study. Maybe the need for 3‐way stopcocks should be reassessed on a daily basis in a similar way as that recommended for temporary CVCs.[3, 19] By eliminating unnecessary vascular lumens, the risk of CRBSI could be diminished without compromising the availability of vascular access for preemptive purposes.

The present surveillance also provides an accurate insight into the real‐life vascular catheter practices in a hospital‐wide setting, in contrast with most of the previous studies, which have been conducted in specific wards or units.[13, 15, 17] One relevant finding was the relatively low use of the subclavian vein site for central venous access (only 40.8% of all CVCs inserted), with significant differences between medical wards and the remaining hospital areas. Various studies have shown that the subclavian site is associated with a lower risk of infectious and thrombotic complications.[4, 26, 27, 28] Therefore, the HICPAC and IDSA guidelines strongly recommend using a subclavian site, rather than a jugular or a femoral site, to minimize infection risk for nontunneled CVCs.[3, 19] Nevertheless, recent studies have suggested that internal jugular and femoral sites could be acceptable when a subclavian approach is not feasible, particularly if chlorhexidine‐impregnated dressings are used and catheters are left in place for <4 days.[29]

The current study has a number of inherent limitations; the most significant is its cross‐sectional design, which precludes direct comparison of the rates of catheter use with other prospective cohort surveys.[14, 16, 21] In addition, we were not able to assess the changing dynamics of catheter use over time. In other words, the lack of use of a given device on the day of the survey does not necessarily imply inappropriateness. The criteria used to determine appropriateness of vascular catheterization were consensus opinion and not evidence‐based, a weakness shared by previous studies,[21] as current guidelines only address the indications for certain devices (ie, HICPAC and Infusion Nurses Society recommendations for PICC use).[3, 30] Although we have attempted to be liberal in accepting indications for catheter use (ie, preemptive access in patients deemed at risk of hemodynamic instability), some misclassification bias cannot be ruled out. In evaluating the adequacy of catheter lumens, we did not take into account the simultaneous delivery of incompatible infusateswhich must be infused through separate linesor other relevant variables (eg, nursing availability). Because the aim of our study was simply to determine whether a patient had an appropriate number of vascular catheters and vascular lumens in overall terms, all vascular lumens in each subject were individually counted and added regardless of the nature of the device, and therefore we were not able to disaggregate the adequacy rate by specific catheter types. Finally, the generalizability of the results may be hampered by their single‐center nature, and this limitation applies particularly to institutions with different policies than ours regarding preemptive vascular catheterization (ie, those requiring that all inpatients have at least 1 vascular lumen at any time during hospitalization).

On the other hand, some strengths of this survey merit consideration, namely its comprehensive design, capturing the entire population of adult inpatients in different hospital areas and every type of vascular catheter. Moreover, we addressed the adequacy of maintaining catheterization not only in terms of idle catheters in place, but also in terms of unnecessary lumens. In conclusion, there remains room for improvement in daily practice regarding the prompt removal of vascular catheters and vascular lumens that are no longer medically necessary. Further educational efforts among physicians and nursing staff should be targeted toward achieving this simple but effective measure to reduce the incidence of CRBSI.

Catheter‐related bloodstream infections (CRBSIs) are among the most common forms of hospital‐acquired infection and increase both length of stay and cost of hospitalization.[1, 2] Notable efforts are being devoted to reduce the rate of CRBSI, usually by implementing a bundle of measures.[3, 4, 5] One measure focuses on reducing to a minimum the exposure to vascular catheters.[3] In addition, various studies have shown that multilumen central venous catheters (CVCs) are associated with a higher risk of CRBSI than are single‐lumen catheters.[6, 7, 8, 9, 10] Accordingly, the Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline recommends that clinicians use a CVC with the minimum number of ports or lumens essential for the management of the patient.[3]

Despite the fact that most CRBSIs occur in conventional wards,[1, 11] only a few studies have been focused on the potential magnitude of reducing the number of unnecessary vascular catheters and catheter lumens in the noncritical‐care setting.[12, 13, 14, 15, 16] The adequacy of vascular‐catheter use has been predominantly assessed for nontunneled CVCs.[14, 16, 17, 18] An institutional program aimed at reducing the overall rate of CRBSI should also include other sources, such as conventional peripheral venous catheters (PVCs), peripherally inserted central catheters (PICCs), and arterial catheters (ACs).[3] The need to extend surveillance to other types of catheters has been identified by the Infectious Diseases Society of America (IDSA) as an unresolved issue.[19]

We sought to investigate the rate and appropriateness of use of vascular catheters in the entire population of inpatients at a tertiary‐care center on a single day, as well as the adequacy of the number of catheter lumens harbored by each patient, by using a set of preestablished objective criteria.

METHODS

RESULTS

Out of 1134 reviewed inpatient beds, 834 (73.5%) were occupied on the day of the survey. The mean age of the included patients was 64.518.8 years, and 415 (49.8%) were male. Of these patients, 575 (68.9%) had 1 vascular catheter in place. The proportion of patients with a vascular catheter was significantly higher in ICUs compared with conventional wards (100% vs 66.7%, P<0.0001; Table 2). The overall numbers of vascular catheters and catheter lumens analyzed were 703 and 1448, respectively. Regarding the type of device, 567 (80.6%) were PVCs, 111 (15.8%) were CVCs (including 65 nontunneled CVCs, 16 dialysis catheters, 15 PICCs, 7 skin‐tunneled CVCs, 5 totally implantable CVCs, and 3 Swan‐Ganz catheters), and 25 (3.5%) were ACs. The distribution according to hospital ward and anatomic site of insertion is detailed in Table 2. The use of CVCs and ACs was higher in ICUs (42.0% and 28.4% of all catheters in place, respectively) compared with conventional wards (12.0% and 0.0%, P<0.0001). The use of the subclavian vein insertion site was more common in medical wards (65.7% of all CVCs, excluding PICCs) than in surgical wards or ICUs (26.9%, P=0.0002). Most of the catheters had been inserted by nursing staff members (75.2%), followed by anesthesia physicians (13.4%) and critical‐care medicine physicians (4.8%). An opaque gauze or transparent polyurethane insertion‐site dressing was present in 378 (53.8%) and 319 (45.3%) catheters, respectively, with no significant differences according to the type of device or hospital ward.

