Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics
Introducción: Las infecciones asociadas a catéter venoso central (IACVC) se encuentran dentro de las patologías que aumentan la mortalidad y morbilidad en pacientes hospitalizados con algún tipo de dispositivo, estando consideradas como parte los indicadores de gestión clínica. Objetivo: Describir l...
- Autores:
-
Gomez Boada, Diego Fernando
Parra Amaris, Camilo Andres
- Tipo de recurso:
- Trabajo de grado de pregrado
- Fecha de publicación:
- 2021
- Institución:
- Universidad Militar Nueva Granada
- Repositorio:
- Repositorio UMNG
- Idioma:
- spa
- OAI Identifier:
- oai:repository.unimilitar.edu.co:10654/37418
- Acceso en línea:
- http://hdl.handle.net/10654/37418
- Palabra clave:
- Central venous catheter-associated infection
Direct costs
Catheter-associated bacteraemia
Health related infection
Cateterismo Venoso Central
Infecciones Relacionadas con Catéteres
Infección Hospitalaria
Control de Infecciones
Infección asociada a catéter venoso central
Costos directos
Bacteriemia asociada a catéter
Infección relacionada con el cuidado de la salud
- Rights
- openAccess
- License
- http://creativecommons.org/licenses/by-nc-nd/4.0/
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dc.title.spa.fl_str_mv |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
dc.title.translated.spa.fl_str_mv |
Analysis and cost of infection associated with a central venous catheter in the Central Military Hospital using the Health Analytics tool |
title |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
spellingShingle |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics Central venous catheter-associated infection Direct costs Catheter-associated bacteraemia Health related infection Cateterismo Venoso Central Infecciones Relacionadas con Catéteres Infección Hospitalaria Control de Infecciones Infección asociada a catéter venoso central Costos directos Bacteriemia asociada a catéter Infección relacionada con el cuidado de la salud |
title_short |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
title_full |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
title_fullStr |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
title_full_unstemmed |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
title_sort |
Análisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health Analytics |
dc.creator.fl_str_mv |
Gomez Boada, Diego Fernando Parra Amaris, Camilo Andres |
dc.contributor.advisor.none.fl_str_mv |
Uscategui Ruiz, Adriana Catalina Carreño Jaimes, Marisol |
dc.contributor.author.none.fl_str_mv |
Gomez Boada, Diego Fernando Parra Amaris, Camilo Andres |
dc.subject.keywords.spa.fl_str_mv |
Central venous catheter-associated infection Direct costs Catheter-associated bacteraemia Health related infection |
topic |
Central venous catheter-associated infection Direct costs Catheter-associated bacteraemia Health related infection Cateterismo Venoso Central Infecciones Relacionadas con Catéteres Infección Hospitalaria Control de Infecciones Infección asociada a catéter venoso central Costos directos Bacteriemia asociada a catéter Infección relacionada con el cuidado de la salud |
dc.subject.decs.spa.fl_str_mv |
Cateterismo Venoso Central Infecciones Relacionadas con Catéteres Infección Hospitalaria Control de Infecciones |
dc.subject.proposal.spa.fl_str_mv |
Infección asociada a catéter venoso central Costos directos Bacteriemia asociada a catéter Infección relacionada con el cuidado de la salud |
description |
Introducción: Las infecciones asociadas a catéter venoso central (IACVC) se encuentran dentro de las patologías que aumentan la mortalidad y morbilidad en pacientes hospitalizados con algún tipo de dispositivo, estando consideradas como parte los indicadores de gestión clínica. Objetivo: Describir las características de la infección asociada a catéter venoso central y los costos directos asociados a la misma en el Hospital Militar Central utilizando una herramienta de Health Anlytics en el periodo 2017 hasta el 2020. Metodología: Estudio de evaluación económica, estimación de costos directos relacionados con la infección asociada a CVC. Se utilizo la metodología de costos directos, por medio de la revisión de registros médicos electrónicos con estimación de costos de acuerdo con las recomendaciones del IETS. Análisis estadístico bivariado para identificar diferencias estadísticamente significativas Resultados: La población incluida para el análisis fue un total de 821 CVC entre 2017 y 2020. En relación con el análisis