Cost of intensive care unit-acquired bloodstream infections
Introduction
Bloodstream infection (BSI) is a serious complication of critical illness.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Although a significant body of literature exists investigating specific aetiologies or foci of intensive-care-unit-acquired (ICU-acquired) BSI,11, 12, 13, 14, 15, 16 few studies have attempted to comprehensively define the impact of ICU-acquired BSI by determining the length of stay, cost and mortality attributable to these infections.4, 10, 17, 18 Dimick et al. conducted a cohort study in an American surgical ICU and found an increased length of stay and cost associated with catheter-related BSI.18 They did not assess attributable mortality. Rello et al. reported a matched study of catheter-related BSI in a mixed medical–surgical ICU in Spain and found increased costs associated with development of these infections.17 They did not observe a significant difference in either attributable length of stay or mortality although their study was small (49 matched pairs). DiGiovine et al. conducted another study with 68 matched pairs in an American medical ICU and found significantly increased costs and length of stay, but not mortality, associated with primary ICU-acquired BSI.10 Pittet et al. conducted the prior largest matched study to date (86 matched pairs) in a single American tertiary care surgical ICU, and found that ICU-acquired BSI was associated with significantly increased length of stay, mortality and cost.4 The present authors recently identified that development of an ICU-acquired BSI was independently associated with mortality in a cohort study conducted among all patients admitted to ICUs in the Calgary Health Region (CHR).19 However, costs and attributable length of stay were not assessed.
The summation of the available evidence to date supports the notion that ICU-acquired BSI results in excess length of stay and cost.4, 10, 17, 18 However, due to the small number of subjects from selected populations and crude methods of costing in many studies, significant variability in the estimates of attributable length of stay and cost has occurred.4, 10, 17, 18, 20 Furthermore, only the authors' previous cohort study and one other matched study conducted in a surgical ICU demonstrated a significantly increased risk of death attributable to ICU-acquired BSI.4, 19 Therefore, the authors conducted a matched cohort study within the population of all critically ill patients in a large Canadian health region over a three-year period to determine the attributable mortality, length of stay and cost associated with ICU-acquired BSI.
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Study population
The CHR administers all acute hospital care to the residents of the cities of Calgary and Airdrie and approximately 20 nearby small towns, villages and hamlets (population ≈ 1 million). All ICUs within the CHR are closed units staffed by fully trained intensivists and are administered by the Department of Critical Care Medicine, University of Calgary and CHR. These ICUs include a 14-bed cardiovascular surgery ICU (CVICU) and a 22-bed multi-system ICU that serves as the regional trauma and
Results
During surveillance, 160 cases of ICU-acquired BSI occurred among 4473 patients during their first admission to an ICU in the CHR. Of these, 144 (90%) were successfully matched to control patients that did not have ICU-acquired BSI. Among the mandatory matching criteria, one matched pair was chronic dialysis dependent and 73/144 (51%) were surgical patients. Ninety-six (67%) of the 144 case patients were matched using initial criteria, and 48 (33%) were matched using the a priori defined
Discussion
This study demonstrates that development of an ICU-acquired BSI results in significantly lower patient survival and higher resource use. Moreover, patients who develop these infections suffer increased morbidity as measured by excess length of stay. Patients presumably also experience the potential discomfort of management changes arising from the diagnosis of an ICU-acquired BSI, such as increased investigation and interventions including, but not limited to, intravascular access changes and
Conclusion
The article has reported the largest study to date evaluating the cost of ICU-acquired BSI. As a result of the methodological rigor employed, the results presented herein should be valid and generalizable elsewhere. It has been clearly demonstrated that development of an ICU-acquired BSI adversely impacts patient morbidity and mortality, and results in significant excess healthcare resource consumption. These data support allocation of scarce healthcare resources to infection prevention and
Acknowledgements
This study was funded by a grant from the Calgary Health Region Research and Development Fund. The authors thank Linda Greensword, Peter Rymkiewicz and Doris Hawkins, Financial Services and Quality Improvement and Health Information, Calgary Health Region, for providing costing information.
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