After excluding ACs, we found an overall mean number of 2.060.82 lumens per catheter (1.860.45 per PVC and 3.091.39 per CVC), with significant differences between ICUs and conventional wards (P<0.0001; Table 2). There was a mean of 0.860.57 3‐way stopcocks per catheter. The mean number of concurrent IV medications per patient was 2.82.7 (ranging from 2.32.1 in those with a single catheter to 10.52.6 in those with 4 catheters). The most commonly administered medications were antimicrobials (46.6% of patients with a vascular catheter), fluid therapy (33.4%), chemotherapy (2.3%), and vasoactive and inotropic drugs (1.0%). According to the administration regimen, 455 (79.1%), 30 (5.2%), and 182 (31.6%) patients were receiving medications by rapid infusion, infusion over 124 hours, or continuous infusion over a 24‐hour period, respectively. In 57 patients (9.9%), the catheter was used only as preemptive vascular access. No apparent indication for the use of a vascular catheter was found in 63 patients (10.9%).

Based on our criteria, 126 out of 834 inpatients (15.1%, 95% CI: 12.817.7) had 1 inappropriate catheter, with significant differences between conventional wards and ICUs (13.2% vs 26.3%, P=0.014). This prevalence rate increases to 21.9% (95% CI: 18.725.5) when only patients with 1 vascular catheter in place were analyzed.

Focusing on the number of catheter lumens, 631 out of 1448 (43.6%, 95% CI: 41.046.1) were considered unnecessary. There was a nonsignificant trend toward a higher rate of unnecessary lumens in conventional wards compared with ICUs (44.8% vs 39.4%, P=0.086; Table 3). Because some centers have policies requiring all inpatients to harbor 1 PVC in place throughout the entire hospitalization period, we performed a first sensitivity analysis in which we assumed that having a single functional vascular lumen was appropriate in all cases, regardless of any other criteria. Under this assumption, only 248 lumens (17.1%, 95% CI: 15.319.2) could be regarded as unnecessary. We conducted a second sensitivity analysis by including in the rate denominator only those catheter lumens potentially removable (eg, PVCs, nontunneled CVCs, and noncoring needles inserted in Port‐A‐Cath catheters). By applying this method, 48.6% of lumens (631 out of 1298, 95% CI: 45.951.3) could be considered inappropriate.

DISCUSSION

In this cross‐sectional survey, we found that 1 out of every 5 (20%) adult inpatients with a vascular catheter in place in our tertiary‐care center had an inappropriate number of catheters. This figure increased to 43.6% when the number of catheter lumens was analyzed (or 17.1% if we assumed that all patients should have at least 1 vascular access during their hospitalization period solely on the basis of preemptive reasons). Such rates of unnecessary catheter use throughout an entire institution offer an opportunity for improvement in clinical practice and, eventually, for reducing catheter‐related morbidity.

Other authors have also assessed the adequacy of CVC use in either ICU[16, 17] or non‐ICU settings.[14, 15, 16, 18, 21] A recent hospital‐wide survey found that 4.8% of catheter‐days were unnecessary, with a higher proportion in conventional wards than in the ICU,[16] mirroring the results from previous studies.[14] Another prospective study, limited to conventional wards, reported that almost half of the patients had 1 day with inappropriate vascular‐device use; age, total number of catheters used, and duration of catheterization were significantly associated with this event.[21] On the contrary, compliance with the criteria drawn up by the HICPAC and the Infusion Nurses Society for PICC use was found to be high overall in a medium‐sized community hospital.[22] Interestingly, we found a differential pattern in the adequacy of catheter use between hospital areas in function of the variable analyzed: number of inappropriate vascular catheters (higher rate in ICUs) or number of unnecessary vascular lumens (higher rate in conventional wards). Although our assessment criteria may partially account for such differences (ie, drug infusions for >1 hour justified the use of an exclusive catheter lumen), this finding raises the question of whether future interventions should be aimed at modifying specific catheter practices according to the type of hospital ward.

In contrast to the amount of literature on CVC, there is a scarcity of studies evaluating the appropriateness of PVC use in clinical practice. Lederle et al. reported that 17% of patients admitted in conventional wards of a university hospital had an idle PVC, with 20% of patient‐days of catheter exposure considered unnecessary.[12] The same authors subsequently demonstrated a significant decrease in these figures by implementing a multidisciplinary quality‐improvement intervention.[13] A previous cross‐sectional survey in our center revealed a PVC use rate as high as 46.2% among non‐critically ill adult inpatients.[23] Phlebitis is a common complication of PVC use, occurring in about 7% of inpatients and usually leading to catheter removal and replacement.[24] Although at a much lower incidence, peripheral catheterization also represents a non‐negligible source of CRBSI.[25] In our institution, in which a recently implemented specific bundle has resulted in a clear improvement in CVC care,[4, 20] about 60% of CRBSI occurring during the first 3 months of 2013 were due to PVCs (unpublished data). Therefore, this type of device should be routinely included in future surveys seeking to investigate the local epidemiology of catheter use at each institution. In that sense, it should be noted that a recent clinical trial showed no benefit of routine third‐day replacement vs clinically indicated replacement for phlebitis or CRBSI.[24]

