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Cost analysis of blood purification in intensive care units: continuous versus intermittent hemodiafiltration

We implemented a program for continuous renal replacement therapies (CRRT) in intensive care units (ICU) based on the cooperative work of dialysis and ICU personnel. Our aim was to report the main details of this program and compare its cost with
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  572 I NTRODUCTION Continuous renal replacement therapy (CRRT) is oneof the most easily tolerated treatments of acute renalfailure for critically ill patients (1). The vast experience of nephrology physicians andnurses with extracorporeal blood purification suggeststhat they are the ideal personnel to develop and sup-port CRRT programs. Unfortunately, it is often diffi-cult for nephrology staff to take care of daily, 24-hr CRRT in intensive care units (ICU). On the otherhand, ICU nurses are generally not as accustomed toblood purification as dialysis personnel are, and theycannot easily gain adequate expertise and autonomywith CRRT with only occasional treatments.Therefore, it can be concluded that close collabora-tion between dialysis and ICU staff is an optimal solu-tion for the management of renal replacement thera-pies in critically ill patients. Accordingly, we imple-mented a CRRT program, based on the cooperativework of the dialysis and the ICU personnel. In this pa-per, we report the main program details and comparethe cost with that of intermittent, 4 hr daily hemodi-afiltration (IHDF). S UBJECTSANDMETHODS The cost analysis refers to 181 renal failure patients,admitted in two medical ICUs and one surgical ICU atthe Mauriziano Umberto I Hospital of Turin (Italy),from 1 July 1998 through to 1 October 2002. Of thesepatients, 156 had acute renal failure due to ischemicor nephrotoxic injury and 26 were already on regular JN EPHROL2003; 16: 572-579 OO  RIGINAL RIGINAL INVESTIGA INVESTIGATION TION  Cost analysis of blood purification in intensive care units: Continuous versusintermittent hemodiafiltration Corrado Vitale  1 Cristiana Bagnis  1 , Martino Marangella  1 , Giuseppe Belloni  2  , Mario Lupo  3  , Giuseppe Spina  2  ,Piervincenzo Bondonio  4  , Adriano Ramello  1 1 Nephrology and Dialysis Unit and Renal Stone Centre, 2 General Intensive Care Unit, 3 Cardiovascular Intensive Care Unit,Mauriziano Umberto I Hospital, Turin - Italy 4 Political Economy University, Department of Economics, Turin - Italy ABSTRACT: Background: We implemented a program for continuous renal replacement therapies (CRRT) in intensivecare units (ICU) based on the cooperative work of dialysis and ICU personnel. Our aim was to report the main details of this program and compare its cost with that of intermittent hemodiafiltration (IHDF). Methods:  The study referred to 181 ICU patients with renal failure. We considered the costs of both technical devices andassisting personnel. CRRT was performed as continuous veno-venous hemodiafiltration (CVVHDF)(24 hr daily); dialysisand ICU nurses shared surveillance. Only dialysis nurses performed IHDF (as acetate-free biofiltration, 4 hr daily) in theICU. Results: The daily cost of CRRT was 󲂬 276.70; of which 79% was for devices and 21% was for human resources. Nurse sur-veillance required 141 min per day, ICU nurses supplied 55% (77 min) and dialysis nurses 45% (64 min). On average, CRRT surveillance required less than 1 min/nurse/hr for both dialysis and ICU nurses.The daily cost of 4-hr IHDF sessions of was 󲂬 247.83, of which 44% was for technical devices and 56% was for humanresources. Conclusions:  The cooperation between dialysis and ICUs improved the use of human resources and allowed us to supplyCRRT to all critically ill patients with acute renal failure. The expenditure for CRRT was 12% higher than that for IHDF,due to the cost of technical devices. Key words:  Acute renal failure, CRRT, Hemodiafiltration, Hemodialysis  Vitale et al 573 