One of the most common complications associated with TPN is catheter related blood stream infection. In most instances this requires hospitalization. This always has been and will continue to be a hospital stay that is covered by insurance benefits.

In October 2008, Medicare is changing reimbursement for preventable complications that occur during hospitalization.  This means that if a home TPN consumer is admitted for another reason and a catheter related blood stream infection occurs during the hospitalization, Medicare considers this episode preventable and will not reimburse the institution for care associated with this infection.  The hospital cannot bill the consumer for these un-reimbursed charges.

A hospital acquired blood stream infection increases length of stay an average of 7 days, with an estimated cost of $10,000 - $30,000.  Not receiving reimbursement for this extra care has created an incentive to hospitals nation-wide to identify strategies to reduce hospital acquired blood stream infections.  This becomes a win-win situation for the home TPN consumer who commonly sees health care providers in hospital and clinic settings use poor aseptic technique during catheter care and accessing.

Over the last several years, hospitals have begun to implement “Care Bundles” which are evidence based best practices that when applied as a group have shown to  significantly improve care and reduce complications.  The key components of the “Central Line Bundle” are:

• Hand Hygiene
• Maximal barrier precautions during catheter insertion
• Chlorhexidine skin antisepsis
• Optimal catheter site selection
• Daily review of line necessity and prompt removal of unnecessary lines
• Scrupulous hub care

These apply to short term, hospital appropriate central lines, but are applicable to a home TPN consumer who is in the hospital and needs an additional short term line or temporary access until a tunneled catheter or port can be placed.  In the home, hand hygiene is also the first defense against infection.  Maximal barrier precautions include work area and surface preparation, which is so important with admixing and hook up.  Hub care with friction, 10-20 seconds, and drying should be practiced with each device access, and chlorhexidine is superior for exit site and port access site care.

I recently heard presentations from several hospitals who have achieved significant reduction in infection rates by implementing catheter care bundles:  Johns Hopkins, University of Pittsburgh Medical Center, Missouri Baptist Medical Center, St. Joseph’s Hospital, and Sutter Roseville Medical Center.  These “back to the basics” strategies are not new to health care providers, but extensive re-education along with surveillance and commitment from hospital administrators have allowed these hospitals to achieve nearly zero infection rates in their intensive care units and with their catheter insertion and care teams.

Implementation of catheter care bundles should increase awareness of health care providers and allow HPN consumers to receive safer, quality access device care when hospitalization is necessary.