Our study suggests that the daily review of the need for maintaining the vascular catheter should take into account the number of vascular lumens, as >40% of them were deemed unnecessary. To our knowledge, this area for potential intervention has not been addressed in previous surveys. Numerous studies have long demonstrated that the use of double‐lumen or triple‐lumen CVCs is associated with a higher rate of CRBSI than single‐lumen devices.[6, 7, 8] Even though a meta‐analysis concluded that this relationship diminishes when only high‐quality studies were included,[9] a more recent prospective study reported a hazard ratio for infection of 4.4 for each additional lumen.[10] However, it might be argued against our decision to count each inflow port in multiway stopcocks as a separate vascular lumen. Because the present survey was ultimately aimed at identifying opportunities to reduce the risk of CRBSI by decreasing catheter exposure, such an approach was chosen to properly capture and quantify every single potential source of infection in catheterized patients. We hypothesize that the use of 3‐lumen stopcocks could involve an increased number of manipulations, thus jeopardizing the integrity of the insertion‐site dressing and subsequently favoring the intraluminal bacterial colonization of the common catheter. Although the current guidelines do not provide specific recommendations regarding the number of lumens in devices other than CVCs,[3, 19] the potential benefit of reducing this figure to the minimum in PVCs and ACs should also be assumed. In our opinion, specific efforts have to be focused on improving the use of 3‐way stopcocks, as we found a mean of 1.86 lumens per PVC and >3 lumens per CVC in our study. Maybe the need for 3‐way stopcocks should be reassessed on a daily basis in a similar way as that recommended for temporary CVCs.[3, 19] By eliminating unnecessary vascular lumens, the risk of CRBSI could be diminished without compromising the availability of vascular access for preemptive purposes.

The present surveillance also provides an accurate insight into the real‐life vascular catheter practices in a hospital‐wide setting, in contrast with most of the previous studies, which have been conducted in specific wards or units.[13, 15, 17] One relevant finding was the relatively low use of the subclavian vein site for central venous access (only 40.8% of all CVCs inserted), with significant differences between medical wards and the remaining hospital areas. Various studies have shown that the subclavian site is associated with a lower risk of infectious and thrombotic complications.[4, 26, 27, 28] Therefore, the HICPAC and IDSA guidelines strongly recommend using a subclavian site, rather than a jugular or a femoral site, to minimize infection risk for nontunneled CVCs.[3, 19] Nevertheless, recent studies have suggested that internal jugular and femoral sites could be acceptable when a subclavian approach is not feasible, particularly if chlorhexidine‐impregnated dressings are used and catheters are left in place for <4 days.[29]

The current study has a number of inherent limitations; the most significant is its cross‐sectional design, which precludes direct comparison of the rates of catheter use with other prospective cohort surveys.[14, 16, 21] In addition, we were not able to assess the changing dynamics of catheter use over time. In other words, the lack of use of a given device on the day of the survey does not necessarily imply inappropriateness. The criteria used to determine appropriateness of vascular catheterization were consensus opinion and not evidence‐based, a weakness shared by previous studies,[21] as current guidelines only address the indications for certain devices (ie, HICPAC and Infusion Nurses Society recommendations for PICC use).[3, 30] Although we have attempted to be liberal in accepting indications for catheter use (ie, preemptive access in patients deemed at risk of hemodynamic instability), some misclassification bias cannot be ruled out. In evaluating the adequacy of catheter lumens, we did not take into account the simultaneous delivery of incompatible infusateswhich must be infused through separate linesor other relevant variables (eg, nursing availability). Because the aim of our study was simply to determine whether a patient had an appropriate number of vascular catheters and vascular lumens in overall terms, all vascular lumens in each subject were individually counted and added regardless of the nature of the device, and therefore we were not able to disaggregate the adequacy rate by specific catheter types. Finally, the generalizability of the results may be hampered by their single‐center nature, and this limitation applies particularly to institutions with different policies than ours regarding preemptive vascular catheterization (ie, those requiring that all inpatients have at least 1 vascular lumen at any time during hospitalization).

On the other hand, some strengths of this survey merit consideration, namely its comprehensive design, capturing the entire population of adult inpatients in different hospital areas and every type of vascular catheter. Moreover, we addressed the adequacy of maintaining catheterization not only in terms of idle catheters in place, but also in terms of unnecessary lumens. In conclusion, there remains room for improvement in daily practice regarding the prompt removal of vascular catheters and vascular lumens that are no longer medically necessary. Further educational efforts among physicians and nursing staff should be targeted toward achieving this simple but effective measure to reduce the incidence of CRBSI.

Cardiopulmonary resuscitation (CPR) is a potentially lifesaving intervention associated with intense resource utilization and poor outcomes.[1, 2, 3] CPR is the default intervention for hospitalized patients in cardiopulmonary arrest in the United States. The most common measure of successful in‐hospital CPR reported in the literature is survival to (hospital) discharge, with most estimates between 13% and 37%.[3, 4, 5, 6] Poor rates of survival to discharge may be explained by use of CPR in patients for whom it was not originally intended, such as the very elderly with multiple illnesses or the terminally ill.[7, 8] Use of CPR in patients unlikely to benefit may be due to a physician's inability to estimate the probability of survival, desire to offer hope to patients, fear of litigation, and poor communication with patients about goals of care.[7, 8, 9, 10]

The general public has overly optimistic expectations about CPR; surveys have reported perceived survival after CPR of up to 90%.[11, 12, 13] Although objective information substantially affects patient preferences for resuscitation,[14] prognosis is rarely discussed during code status encounters[15, 16]; physician estimates of prognosis also are often inaccurate.[9, 17] With a scarcity of data describing the characteristics of patients undergoing multiple CPR attempts, and their outcomes, patients and their families could have false expectations about the likely outcomes from multiple CPR attempts, because physician counsel is not well‐informed.