dialysis treatment (RDT) before their admission to theICU. The analysis included both the costs of technical de-vices and the costs of the assisting personnel, i.e.nephrology nurses, ICU nurses and nephrology physi-cians. To take also into account the average costs forleasing, maintenance and technical assistance of ourdialysis machines, the technical costs of each treat-ment should have been further increased by about6%-9%, for both CRRT and IHDF. Therefore, due totheir similar variability, we excluded these additionalcosts from our calculations. The costs of general man-agement of ICU patients were not taken into account. We considered CRRT as the first choice for renal re-placement therapy in critically ill patients. Conversely,we used IHDF for patients who still needed blood pu-rification when they were due to be discharged fromthe ICU, either because they had persistent acuterenal failure, or because they were already on RDT before ICU admittance. Others had been switched toIHDF even earlier, to favor physical rehabilitation. Ingeneral, their cardiovascular equilibrium was accept-able and they had already been weaned from vasoac-tive amines. IHDF was employed as a “bridge” between CRRT inthe ICU and the following intermittent renal replace-ment therapy in the dialysis unit. CRRT program  First, our Nephrology staff defined the guidelines formanagement and technical surveillance of CRRT.Afterwards, on that basis, dialysis and ICU personneldrew up a detailed protocol for CRRT nursing, ap-proved by the Heads of the Nephrology Unit and ICUsand ratified by the Director of Mauriziano Hospital. According to that protocol, dialysis and ICU nursesshared all interventions required during CRRT. How-ever, because of their minor expertise in blood purifi-cation and close involvement in all the critical care activities, ICU nurses were mainly required to providethe ancillary procedures during CRRT. We reported the main points of the protocol referringto both the activities scheduled at definite times dur-ing the day (scheduled activities, Tab. I) and thosemade on demand (unscheduled activities, Tab. II). The CRRT technique used was continuous veno-ve-nous hemodiafiltration (CVVHDF ), with a continu-ous treatment duration of 24 hr/day (2). The ma-chine was Hospal Prisma ® , equipped with M100Pre ® kit (AN69 membrane, 0.9 m 2 ); bicarbonate-bufferedsolutions were used as dialysate (Q Dial =2 L/hr) andpredilutional reinfusion (Q Reinf  =0.5 L/hr); heparinwas used for anticoagulation. All CRRT patients had dual lumen venous catheters,including those with AV fistulae or grafts, to avoid sus-tained stress on their own vascular access. Before starting CVVHDF, the blood circuit was primedand flushed with 2 L of normal saline containing 10000IU of heparin. Thereafter, continuous anticoagulationwas provided with syringes containing 500 IU/mL of heparin; the infusion rates were adjusted to keepblood APTT ranging from 50-70 sec for patients withno risk of bleeding, and from 40-60 sec in cases of amoderate risk of bleeding. For patients with a high risk of bleeding, heparin infusion was avoided. Every day,0.5 L of saline solution were used for filter flushing. IHDF program  Dialysis nurses performed the IHDF treatments in theICU, following the same protocols used routinely withRDT patients. The duration of the treatments, per-formed according to the acetate-free biofiltration(AFB) technique (3) was 4 hr; the dialysis machinewas a Hospal Integra ® ; the membrane was AN69, 1.3m 2 . Acetate-free dialysate flow was 0.5 L/min; bicar-bonate-buffered solutions (with NaHCO 3 concentra-tions of either 167 mEq/L or 145 mEq/L) were sup-plied as post-dilutional reinfusion (Q Reinf  =1.8-2.2 TABLE I - NURSE SURVEILLANCE TO CVVHDF. SCHEDULED ACTIVITIESTimePersonnelActivity6 a.m.ICU nursesmeasurement of the 24-hr fluid balance;blood sampling for coagulation and chemistries.9 a.m.Dialysis nurses blood circuit flushing with saline fluid;check-up of the dialysis machine.4 p.m.ICU nursesblood sampling for coagulation and electrolytes.8 p.m.Dialysis nurses blood circuit flushing with saline fluid;check-up of the dialysis machine;check-up of the CRRT equipment for nighttime.10 p.m.ICU nursesblood sampling for coagulation and electrolytes.   