bivariado se identificaron diferencias estadísticamente significativas en el caso sexo, edad, frecuencia de comorbilidades, especialidad tratante, numero de vías del CVC, sitio de inserción, profesional a cargo de inserción, lugar del procedimiento, duración en días del CVC, tiempo de hospitalización, tiempo de estancia en hospitalización convencional, tiempo de estancia en Unidad de Cuidado Intensivo, uso de Ventilacion Mecanica Invasiva, uso de Ventilacion Mecanica No Invasiva, uso de Nutricion Parenteral Total, uso de Antibiotico, uso de Terapia de reemplazo renal. Para el análisis de costos directos a nivel hospitalario se identificó un costo total en lo pacientes sin diagnóstico de infección CVC fue de $31.822.751 COP (RIC $16.772.009-69.038.536 COP). Se identificó una diferencia estadísticamente significativa entre los pacientes con infección asociada al CVC comparado con aquellos pacientes sin infección para los casos de costos asociados a hospitalización (p=0,013), a procedimientos (p=0,0002), a imágenes diagnosticas (p=0,061), a terapia de reemplazo renal (p=0,0003) y costos totales (p=0,028). Conclusiones El presente estudio permite confirmar hallazgos previamente descritos en nuestra institución de una frecuencia similar de IACVC al compararse con reportes nacionales y mayor en comparación con lo repostado por literatura anglosajona, así mismo permite confirmar el incremento de los costos directos asociados a la presencia de IACVC, en donde se evidencia un incremento en los costos asociados a hospitalización, a procedimientos, a imágenes diagnosticas, a terapia de reemplazo renal y costos totales de forma estadísticamente significativa. |
publishDate |
2021 |
dc.date.accessioned.none.fl_str_mv |
2021-02-22T16:28:44Z |
dc.date.available.none.fl_str_mv |
2021-02-22T16:28:44Z |
dc.date.issued.none.fl_str_mv |
2021-01-28 |
dc.type.local.spa.fl_str_mv |
Tesis/Trabajo de grado - Monografía - Especialización |
dc.type.driver.spa.fl_str_mv |
info:eu-repo/semantics/bachelorThesis |
dc.type.coar.*.fl_str_mv |
http://purl.org/coar/resource_type/c_7a1f |
format |
http://purl.org/coar/resource_type/c_7a1f |
dc.identifier.uri.none.fl_str_mv |
http://hdl.handle.net/10654/37418 |
dc.identifier.instname.spa.fl_str_mv |
instname:Universidad Militar Nueva Granada |
dc.identifier.reponame.spa.fl_str_mv |
reponame:Repositorio Institucional Universidad Militar Nueva Granada |
dc.identifier.repourl.spa.fl_str_mv |
repourl:https://repository.unimilitar.edu.co |
url |
http://hdl.handle.net/10654/37418 |
identifier_str_mv |
instname:Universidad Militar Nueva Granada reponame:Repositorio Institucional Universidad Militar Nueva Granada repourl:https://repository.unimilitar.edu.co |
dc.language.iso.spa.fl_str_mv |
spa |
language |
spa |
dc.relation.references.spa.fl_str_mv |
Hajjej Z, Nasri M, Sellami W, Gharsallah H, Labben I, Ferjani M. Incidence, risk factors and microbiology of central vascular catheterrelated bloodstream infection in an intensive care unit. J Infect Chemother. 2014;20(3):163–8. Esposito S, Purrello SM, Bonnet E, Novelli A, Tripodi F, Pascale R, et al. Central venous catheter-related biofilm infections: An up-to-date focus on meticillin-resistant Staphylococcus aureus. J Glob Antimicrob Resist. 2013;1(2):71–8 Kandilov A, Coomer N, Dalton K. The Impact of Hospital-Acquired Conditions on Medicare Program Payments. Medicare Medicaid Res Rev. 2014;4(4):E1–23. Herzer KR, Niessen L, Constenla DO, Ward WJ, Pronovost PJ. Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA. BMJ Open. 2014;4(9). Moreno CA, Rosenthal VD, Olarte N, Gomez WV, Sussmann O, Agudelo JG, et al. Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium. Infect Control Hosp Epidemiol. 2006 Apr;27(4):349–56. Zingg W, Sax H, Inan C, Cartier V, Diby M, Clergue F, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. J Hosp Infect. 2009;73(1):41–6. Rodríguez-Baño J, López-Prieto MD, Portillo MM, Retamar P, Natera C, Nuño E, et al. Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals. Clin Microbiol Infect. 2010 Sep;16(9):1408–13. Richet H, Hubert B, Nitemberg G, Andremont A, Buu-Hoi A, Ourbak P, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990;28(11):2520–5. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19(11):842–5. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med. 2002;30(2):454–60. M.T. O, D.F. K, M.B. E. Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients. J Parenter Enter Nutr. 2007;31(4):302–5. Zürcher M, Tramèr MR, Walder B. Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: A quantitative systematic review. Anesth Analg. 2004;99(1):177–82. Chen HS, Wang FD, Lin M, Lin YC, Huang LJ, Liu CY. Risk factors for central venous catheter-related infections in general surgery. J Microbiol Immunol Infect. 2006;39(3):231–6. Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jul 1;49(1):1–45. Zingg W, Cartier-Fässler V, Walder B. Central venous catheter-associated infections. Best Pract Res Clin Anaesthesiol. 2008;22(3):407–21. Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters (Review). Chochrane Libr. 2010;(3):1–29. Webster J, Osborne S, Rickard CM, Marsh N. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane database Syst Rev. 2019;1:CD007798. Tacconelli E, Smith G, Hieke K, Lafuma A, Bastide P. Epidemiology, medical outcomes and costs of catheter-related bloodstream infections in intensive care units of four European countries: literature- and registry-based estimates. J Hosp Infect. 2009;72(2):97–103. Peng S, Lu Y. Clinical epidemiology of central venous catheter-related bloodstream infections in an intensive care unit in China. J Crit Care. 2013;28(3):277–83. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial Infections in Pediatric Intensive Care Units in the United States. Pediatrics. 2004;103(4):e39–e39. Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;67(2):168–74. Ramirez Barba EJ, Rosenthal VD, Higuera F, Oropeza MS, Hernández HT, López MS, et al. Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals. Am J Infect Control. 2006;34(4):244–7. Rosenthal VD, Guzmán S, Crnich C. Device-Associated Nosocomial Infection Rates in Intensive Care Units of Argentina. Infect Control Hosp Epidemiol. 2004 Mar 2;25(3):251–5. Ávila Guzmán, Miriam Lucia Moreno Peralta, Colombia Torres Pinzón H. Factores de riesgo asociados a infección por catéter venoso central en pacientes hospitalizados mayores de 18 años en el Hospital Militar Central de Bogotá Colombia entre enero y abril de 2008 ulido Daza SL, Cardona Vargas F, Jaramillo L, Rodrigo Bastidas A. Incidencia de la bacteriemia asociada a catéter venoso central y prevalencia de los diferentes factores de riesgo para la misma en el hospital militar central (homic) entre el año 2013 al 2015. 2016. Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med. 2006;34(8):2084–9 Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg. 2001;136(2):229–34 Rosa E, Borba A. Infección De Corriente Sanguínea En Pacientes Con Catéter Venosos Bloodstream Infections Among Patients Using Central Venous. Online. 2007;15(3). Brunelli SM, Turenne W, Sibbel S, Hunt A, Pfaffle A. Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters. J Crit Care. 2016;35:69–74. Blot SI, Depuydt P, Annemans L, Benoit D, Hoste E, De Waele JJ, et al. Clinical and Economic Outcomes in Critically Ill Patients with Nosocomial Catheter-Related Bloodstream Infections. Clin Infect Dis. 2005;41(11):1591–8. Renaud B, Brun-Buisson C. Outcomes of primary and catheter-related bacteremia: A cohort and case-control study in critically III patients. Am J Respir Crit Care Med. 2001;163(7):1584–90. Leistner R, Hirsemann E, Bloch A, Gastmeier P, Geffers C. Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): A matched prospective cohort study. Infection. 2014;42(1):31–6. Guembe M, Pérez-Granda MJ, Capdevila JA, Barberán J, Pinilla B, Martín-Rabadán P, et al. Nationwide study on peripheral-venous-catheter-associated-bloodstream infections in internal medicine departments. J Hosp Infect. 2017;97(3):260–6. Cai Y, Zhu M, Sun W, Cao X, Wu H. Study on the cost attributable to central venous catheter-related bloodstream infection and its influencing factors in a tertiary hospital in China. Health Qual Life Outcomes. 2018;16(1):2–7. Nakamura I, Fukushima S, Hayakawa T, Sekiya K, Matsumoto T. The additional costs of catheter-related bloodstream infections in intensive care units. Am J Infect Control. 2015;43(10):1046–9. del Pozo JL, Serrera A, Martínez-Cuesta A, Leiva J, Penadés J, Lasa I. Biofilm related infections: Is there a place for conservative treatment of port-related bloodstream infections? Int J Artif Organs. 2006;29(4):379–86 Stevens V, Geiger K, Concannon C, Nelson RE, Brown J, Dumyati G. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2014;20(5):O318–24. Hsu E, Lin D, Evans SJ, Hamid KS, Frick KD, Yang T, et al. Doing Well by Doing Good: Assessing the Cost Savings of an Intervention to Reduce Central Line–Associated Bloodstream Infections in a Hawaii Hospital. Am J Med Qual. 2014;29(1):13–9. Voor in ‘t holt AF, Helder OK, Vos MC, Schafthuizen L, Sülz S, van den Hoogen A, et al. Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis. Int J Nurs Stud. 2017;69:34–40. Cooper K, Frampton G, Harris P, Jones J, Cooper T, Graves N, et al. Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective? J Hosp Infect. 2014;86(1):47–52. Shimoyama Y, Umegaki O, Agui T, Kadono N, Komasawa N, Minami T. An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study. JA Clin Reports. 2017;3(1):2–7. Musu M, Finco G, Mura P, Landoni G, Piazza MF, Messina M, et al. Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units. J Hosp Infect. 2017;97(3):275–81 Cohen ER, Feinglass J, Barsuk JH, Barnard C, O’Donnell A, McGaghie WC, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010;5(2):98–102 Nelson RE, Angelovic AW, Nelson SD, Gleed JR, Drews FA. An Economic Analysis of Adherence Engineering to Improve Use of Best Practices during Central Line Maintenance Procedures. Infect Control Hosp Epidemiol. 2015;36(5):550–6. Halton KA, Cook D, Paterson DL, Safdar N, Graves N. Cost-effectiveness of a central venous catheter care bundle. PLoS One. 2010;5(9):1–11. Cicalini S, Palmieri F, Petrosillo N. Clinical review: New technologies for prevention of intravascular catheter-related infections. Crit Care. 2004;8(3):157–62 Nuckols TK, Keeler E, Morton SC, Anderson L, Doyle B, Booth M, et al. Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: A systematic review. JAMA Intern Med. 2016;176(12):1843–54. O’Horo JC, Silva GLM, Safdar N. Anti-infective locks for treatment of central line-associated bloodstream infection: A systematic review and meta-analysis. Am J Nephrol. 2011;34(5):415–22. Civetta JM, Hudson-Civetta J, Ball S. Decreasing catheter-related infection and hospital costs by continuous quality improvement. Vol. 24, Critical Care Medicine. 1996. p. 1660–5. Veenstra DL, Saint S, Sullivan SD. Central Venous Catheters for the Prevention of Catheter-Related Bloodstream Infection. JAMA. 1999;282:554–60 Heimann SM, Biehl LM, Vehreschild JJ, Franke B, Cornely OA, Vehreschild MJGT. Chlorhexidine-containing dressings in the prevention of central venous catheter-related bloodstream infections: A cost and resource utilization analysis. Am J Infect Control. 2018;46(9):992–7 Lorente L, Lecuona M, Jiménez A, Santacreu R, Raja L, Gonzalez O, et al. Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs. Am J Infect Control. 2014;42(3):321–4. Lorente L, Lecuona M, Ramos MJ, Jiménez A, Mora ML, Sierra A. Lower associated costs using rifampicin-miconazoleimpregnated catheters compared with standard catheters. Am J Infect Control. 2011;39(10):895–7 Lorente L. Antimicrobial-impregnated catheters for the prevention of catheter-related bloodstream infections. World J Crit Care Med. 2016;5(2):137 Halton KA, Cook DA, Whitby M, Paterson DL, Graves N. Cost effectiveness of antimicrobial catheters in the intensive care unit: Addressing uncertainty in the decision. Crit Care. 2009;13(2):1–10. Crawford AG, Fuhr JP, Rao B. Cost-benefit analysis of chlorhexidine gluconate dressing in the prevention of catheter-related bloodstream infections. Infect Control Hosp Epidemiol. 2004 Aug;25(8):668–74 Schwebel C, Lucet JC, Vesin A, Arrault X, Calvino-Gunther S, Bouadma L, et al. Economic evaluation of chlorhexidine-impregnated sponges for preventing catheter-related infections in critically ill adults in the Dressing Study. Crit Care Med. 2012;40(1):11–7 Maenthaisong R, Chaiyakunapruk N, Thamlikitkul V. Cost-effectiveness analysis of chlorhexidine gluconate compared with povidone-iodine solution for catheter-site care in Siriraj Hospital, Thailand. J Med Assoc Thail. 2006;89(SUPPL. 5):94–101. Fraher MH, Collins CJ, Bourke J, Phelan D, Lynch M. Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections. J Hosp Infect. 2009;73(2):129–34. National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004 Dec;32(8):470–85 |
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Universidad Militar Nueva Granada |