In this study, we examine the epidemiology of in‐hospital CPR recipients stratified by the number of occurrences of CPR during a single hospitalization, along with their outcomes. We hypothesize that recipients of multiple CPR during a single hospitalization are an epidemiologically distinct group compared with those who receive CPR once during their hospitalization, and that their outcomes are worse.

METHODS

RESULTS

Of a total of 65,308,185 adults hospitalized between the years 2000 and 2009, there were 166,519 CPR recipients, yielding a CPR incidence of 2.5 per 1000 hospitalizations. Among CPR recipients, 96.6% (n=166,899) had 1 CPR and 3.4% (n=5620) had multiple CPR during their hospitalization (range, 111 CPR). When further stratified, 3% had 2 CPR attempts (n=4949) and 0.4% (n=671) had 3 CPR attempts.

Compared with patients who had 1 CPR, those who had multiple CPR were more often younger (median age, 71 vs 67 years), nonwhite, and in a low‐income quartile (all P<0.001; Table 1). Rates of admission from a nursing facility (3.3% for the 1‐CPR group vs 3.1% for the multiple‐CPR group, P=0.65) or as a trauma (0.3% for the 1‐CPR group and 0.4% for the multiple‐CPR group, P=0.34) were similar.

Patients who had multiple CPR had slightly higher mean CCI scores (2.7 vs 2.6, P=0.02). They had higher rates of neurologic compromise and aggressive interventions; they were also more commonly treated in nonteaching hospitals, and in the western region of the United States (Table 2). After multivariate analysis, several patient, clinical, and hospital factors were independently associated with occurrence of multiple CPR (Figure 1).

Figure 1

In bivariate analysis of survival, patients who had multiple CPR had lower rates of survival to discharge (11.3% vs 23.4%, P<0.001). Results were similar (11.6% for multiple CPR vs 22.5% for 1 CPR, P<0.001) when all patients who had CPR but did not have valid timing data were excluded in sensitivity analyses. Further stratification showed that survival to discharge decreased by >40% for each increase in CPR attempt (23.4%, 11.9%, and 6.7% for 1, 2, and 3 CPR attempts, respectively, P<0.001; Figure 2). After adjustment, multiple CPR versus 1 CPR during a hospitalization was independently associated with a lower likelihood of survival to discharge (adjusted OR: 0.41, 95% CI: 0.37‐0.44, P<0.001; Table 3).

Figure 2

Survivors with multiple CPR were less likely to be discharged home compared with survivors with 1 CPR (19.3% vs 29.9%, respectively, P<0.001); 1 in 15 survivors of multiple CPR were discharged to a hospice (6.8%) versus 1 in 23 1‐CPR survivors (4.3%; P=0.002). Mean length of stay was 5.8 versus 5.5 days for patients who had multiple CPR versus 1 CPR, respectively (P<0.001), and 16.0 versus 10.5 days for discharged survivors of multiple CPR versus 1 CPR (P<0.001). The average cost per day of hospitalization was higher for recipients of multiple CPR versus 1 CPR ($4484.60 vs $3581.40, P<0.001). The aggregate cost of hospitalization for 1‐time CPR recipients doubled between the years 2001 and 2009 (from $1.3 billion to $2.9 billion); that of recipients of multiple CPR attempts quadrupled in the same time frame (from $38.6 million to $160.7 million).

DISCUSSION

A number of studies have investigated the epidemiology of patients in whom CPR is attempted.[2, 3, 5, 20, 23, 24] Several pre‐, intra‐, and post‐resuscitation factors have been shown to affect the survival of resuscitated patients.[6, 7, 25, 26] To our knowledge, neither the epidemiology of hospitalized patients in whom resuscitation is attempted multiple times nor the prognostic value of multiple CPR attempts has been investigated. In this study, we found that multiple resuscitations are more commonly performed on younger, generally sicker patients; their outcomes are significantly compromised compared with patients who are resuscitated once during their hospitalization.

There was a steep decline in survival based on the number of resuscitation events. In multivariate analysis, patients who had multiple CPR were 2.5‐fold less likely to survive their hospitalization; survivors of multiple CPR also were more likely to be discharged to a hospice. Overall, this is indicative of clinical deterioration and prolongation of dying should a patient suffer multiple cardiopulmonary arrests during a hospitalization. The robust inverse relationship between multiple CPR and survival to discharge has implications for the development of prognostic models of outcomes following CPR, as previously designed prediction models of CPR outcomes such as the Cardiac Arrest Survival Post‐Resuscitation In‐hospital (CASPRI) score,[25] Pre‐Arrest Morbidity (PAM) score,[27] and Prognosis After Resuscitation (PAR) score[28] do not include multiple resuscitations as a variable of interest.

In‐hospital factors were found to be more important than patient factors, such as comorbidities or race, in determining the likelihood of multiple CPR attempts. Hospital teaching status and region remained significantly associated with likelihood of multiple CPR attempts. This is in agreement with studies that have described demographic and regional variation in utilization of do‐not‐resuscitate orders.[29, 30] These findings suggest substantial heterogeneity in the clinical culture and hospital practices across the United States regarding preemptive discussions about resuscitation. This means that where a patient receives care is a significant determinant of their probability of undergoing multiple CPR.