Blood purification in ICU: cost analysis 574 L/hr). Anticoagulation was performed with heparin.Before starting AFB, the blood circuit was primed andflushed with 2 L of normal saline containing 10000 IUof heparin. Thereafter, anticoagulation was providedwith heparin, with an initial bolus of 1500 IU and con-tinuous infusion at the same rate used in previousCVVHDF sessions. A portable device for reverse osmosis provided purewater for sterile dialysate. The cost of the membraneof the reverse osmosis device was not included in cal-culations because, due to the small number of IHDFsessions that would have led to misleadingly highcosts. Cost analysis  a) Technical devices For the evaluation of the technical costs of CVVHDF,we took the amount of resources consumed each dayand multiplied it by the unit prices gathered from ten-ders (Tab. III). Based on the real amount of blood cir-cuits used over 706 days of treatment, we calculatedboth the average life of circuits and their cost per 24hr of treatment. As far as fluids were concerned (dialysate, reinfusate,priming and flushing fluids and heparin), their pre-scribed doses recorded on treatment flowsheets wereconsidered as a reliable consumption index and usedfor the daily expenditure calculation. From the prescribed electrolyte compositions of CVVHDF fluids, we calculated the expenditure for NaCl and KCl added to standard fluid-bags to obtainthe electrolyte concentrations required. The data concerning heparin consumption are inclu-sive of the amounts used for both priming solutionand continuous anticoagulation; the number of sy-ringes required for continuous heparin infusion wascalculated based on prescribed infusion rates. The cost of our medication kit was considered as theexpenditure for daily vascular access care. Dual-lumenvenous catheters were used only for renal replacementtherapies; therefore, from the average duration of CRRT we calculated the percentage of their cost to becharged for every day of treatment. The technical costs of IHDF were calculated by usingthe same criteria and methods for CVVHDF. The aver- TABLE III - CVVHDF: COST OF TECHNICAL DEVICESItemCost / unit ( 􂂬 )Unit / 24 hr (N°)Cost / 24 hr ( 􂂬 ) Blood circuit Prisma kit150.000.67100.50Heparin syringe0.311.50.46Effluent bag2.000.671.34T-line1.290.670.86 Fluids Dialysate (liters)1.554874.40Reinfusate (liters)1.551218.60Flushing (liters)0.460.50.23Priming (liters)0.460.670.31Heparin (UI x 1000)0.0000321,9020.66KCl (mL)0.03601.80NaCl (mL)0.03601.80Venous catheter51.650.2512.91Medication kit3.5913.59Total217.46 TABLE II - NURSE SURVEILLANCE TO CVVHDF.UNSCHEDULED ACTIVITIES ICU nurses Replacement of exhausted fluids (dialysate, reinfusate andanticoagulant);Dialysis machine resetting after minor troubles;Circuit removal and catheter refilling with anticoagulant aftercircuit clotting or major machine troubles, during the night. Dialysis nurses Installation of the circuit and CRRT starting up;Dialysis machine resetting after major troubles;Substitution of exhausted blood circuits and re-initiation of CRRT, during the day.  Vitale et al 575 age amount of materials required for IHDF treat-ments was taken from the flowsheets of 20 AFB ses-sions. The results are reported in Table V. b) Personnel To calculate the total cost of nurses and physiciansattending to renal replacement therapies, we record-ed the time spent for their scheduled and unsched-uled activities during both CVVHDF and IHDF; thenwe multiplied that by their average salary in our hos-pital (49.17 󲂬  /hr for physicians, 14.75 󲂬  /hr for nurs-es).As far as CVVHDF was concerned, the time requiredfor each type of activity was gathered from 15 succes- TABLE IV - CVVHDF: COST OF