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Uscategui Ruiz, Adriana CatalinaCarreño Jaimes, MarisolGomez Boada, Diego FernandoParra Amaris, Camilo AndresEspecialista en Medicina InternaHospital Militar Central, Bogota, Colombia2017-2020Medicina2021-02-22T16:28:44Z2021-02-22T16:28:44Z2021-01-28http://hdl.handle.net/10654/37418instname:Universidad Militar Nueva Granadareponame:Repositorio Institucional Universidad Militar Nueva Granadarepourl:https://repository.unimilitar.edu.coIntroducción: Las infecciones asociadas a catéter venoso central (IACVC) se encuentran dentro de las patologías que aumentan la mortalidad y morbilidad en pacientes hospitalizados con algún tipo de dispositivo, estando consideradas como parte los indicadores de gestión clínica. Objetivo: Describir las características de la infección asociada a catéter venoso central y los costos directos asociados a la misma en el Hospital Militar Central utilizando una herramienta de Health Anlytics en el periodo 2017 hasta el 2020. Metodología: Estudio de evaluación económica, estimación de costos directos relacionados con la infección asociada a CVC. Se utilizo la metodología de costos directos, por medio de la revisión de registros médicos electrónicos con estimación de costos de acuerdo con las recomendaciones del IETS. Análisis estadístico bivariado para identificar diferencias estadísticamente significativas Resultados: La población incluida para el análisis fue un total de 821 CVC entre 2017 y 2020. En relación con el análisis bivariado se identificaron diferencias estadísticamente significativas en el caso sexo, edad, frecuencia de comorbilidades, especialidad tratante, numero de vías del CVC, sitio de inserción, profesional a cargo de inserción, lugar del procedimiento, duración en días del CVC, tiempo de hospitalización, tiempo de estancia en hospitalización convencional, tiempo de estancia en Unidad de Cuidado Intensivo, uso de Ventilacion Mecanica Invasiva, uso de Ventilacion Mecanica No Invasiva, uso de Nutricion Parenteral Total, uso de Antibiotico, uso de Terapia de reemplazo renal. Para el análisis de costos directos a nivel hospitalario se identificó un costo total en lo pacientes sin diagnóstico de infección CVC fue de $31.822.751 COP (RIC $16.772.009-69.038.536 COP). Se identificó una diferencia estadísticamente significativa entre los pacientes con infección asociada al CVC comparado con aquellos pacientes sin infección para los casos de costos asociados a hospitalización (p=0,013), a procedimientos (p=0,0002), a imágenes diagnosticas (p=0,061), a terapia de reemplazo renal (p=0,0003) y costos totales (p=0,028). Conclusiones El presente estudio permite confirmar hallazgos previamente descritos en nuestra institución de una frecuencia similar de IACVC al compararse con reportes nacionales y mayor en comparación con lo repostado por literatura anglosajona, así mismo permite confirmar el incremento de los costos directos asociados a la presencia de IACVC, en donde se evidencia un incremento en los costos asociados a hospitalización, a procedimientos, a imágenes diagnosticas, a terapia de reemplazo renal y costos totales de forma estadísticamente significativa.1. RESUMEN 4 2. INTRODUCCIÓN 7 3. MARCO TEÓRICO 9 4. IDENTIFICACIÓN Y FORMULACIÓN DEL PROBLEMA 19 4.1. PREGUNTA DE INVESTIGACIÓN 20 5. OBJETIVOS E HIPÓTESIS 21 5.1. GENERAL 21 5.2. ESPECÍFICOS 21 6. METODOLOGÍA 22 6.1 Tipo y diseño general del estudio 22 6.2 Lugar de la investigación 22 6.3 Población 22 6.3.1. Población Blanco 22 6.3.2. Población Referencia 22 6.3.3. Población estudio 22 6.4 Criterios de inclusión y exclusión 22 6.4.1 Criterios de inclusión 22 6.4.2 Criterios de exclusión 23 6.5 Selección y tamaño de muestra 23 6.5.1. Muestreo 23 6.5.2. Tamaño de la muestra 23 6.6 Definición de las variables 24 6.7. Estudios de intervención 26 6.8. Estrategias para suprimir amenazas a la validez de resultados 26 6.9. Plan de recolección de datos 27 6.10. Plan de análisis 27 7. ASPECTOS ÉTICOS 29 8. RESULTADOS 30 9. DISCUSIÓN 38 10. CONCLUSIONES 43 11. REFERENCIAS BIBLIOGRÁFICAS 44Introduction: Central venous catheter-associated infections (CVCAI) are among the pathologies that increase mortality and morbidity in patients hospitalized with some type of device, being considered as part of the clinical management indicators. Objective: To describe characteristics of CVCAI and the direct costs associated with them in the Central Military Hospital using a Health Analysis tool in the period 2017 to 2020. Methodology: Economic evaluation study, estimation of direct costs related to CVCAI. The direct costs methodology was used, through the review of electronic medical records with cost estimates in accordance with the IETS recommendations. Bivariate statistical analysis was used to identify statistically significant differences. Results: The population included for the analysis was a total of 821 CVC between 2017 and 2020. Statistically significant differences were identified for sex, age, comorbidities, treating specialty, number of CVC routes, site of insertion, professional in charge of insertion, place of the