It is known that older patients are more likely to have advance directive orders[30, 31] and possibly document their wishes with regard to further resuscitation efforts. There also may be an inclination toward more aggressive care for younger adults compared with those of an advanced age. Uncertainty about a patient's goals of care likely feeds into an increased possibility of multiple resuscitation attempts; this may explain why neurologic compromise and being on ventilator support were independently associated with likelihood of multiple CPR, as these patients often have lost their ability to actively participate in decision‐making. The results of this study highlight the importance of engaging patients with a plausible risk of cardiopulmonary arrest about their goals for care and advance directives in a timely manner, regardless of age.

We found that the care of patients who undergo multiple resuscitations is associated with a higher cost of hospitalization than for patients in whom resuscitation is attempted once during their hospitalization. In addition, there was an exponential increase in aggregate cost over time for multiple CPR recipients compared with 1‐time CPR recipients. In a prior study, Ebell and Kruse showed an exponential inverse relationship between cost per surviving patient and rate of survival to discharge.[32] Considering that 93.3% of patients who had 3 resuscitation attempts died during their hospitalization, and that hospital‐level factors appear to play a significant role in likelihood of multiple CPR, consensus guidelines regarding the appropriateness of 3 resuscitation attempts during a single hospitalization may be relevant to aid the care of these patients.

Although the NIS is well‐validated,[18] there are some limitations. Whereas CPR incidence in this study (2.5 per 1000 hospitalizations) is within estimates (15 arrests per 1000 hospitalizations) reported in previous studies,[3, 5] potential undercoding of multiple CPR may explain why the multiple‐CPR rate in this study is lower than re‐arrest estimates provided in published studies.[2, 33] Indeed, accurate calculation of re‐arrest rates requires data on do‐not‐resuscitate orders instituted after successful resuscitation, which are not provided in the NIS. Information on patient‐provider discussions about CPR or prognosis is not included. Data regarding the underlying cause and type of arrest rhythm, rates of return to spontaneous circulation, length of code, patient location, critical‐care resources and length of critical‐care stay, availability of rapid‐response/code teams, time to defibrillation, use of therapeutic hypothermia, adherence to resuscitation guidelines, quality of CPR, and long‐term follow‐up are not included in the database. Presenting rhythms were not assessed, as there are no ICD‐9 codes for asystole and pulseless electrical activity. The NIS is de‐identified; therefore, chart review to assess the validity of codes is impossible. However, our sensitivity analyses indicate the reliability of using the number of occurrences of the CPR code as a marker of multiple CPR. The strength of our study lies in the use of data that provide a population‐level insight into the epidemiology of patients resuscitated multiple times during their hospitalization, and their outcomes.

Decision‐making about CPR is at the center of a complex debate that incorporates often divergent clinical, economic, ethical, and personal issues. As debate continues regarding when to not resuscitate,[34, 35, 36, 37] studies that explore the public perspective of survival thresholds for the provision of multiple resuscitations will be crucial. As competition for finite healthcare dollars escalates, stratified analyses of the cost implications of resuscitation care are essential. Studies are needed to examine the impact of a history of successful resuscitation in a previous hospitalization on outcomes following CPR in a subsequent hospitalization. Overall, our study fills an important knowledge gap in resuscitation practice and outcomes in the United States and highlights the importance of discussing resuscitation options between a patient and his or her family on hospital admission and, if needed, again after the first successful resuscitation attempt.

Cardiopulmonary resuscitation (CPR) is a potentially lifesaving intervention associated with intense resource utilization and poor outcomes.[1, 2, 3] CPR is the default intervention for hospitalized patients in cardiopulmonary arrest in the United States. The most common measure of successful in‐hospital CPR reported in the literature is survival to (hospital) discharge, with most estimates between 13% and 37%.[3, 4, 5, 6] Poor rates of survival to discharge may be explained by use of CPR in patients for whom it was not originally intended, such as the very elderly with multiple illnesses or the terminally ill.[7, 8] Use of CPR in patients unlikely to benefit may be due to a physician's inability to estimate the probability of survival, desire to offer hope to patients, fear of litigation, and poor communication with patients about goals of care.[7, 8, 9, 10]

The general public has overly optimistic expectations about CPR; surveys have reported perceived survival after CPR of up to 90%.[11, 12, 13] Although objective information substantially affects patient preferences for resuscitation,[14] prognosis is rarely discussed during code status encounters[15, 16]; physician estimates of prognosis also are often inaccurate.[9, 17] With a scarcity of data describing the characteristics of patients undergoing multiple CPR attempts, and their outcomes, patients and their families could have false expectations about the likely outcomes from multiple CPR attempts, because physician counsel is not well‐informed.

In this study, we examine the epidemiology of in‐hospital CPR recipients stratified by the number of occurrences of CPR during a single hospitalization, along with their outcomes. We hypothesize that recipients of multiple CPR during a single hospitalization are an epidemiologically distinct group compared with those who receive CPR once during their hospitalization, and that their outcomes are worse.

METHODS

RESULTS

Of a total of 65,308,185 adults hospitalized between the years 2000 and 2009, there were 166,519 CPR recipients, yielding a CPR incidence of 2.5 per 1000 hospitalizations. Among CPR recipients, 96.6% (n=166,899) had 1 CPR and 3.4% (n=5620) had multiple CPR during their hospitalization (range, 111 CPR). When further stratified, 3% had 2 CPR attempts (n=4949) and 0.4% (n=671) had 3 CPR attempts.

Compared with patients who had 1 CPR, those who had multiple CPR were more often younger (median age, 71 vs 67 years), nonwhite, and in a low‐income quartile (all P<0.001; Table 1). Rates of admission from a nursing facility (3.3% for the 1‐CPR group vs 3.1% for the multiple‐CPR group, P=0.65) or as a trauma (0.3% for the 1‐CPR group and 0.4% for the multiple‐CPR group, P=0.34) were similar.