ATTENDING PERSONNELActionsMinutes Actions Minutes Cost per actionper dayper dayper day ( 󲂬 ) Dialysis nurses Circuit set-up400.6727Circuit removal100.677Scheduled interventions15230Total6415.73 ICU nurses Dialysate-bag change39.629Reinfusate-bag change32.47Effluent-bag emptying31236Heparin-syringe change31.55Total7718.93 Dialysis physician First visit20120Second visit10110Total3024.58 Total 59.24 TABLE V - IHDF: COST OF TECHNICAL DEVICESItemCost / unit ( 􂂬 )Unit / 24 hr (N°)Cost / 24 hr ( 􂂬 ) Blood circuit Filter (Nephral 300) 55.00155.00Arterial blood line2.7012.70Venous blood line2.7012.70Reinfusion line3.8013.80Heparin syringe0.3110.31Effluent-bag0.5210.52T-line1.2911.29 Fluids Osmotic water (liters)0.0051500.75Dialysate concentrate (liters)1.0355.15Priming fluids (liters)0.4620.92Reinfusional HCO 3 (liters)2.06918.54Heparin (UI)0.0000330,0000.90Cleaner (Instrunet ®) catheter51.650.2512.91Medication kit3.5913.59Total110.16   Blood purification in ICU: cost analysis 576 sive assays and recorded as time-intervals, which weremultiples of either 3 min for simple procedures (i.e.fluid-bag replacements) or 5 min for complex proce-dures (i.e. blood circuit set-up). As the “necessarytime” to accomplish each intervention, we chose thetime that allowed the nurses to succeed in at least 10of the 15 assays. The average number of interventionsduring the day was calculated based on the prescribedCVVHDF regimen. For example, from prescribedQ Dial of 2 L/hr, one dialysate-bag change every 2.5 hr(5 L per bag) was considered (Tab. IV).The expenditure was calculated for each AFB session(referring to approximately 6 hr of work, all proce-dures included) by the same criteria and methodsused for CVVHDF and was taken as the cost of eachday of IHDF treatment (Tab. VI). R ESULTS CRRT  The data regarding daily expenditures for technicaldevices are reported in Table III. The average blood circuit life was 36 hr (range: 4-72hr). Consequently, the 24-hr expenditure for bloodcircuits and the related devices (i.e. priming solutions,T-line and effluent-bag), was calculated as 67% of their price per unit. The amount of infused heparinwas 633 ±350 IU/hr, i.e. 15202 ±8397 IU/day with 1.5heparin syringes used every day. Therefore, the finalblood circuit cost was 103.16 󲂬  /day. As the average CRRT duration was 3.9 ±4.3 days per patient, one-fourth of the cost of the central venous catheter wasconsidered for each day, i.e. 󲂬 12.91.According to our routine CVVHDF regimen, we pre-scribed 2 L/hr of Q Dial and 0.5 L/hr of predilutionalQ Reinf  . We observed a tendency towards underestima-tion (up to 5%) of the actual versus the prescribed flu-id flows supplied by the machine. Nevertheless, theprescribed fluid amount was considered in calcula-tions; i.e. 48 L/day of dialysate and 12 L/day of rein-fusate. The Na and K basic fluid concentrations were142 mEq/L and 2 mEq/L, respectively. However, weusually rounded them up to values of 144 mEq/L forNa and 4 mEq/L for K. To this purpose, concentratedNaCl and KCl was 60 mL/day. Taken together the heparin used to prime the circuitand the heparin used for continuous anticoagulation,an average consumption was calculated of 21902 ±8397 IU/day. All items considered, the final cost of fluids was 97.80 TABLE VI - IHDF: COST OF ATTENDING PERSONNEL (DIALYSIS NURSES AND PHYSICIAN)ActionsMinutes Actions Minutes Cost per actionper dayper dayper day ( 󲂬 ) Preliminary procedures Circuit and reverse osmosis set-up6016014.75 Dialysis session 240124059 Final procedures Circuit and reverse osmosis removal, vascular access care, monitor sterilization6016014.75 Dialysis physician Medical assistance6016049.17 Total 137.67 TABLE VII - COMPARATIVE EXPENDITURE OF CVVHDF VERSUS IHDFCVVHDF ( 󲂬 )IHDF ( 󲂬 )CVVHDF vs. IHDF Technical devices cost 217.46110.16+97% Personnel cost 59.24137.67-57%Dialysis nurses15.7388.50-82%ICU nurses18.93--Attending nephrologist24.5849.17-50% Total 276.70247.83+12%
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