procedure, duration of CVC, hospitalization length, use of Invasive Mechanical Ventilation, use of Non Invasive Mechanical Ventilation, use of Total Parenteral Nutrition, use of Antibiotics, use of renal replacement therapy. For the analysis of direct costs at the hospital level, a total cost in patients without a diagnosis of CVC infection was identified as $ 31,822,751 COP (IQR $ 16,772,009-69,038,536 COP). A statistically significant difference was identified between patients with CVCAI compared to patients without infection for cases of costs associated with hospitalization (p = 0.013), procedures (p = 0.0002), diagnostic images (p = 0.061), renal replacement therapy (p = 0.0003), and total costs (p = 0.028). Conclusions The present study allows us to confirm findings previously described in our institution of a similar frequency of CVCIA when compared with national reports and higher compared to that reported by Anglo-Saxon literature, likewise it allows confirming the increase in direct costs associated with the presence of CVCIA, where an increase in costs associated with hospitalization, procedures, diagnostic images, renal replacement therapy and total costs is evidenced in a statistically significant way.Especializaciónapplicaction/pdfspahttp://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Attribution-NonCommercial-NoDerivatives 4.0 InternationalAcceso abiertoAnálisis y costo de infección asociada a catéter venoso central en el Hospital Militar Central con utilización de herramienta de Health AnalyticsAnalysis and cost of infection associated with a central venous catheter in the Central Military Hospital using the Health Analytics toolTesis/Trabajo de grado - Monografía - Especializacióninfo:eu-repo/semantics/bachelorThesishttp://purl.org/coar/resource_type/c_7a1fCentral venous catheter-associated infectionDirect costsCatheter-associated bacteraemiaHealth related infectionCateterismo Venoso CentralInfecciones Relacionadas con CatéteresInfección HospitalariaControl de InfeccionesInfección asociada a catéter venoso centralCostos directosBacteriemia asociada a catéterInfección relacionada con el cuidado de la saludMedicina InternaFacultad de MedicinaUniversidad Militar Nueva GranadaHajjej Z, Nasri M, Sellami W, Gharsallah H, Labben I, Ferjani M. Incidence, risk factors and microbiology of central vascular catheterrelated bloodstream infection in an intensive care unit. J Infect Chemother. 2014;20(3):163–8.Esposito S, Purrello SM, Bonnet E, Novelli A, Tripodi F, Pascale R, et al. Central venous catheter-related biofilm infections: An up-to-date focus on meticillin-resistant Staphylococcus aureus. J Glob Antimicrob Resist. 2013;1(2):71–8Kandilov A, Coomer N, Dalton K. The Impact of Hospital-Acquired Conditions on Medicare Program Payments. Medicare Medicaid Res Rev. 2014;4(4):E1–23.Herzer KR, Niessen L, Constenla DO, Ward WJ, Pronovost PJ. Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA. BMJ Open. 2014;4(9).Moreno CA, Rosenthal VD, Olarte N, Gomez WV, Sussmann O, Agudelo JG, et al. Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium. Infect Control Hosp Epidemiol. 2006 Apr;27(4):349–56.Zingg W, Sax H, Inan C, Cartier V, Diby M, Clergue F, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. J Hosp Infect. 2009;73(1):41–6.Rodríguez-Baño J, López-Prieto MD, Portillo MM, Retamar P, Natera C, Nuño E, et al. Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals. Clin Microbiol Infect. 2010 Sep;16(9):1408–13.Richet H, Hubert B, Nitemberg G, Andremont A, Buu-Hoi A, Ourbak P, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990;28(11):2520–5.Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19(11):842–5.Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med. 2002;30(2):454–60.M.T. O, D.F. K, M.B. E. Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients. J Parenter Enter Nutr. 2007;31(4):302–5.Zürcher M, Tramèr MR, Walder B. Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: A quantitative systematic review. Anesth Analg. 2004;99(1):177–82.Chen HS, Wang FD, Lin M, Lin YC, Huang LJ, Liu CY. Risk factors for central venous catheter-related infections in general surgery. J Microbiol Immunol Infect. 2006;39(3):231–6.Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jul 1;49(1):1–45.Zingg W, Cartier-Fässler V, Walder B. Central venous catheter-associated infections. Best Pract Res Clin Anaesthesiol. 2008;22(3):407–21.Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters (Review). Chochrane Libr. 2010;(3):1–29.Webster J, Osborne S, Rickard CM, Marsh N. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane database Syst Rev. 2019;1:CD007798.Tacconelli E, Smith G, Hieke K, Lafuma A, Bastide P. Epidemiology, medical outcomes and costs of catheter-related bloodstream infections in intensive care units of four European countries: literature- and registry-based estimates. J Hosp Infect. 2009;72(2):97–103.Peng S, Lu Y. Clinical epidemiology of central venous catheter-related bloodstream infections in an intensive care unit in China. J Crit Care. 2013;28(3):277–83.Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial Infections in Pediatric Intensive Care Units in the United States. Pediatrics. 2004;103(4):e39–e39.Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;67(2):168–74.Ramirez Barba EJ, Rosenthal VD, Higuera F, Oropeza MS, Hernández HT, López MS, et al. Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals. Am J Infect Control. 2006;34(4):244–7.Rosenthal VD, Guzmán S, Crnich C. Device-Associated Nosocomial Infection Rates in Intensive Care Units of Argentina. Infect Control Hosp Epidemiol. 2004 Mar 2;25(3):251–5.Ávila Guzmán, Miriam Lucia Moreno Peralta, Colombia Torres Pinzón H. Factores de riesgo asociados a infección por catéter venoso central en pacientes hospitalizados mayores de 18 años en el Hospital Militar Central de Bogotá Colombia entre enero y abril de 2008ulido Daza SL, Cardona Vargas F, Jaramillo L, Rodrigo Bastidas A. Incidencia de la bacteriemia asociada a catéter venoso central y prevalencia de los diferentes factores de riesgo para la misma en el hospital militar central (homic) entre el año 2013 al 2015. 2016.Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med. 2006;34(8):2084–9Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg. 2001;136(2):229–34Rosa E, Borba A. Infección De Corriente Sanguínea En Pacientes Con Catéter Venosos Bloodstream Infections Among Patients Using Central Venous. Online. 2007;15(3).Brunelli SM, Turenne W, Sibbel S, Hunt A, Pfaffle A. Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters. J Crit Care. 2016;35:69–74.Blot SI, Depuydt P, Annemans L, Benoit D, Hoste E, De Waele JJ, et al. Clinical and Economic Outcomes in Critically Ill Patients with Nosocomial Catheter-Related Bloodstream Infections. Clin Infect Dis. 2005;41(11):1591–8.Renaud B, Brun-Buisson C. Outcomes of primary and catheter-related bacteremia: A cohort and case-control study in critically III patients. Am J Respir Crit Care Med. 2001;163(7):1584–90.Leistner R, Hirsemann E, Bloch A, Gastmeier P, Geffers C. Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): A matched prospective cohort study. Infection. 2014;42(1):31–6.Guembe M, Pérez-Granda MJ, Capdevila JA, Barberán J, Pinilla B, Martín-Rabadán P, et al. Nationwide study on peripheral-venous-catheter-associated-bloodstream infections in internal medicine departments. J Hosp Infect. 2017;97(3):260–6.Cai Y, Zhu M, Sun W, Cao X, Wu H. Study on the cost attributable to central venous catheter-related bloodstream infection and its influencing factors in a tertiary hospital in China. Health Qual Life Outcomes. 2018;16(1):2–7.Nakamura I, Fukushima S, Hayakawa T, Sekiya K, Matsumoto T. The additional costs of catheter-related bloodstream infections in intensive care units. Am J Infect Control. 2015;43(10):1046–9.del Pozo JL, Serrera A, Martínez-Cuesta A, Leiva J, Penadés J, Lasa I. Biofilm related infections: Is there a place for conservative treatment of port-related bloodstream infections? Int J Artif Organs. 2006;29(4):379–86Stevens V, Geiger K, Concannon C, Nelson RE, Brown J, Dumyati G. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2014;20(5):O318–24.Hsu E, Lin D, Evans SJ, Hamid KS, Frick KD, Yang T, et al. Doing Well by Doing Good: Assessing the Cost Savings of an Intervention to Reduce Central Line–Associated Bloodstream Infections in a Hawaii Hospital. Am J Med Qual. 2014;29(1):13–9.Voor in ‘t holt AF, Helder OK, Vos MC, Schafthuizen L, Sülz S, van den Hoogen A, et al. Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis. Int J Nurs Stud. 2017;69:34–40.Cooper K, Frampton G, Harris P, Jones J, Cooper T, Graves N, et al. Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective? J Hosp Infect. 2014;86(1):47–52.Shimoyama Y, Umegaki O, Agui T, Kadono N, Komasawa N, Minami T. An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study. JA Clin Reports. 2017;3(1):2–7.Musu M, Finco G, Mura P, Landoni G, Piazza MF, Messina M, et al. Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units. J Hosp Infect. 