Patients who had multiple CPR had slightly higher mean CCI scores (2.7 vs 2.6, P=0.02). They had higher rates of neurologic compromise and aggressive interventions; they were also more commonly treated in nonteaching hospitals, and in the western region of the United States (Table 2). After multivariate analysis, several patient, clinical, and hospital factors were independently associated with occurrence of multiple CPR (Figure 1).

Figure 1

In bivariate analysis of survival, patients who had multiple CPR had lower rates of survival to discharge (11.3% vs 23.4%, P<0.001). Results were similar (11.6% for multiple CPR vs 22.5% for 1 CPR, P<0.001) when all patients who had CPR but did not have valid timing data were excluded in sensitivity analyses. Further stratification showed that survival to discharge decreased by >40% for each increase in CPR attempt (23.4%, 11.9%, and 6.7% for 1, 2, and 3 CPR attempts, respectively, P<0.001; Figure 2). After adjustment, multiple CPR versus 1 CPR during a hospitalization was independently associated with a lower likelihood of survival to discharge (adjusted OR: 0.41, 95% CI: 0.37‐0.44, P<0.001; Table 3).

Figure 2

Survivors with multiple CPR were less likely to be discharged home compared with survivors with 1 CPR (19.3% vs 29.9%, respectively, P<0.001); 1 in 15 survivors of multiple CPR were discharged to a hospice (6.8%) versus 1 in 23 1‐CPR survivors (4.3%; P=0.002). Mean length of stay was 5.8 versus 5.5 days for patients who had multiple CPR versus 1 CPR, respectively (P<0.001), and 16.0 versus 10.5 days for discharged survivors of multiple CPR versus 1 CPR (P<0.001). The average cost per day of hospitalization was higher for recipients of multiple CPR versus 1 CPR ($4484.60 vs $3581.40, P<0.001). The aggregate cost of hospitalization for 1‐time CPR recipients doubled between the years 2001 and 2009 (from $1.3 billion to $2.9 billion); that of recipients of multiple CPR attempts quadrupled in the same time frame (from $38.6 million to $160.7 million).

DISCUSSION

A number of studies have investigated the epidemiology of patients in whom CPR is attempted.[2, 3, 5, 20, 23, 24] Several pre‐, intra‐, and post‐resuscitation factors have been shown to affect the survival of resuscitated patients.[6, 7, 25, 26] To our knowledge, neither the epidemiology of hospitalized patients in whom resuscitation is attempted multiple times nor the prognostic value of multiple CPR attempts has been investigated. In this study, we found that multiple resuscitations are more commonly performed on younger, generally sicker patients; their outcomes are significantly compromised compared with patients who are resuscitated once during their hospitalization.

There was a steep decline in survival based on the number of resuscitation events. In multivariate analysis, patients who had multiple CPR were 2.5‐fold less likely to survive their hospitalization; survivors of multiple CPR also were more likely to be discharged to a hospice. Overall, this is indicative of clinical deterioration and prolongation of dying should a patient suffer multiple cardiopulmonary arrests during a hospitalization. The robust inverse relationship between multiple CPR and survival to discharge has implications for the development of prognostic models of outcomes following CPR, as previously designed prediction models of CPR outcomes such as the Cardiac Arrest Survival Post‐Resuscitation In‐hospital (CASPRI) score,[25] Pre‐Arrest Morbidity (PAM) score,[27] and Prognosis After Resuscitation (PAR) score[28] do not include multiple resuscitations as a variable of interest.

In‐hospital factors were found to be more important than patient factors, such as comorbidities or race, in determining the likelihood of multiple CPR attempts. Hospital teaching status and region remained significantly associated with likelihood of multiple CPR attempts. This is in agreement with studies that have described demographic and regional variation in utilization of do‐not‐resuscitate orders.[29, 30] These findings suggest substantial heterogeneity in the clinical culture and hospital practices across the United States regarding preemptive discussions about resuscitation. This means that where a patient receives care is a significant determinant of their probability of undergoing multiple CPR.

It is known that older patients are more likely to have advance directive orders[30, 31] and possibly document their wishes with regard to further resuscitation efforts. There also may be an inclination toward more aggressive care for younger adults compared with those of an advanced age. Uncertainty about a patient's goals of care likely feeds into an increased possibility of multiple resuscitation attempts; this may explain why neurologic compromise and being on ventilator support were independently associated with likelihood of multiple CPR, as these patients often have lost their ability to actively participate in decision‐making. The results of this study highlight the importance of engaging patients with a plausible risk of cardiopulmonary arrest about their goals for care and advance directives in a timely manner, regardless of age.

We found that the care of patients who undergo multiple resuscitations is associated with a higher cost of hospitalization than for patients in whom resuscitation is attempted once during their hospitalization. In addition, there was an exponential increase in aggregate cost over time for multiple CPR recipients compared with 1‐time CPR recipients. In a prior study, Ebell and Kruse showed an exponential inverse relationship between cost per surviving patient and rate of survival to discharge.[32] Considering that 93.3% of patients who had 3 resuscitation attempts died during their hospitalization, and that hospital‐level factors appear to play a significant role in likelihood of multiple CPR, consensus guidelines regarding the appropriateness of 3 resuscitation attempts during a single hospitalization may be relevant to aid the care of these patients.

Although the NIS is well‐validated,[18] there are some limitations. Whereas CPR incidence in this study (2.5 per 1000 hospitalizations) is within estimates (15 arrests per 1000 hospitalizations) reported in previous studies,[3, 5] potential undercoding of multiple CPR may explain why the multiple‐CPR rate in this study is lower than re‐arrest estimates provided in published studies.[2, 33] Indeed, accurate calculation of re‐arrest rates requires data on do‐not‐resuscitate orders instituted after successful resuscitation, which are not provided in the NIS. Information on patient‐provider discussions about CPR or prognosis is not included. Data regarding the underlying cause and type of arrest rhythm, rates of return to spontaneous circulation, length of code, patient location, critical‐care resources and length of critical‐care stay, availability of rapid‐response/code teams, time to defibrillation, use of therapeutic hypothermia, adherence to resuscitation guidelines, quality of CPR, and long‐term follow‐up are not included in the database. Presenting rhythms were not assessed, as there are no ICD‐9 codes for asystole and pulseless electrical activity. The NIS is de‐identified; therefore, chart review to assess the validity of codes is impossible. However, our sensitivity analyses indicate the reliability of using the number of occurrences of the CPR code as a marker of multiple CPR. The strength of our study lies in the use of data that provide a population‐level insight into the epidemiology of patients resuscitated multiple times during their hospitalization, and their outcomes.

Decision‐making about CPR is at the center of a complex debate that incorporates often divergent clinical, economic, ethical, and personal issues. As debate continues regarding when to not resuscitate,[34, 35, 36, 37] studies that explore the public perspective of survival thresholds for the provision of multiple resuscitations will be crucial. As competition for finite healthcare dollars escalates, stratified analyses of the cost implications of resuscitation care are essential. Studies are needed to examine the impact of a history of successful resuscitation in a previous hospitalization on outcomes following CPR in a subsequent hospitalization. Overall, our study fills an important knowledge gap in resuscitation practice and outcomes in the United States and highlights the importance of discussing resuscitation options between a patient and his or her family on hospital admission and, if needed, again after the first successful resuscitation attempt.

Cardiopulmonary resuscitation (CPR) is a potentially lifesaving intervention associated with intense resource utilization and poor outcomes.[1, 2, 3] CPR is the default intervention for hospitalized patients in cardiopulmonary arrest in the United States. The most common measure of successful in‐hospital CPR reported in the literature is survival to (hospital) discharge, with most estimates between 13% and 37%.[3, 4, 5, 6] Poor rates of survival to discharge may be explained by use of CPR in patients for whom it was not originally intended, such as the very elderly with multiple illnesses or the terminally ill.[7, 8] Use of CPR in patients unlikely to benefit may be due to a physician's inability to estimate the probability of survival, desire to offer hope to patients, fear of litigation, and poor communication with patients about goals of care.[7, 8, 9, 10]

The general public has overly optimistic expectations about CPR; surveys have reported perceived survival after CPR of up to 90%.[11, 12, 13] Although objective information substantially affects patient preferences for resuscitation,[14] prognosis is rarely discussed during code status encounters[15, 16]; physician estimates of prognosis also are often inaccurate.[9, 17] With a scarcity of data describing the characteristics of patients undergoing multiple CPR attempts, and their outcomes, patients and their families could have false expectations about the likely outcomes from multiple CPR attempts, because physician counsel is not well‐informed.

In this study, we examine the epidemiology of in‐hospital CPR recipients stratified by the number of occurrences of CPR during a single hospitalization, along with their outcomes. We hypothesize that recipients of multiple CPR during a single hospitalization are an epidemiologically distinct group compared with those who receive CPR once during their hospitalization, and that their outcomes are worse.

METHODS

RESULTS

Of a total of 65,308,185 adults hospitalized between the years 2000 and 2009, there were 166,519 CPR recipients, yielding a CPR incidence of 2.5 per 1000 hospitalizations. Among CPR recipients, 96.6% (n=166,899) had 1 CPR and 3.4% (n=5620) had multiple CPR during their hospitalization (range, 111 CPR). When further stratified, 3% had 2 CPR attempts (n=4949) and 0.4% (n=671) had 3 CPR attempts.

Compared with patients who had 1 CPR, those who had multiple CPR were more often younger (median age, 71 vs 67 years), nonwhite, and in a low‐income quartile (all P<0.001; Table 1). Rates of admission from a nursing facility (3.3% for the 1‐CPR group vs 3.1% for the multiple‐CPR group, P=0.65) or as a trauma (0.3% for the 1‐CPR group and 0.4% for the multiple‐CPR group, P=0.34) were similar.

Patients who had multiple CPR had slightly higher mean CCI scores (2.7 vs 2.6, P=0.02). They had higher rates of neurologic compromise and aggressive interventions; they were also more commonly treated in nonteaching hospitals, and in the western region of the United States (Table 2). After multivariate analysis, several patient, clinical, and hospital factors were independently associated with occurrence of multiple CPR (Figure 1).

Figure 1

In bivariate analysis of survival, patients who had multiple CPR had lower rates of survival to discharge (11.3% vs 23.4%, P<0.001). Results were similar (11.6% for multiple CPR vs 22.5% for 1 CPR, P<0.001) when all patients who had CPR but did not have valid timing data were excluded in sensitivity analyses. Further stratification showed that survival to discharge decreased by >40% for each increase in CPR attempt (23.4%, 11.9%, and 6.7% for 1, 2, and 3 CPR attempts, respectively, P<0.001; Figure 2). After adjustment, multiple CPR versus 1 CPR during a hospitalization was independently associated with a lower likelihood of survival to discharge (adjusted OR: 0.41, 95% CI: 0.37‐0.44, P<0.001; Table 3).

Figure 2

Survivors with multiple CPR were less likely to be discharged home compared with survivors with 1 CPR (19.3% vs 29.9%, respectively, P<0.001); 1 in 15 survivors of multiple CPR were discharged to a hospice (6.8%) versus 1 in 23 1‐CPR survivors (4.3%; P=0.002). Mean length of stay was 5.8 versus 5.5 days for patients who had multiple CPR versus 1 CPR, respectively (P<0.001), and 16.0 versus 10.5 days for discharged survivors of multiple CPR versus 1 CPR (P<0.001). The average cost per day of hospitalization was higher for recipients of multiple CPR versus 1 CPR ($4484.60 vs $3581.40, P<0.001). The aggregate cost of hospitalization for 1‐time CPR recipients doubled between the years 2001 and 2009 (from $1.3 billion to $2.9 billion); that of recipients of multiple CPR attempts quadrupled in the same time frame (from $38.6 million to $160.7 million).