2017;97(3):275–81Cohen ER, Feinglass J, Barsuk JH, Barnard C, O’Donnell A, McGaghie WC, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010;5(2):98–102Nelson RE, Angelovic AW, Nelson SD, Gleed JR, Drews FA. An Economic Analysis of Adherence Engineering to Improve Use of Best Practices during Central Line Maintenance Procedures. Infect Control Hosp Epidemiol. 2015;36(5):550–6.Halton KA, Cook D, Paterson DL, Safdar N, Graves N. Cost-effectiveness of a central venous catheter care bundle. PLoS One. 2010;5(9):1–11.Cicalini S, Palmieri F, Petrosillo N. Clinical review: New technologies for prevention of intravascular catheter-related infections. Crit Care. 2004;8(3):157–62Nuckols TK, Keeler E, Morton SC, Anderson L, Doyle B, Booth M, et al. Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: A systematic review. JAMA Intern Med. 2016;176(12):1843–54.O’Horo JC, Silva GLM, Safdar N. Anti-infective locks for treatment of central line-associated bloodstream infection: A systematic review and meta-analysis. Am J Nephrol. 2011;34(5):415–22.Civetta JM, Hudson-Civetta J, Ball S. Decreasing catheter-related infection and hospital costs by continuous quality improvement. Vol. 24, Critical Care Medicine. 1996. p. 1660–5.Veenstra DL, Saint S, Sullivan SD. Central Venous Catheters for the Prevention of Catheter-Related Bloodstream Infection. JAMA. 1999;282:554–60Heimann SM, Biehl LM, Vehreschild JJ, Franke B, Cornely OA, Vehreschild MJGT. Chlorhexidine-containing dressings in the prevention of central venous catheter-related bloodstream infections: A cost and resource utilization analysis. Am J Infect Control. 2018;46(9):992–7Lorente L, Lecuona M, Jiménez A, Santacreu R, Raja L, Gonzalez O, et al. Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs. Am J Infect Control. 2014;42(3):321–4.Lorente L, Lecuona M, Ramos MJ, Jiménez A, Mora ML, Sierra A. Lower associated costs using rifampicin-miconazoleimpregnated catheters compared with standard catheters. Am J Infect Control. 2011;39(10):895–7Lorente L. Antimicrobial-impregnated catheters for the prevention of catheter-related bloodstream infections. World J Crit Care Med. 2016;5(2):137Halton KA, Cook DA, Whitby M, Paterson DL, Graves N. Cost effectiveness of antimicrobial catheters in the intensive care unit: Addressing uncertainty in the decision. Crit Care. 2009;13(2):1–10.Crawford AG, Fuhr JP, Rao B. Cost-benefit analysis of chlorhexidine gluconate dressing in the prevention of catheter-related bloodstream infections. Infect Control Hosp Epidemiol. 2004 Aug;25(8):668–74Schwebel C, Lucet JC, Vesin A, Arrault X, Calvino-Gunther S, Bouadma L, et al. Economic evaluation of chlorhexidine-impregnated sponges for preventing catheter-related infections in critically ill adults in the Dressing Study. Crit Care Med. 2012;40(1):11–7Maenthaisong R, Chaiyakunapruk N, Thamlikitkul V. Cost-effectiveness analysis of chlorhexidine gluconate compared with povidone-iodine solution for catheter-site care in Siriraj Hospital, Thailand. J Med Assoc Thail. 2006;89(SUPPL. 5):94–101.Fraher MH, Collins CJ, Bourke J, Phelan D, Lynch M. Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections. J Hosp Infect. 2009;73(2):129–34.National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004 Dec;32(8):470–85THUMBNAILGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdf.jpgGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdf.jpgIM Thumbnailimage/jpeg6427http://repository.unimilitar.edu.co/bitstream/10654/37418/4/GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdf.jpg1ff404f81b596f2303b560f45898eafbMD54GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdf.jpgGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdf.jpgIM Thumbnailimage/jpeg7082http://repository.unimilitar.edu.co/bitstream/10654/37418/5/GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdf.jpg5cbbdf8a7208efa7a8fba3bfd50af238MD55ORIGINALGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdfGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdfTesisapplication/pdf514049http://repository.unimilitar.edu.co/bitstream/10654/37418/1/GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021.pdfbab0d8e83d1daf5947392af4869b9730MD51GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdfGomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdfapplication/pdf90990http://repository.unimilitar.edu.co/bitstream/10654/37418/2/GomezBoadaDiegoFernandoParraAmarisCamiloAndres2021_Anexo.pdff1a521a233f843ecafca8bf534d96fbcMD52LICENSElicense.txtlicense.txttext/plain; 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