DISCUSSION

A number of studies have investigated the epidemiology of patients in whom CPR is attempted.[2, 3, 5, 20, 23, 24] Several pre‐, intra‐, and post‐resuscitation factors have been shown to affect the survival of resuscitated patients.[6, 7, 25, 26] To our knowledge, neither the epidemiology of hospitalized patients in whom resuscitation is attempted multiple times nor the prognostic value of multiple CPR attempts has been investigated. In this study, we found that multiple resuscitations are more commonly performed on younger, generally sicker patients; their outcomes are significantly compromised compared with patients who are resuscitated once during their hospitalization.

There was a steep decline in survival based on the number of resuscitation events. In multivariate analysis, patients who had multiple CPR were 2.5‐fold less likely to survive their hospitalization; survivors of multiple CPR also were more likely to be discharged to a hospice. Overall, this is indicative of clinical deterioration and prolongation of dying should a patient suffer multiple cardiopulmonary arrests during a hospitalization. The robust inverse relationship between multiple CPR and survival to discharge has implications for the development of prognostic models of outcomes following CPR, as previously designed prediction models of CPR outcomes such as the Cardiac Arrest Survival Post‐Resuscitation In‐hospital (CASPRI) score,[25] Pre‐Arrest Morbidity (PAM) score,[27] and Prognosis After Resuscitation (PAR) score[28] do not include multiple resuscitations as a variable of interest.

In‐hospital factors were found to be more important than patient factors, such as comorbidities or race, in determining the likelihood of multiple CPR attempts. Hospital teaching status and region remained significantly associated with likelihood of multiple CPR attempts. This is in agreement with studies that have described demographic and regional variation in utilization of do‐not‐resuscitate orders.[29, 30] These findings suggest substantial heterogeneity in the clinical culture and hospital practices across the United States regarding preemptive discussions about resuscitation. This means that where a patient receives care is a significant determinant of their probability of undergoing multiple CPR.

It is known that older patients are more likely to have advance directive orders[30, 31] and possibly document their wishes with regard to further resuscitation efforts. There also may be an inclination toward more aggressive care for younger adults compared with those of an advanced age. Uncertainty about a patient's goals of care likely feeds into an increased possibility of multiple resuscitation attempts; this may explain why neurologic compromise and being on ventilator support were independently associated with likelihood of multiple CPR, as these patients often have lost their ability to actively participate in decision‐making. The results of this study highlight the importance of engaging patients with a plausible risk of cardiopulmonary arrest about their goals for care and advance directives in a timely manner, regardless of age.

We found that the care of patients who undergo multiple resuscitations is associated with a higher cost of hospitalization than for patients in whom resuscitation is attempted once during their hospitalization. In addition, there was an exponential increase in aggregate cost over time for multiple CPR recipients compared with 1‐time CPR recipients. In a prior study, Ebell and Kruse showed an exponential inverse relationship between cost per surviving patient and rate of survival to discharge.[32] Considering that 93.3% of patients who had 3 resuscitation attempts died during their hospitalization, and that hospital‐level factors appear to play a significant role in likelihood of multiple CPR, consensus guidelines regarding the appropriateness of 3 resuscitation attempts during a single hospitalization may be relevant to aid the care of these patients.

Although the NIS is well‐validated,[18] there are some limitations. Whereas CPR incidence in this study (2.5 per 1000 hospitalizations) is within estimates (15 arrests per 1000 hospitalizations) reported in previous studies,[3, 5] potential undercoding of multiple CPR may explain why the multiple‐CPR rate in this study is lower than re‐arrest estimates provided in published studies.[2, 33] Indeed, accurate calculation of re‐arrest rates requires data on do‐not‐resuscitate orders instituted after successful resuscitation, which are not provided in the NIS. Information on patient‐provider discussions about CPR or prognosis is not included. Data regarding the underlying cause and type of arrest rhythm, rates of return to spontaneous circulation, length of code, patient location, critical‐care resources and length of critical‐care stay, availability of rapid‐response/code teams, time to defibrillation, use of therapeutic hypothermia, adherence to resuscitation guidelines, quality of CPR, and long‐term follow‐up are not included in the database. Presenting rhythms were not assessed, as there are no ICD‐9 codes for asystole and pulseless electrical activity. The NIS is de‐identified; therefore, chart review to assess the validity of codes is impossible. However, our sensitivity analyses indicate the reliability of using the number of occurrences of the CPR code as a marker of multiple CPR. The strength of our study lies in the use of data that provide a population‐level insight into the epidemiology of patients resuscitated multiple times during their hospitalization, and their outcomes.

Decision‐making about CPR is at the center of a complex debate that incorporates often divergent clinical, economic, ethical, and personal issues. As debate continues regarding when to not resuscitate,[34, 35, 36, 37] studies that explore the public perspective of survival thresholds for the provision of multiple resuscitations will be crucial. As competition for finite healthcare dollars escalates, stratified analyses of the cost implications of resuscitation care are essential. Studies are needed to examine the impact of a history of successful resuscitation in a previous hospitalization on outcomes following CPR in a subsequent hospitalization. Overall, our study fills an important knowledge gap in resuscitation practice and outcomes in the United States and highlights the importance of discussing resuscitation options between a patient and his or her family on hospital admission and, if needed, again after the first successful resuscitation attempt.