PICC lines trim costs in outpatient clinic
PICC lines trim costs in outpatient clinic
Drop from $250,000 to $100,000 per case
Providing treatment to victims of multidrug-resistant tuberculosis is expensive. When the MDR cases occur in what amounts to a Third World setting, as in the MDR outbreak along the south Texas border, the pressure to stretch a dollar becomes enormous.
That has prompted TB controllers at South Texas Hospital in Harlingen to search out innovative ways to save money, while improving adherence to treatment. Better compliance, in turn, has led to rates of response approaching 100%.
According to Teresa Lightner, MD, staff physician at South Texas Hospital, the average length of stay in the hospital has declined from almost a year to less than six months. Time of conversion of sputum to negative has dropped from a little more than three to four months, to less than two months. Finally, cost per case has plummeted, from $250,000 to $100,000.
The linchpin for the cost-cutting strategies is the use of percutaneous intravenous central catheterization, or PICC lines, says Mike Kelley, MD, MPH, chief of the bureau of communicable diseases at the Texas Department of Health.
The PICClines are placed permanently in the crook of the arm and kept safely covered except when needed for infusions of medication, and they enable patients toleave the hospital much sooner. Because the lines replace intramuscular injections, patients like them and stay with their lengthy regimens longer, Lightner says.
South Texas Hospital has inaugurated other measures that have helped cut the cost of care. For example, Lightner now uses telemedicine to consult with experts in other parts of the state. That means very complicated cases no longer have to be sent away to National Jewish Hospital in Colorado, as they once were, but can be kept close to home and followed up on site in the outpatient clinic. In addition, the Harlingen program has enlisted the part-time services of a thoracic surgeon in northern Texas.
From the patient’s standpoint, the best thing about PICC lines is that they don’t hurt. "It’s a difficult regimen when you’re talking about taking an injectable drug daily for six months intramuscularly and then three times a week for months beyond that," she says. "Plus, we see many patients who are just skin and bones. They lack the muscle mass for injections."
Since patients come to the clinic just three times a week for intravenous therapy, the rest of the time they can go about their lives. "We have one guy with a PICC line who works in an onion field," Lightner says. "He’s doing fine."
The convenience factor is especially important for people living in the border area, Lightner adds. "We have people who live 50 to 60 miles from the nearest clinic," she says. "We don’t exactly have home health care nurses climbing over each other to give home infusions, either."
PICC lines pose risk to patients
Lightner is training providers on the Mexican side of the border to use PICC lines, too. Health care workers in Reynosa and Matamoros, where many MDR-TB cases have been identified, are being trained in how to place the lines and care for them. There, the response has been as positive as here, Leitner adds.
From a physician’s standpoint, PICC lines offer substantial advantages compared with other modes of delivering medications, says Lightner. Placed in the antecubital fossa and threaded into the subclavian vein, the devices avoid most difficulties that come with central lines.
For one, they eliminate the chance of an accidental pneumothorax (which happens if a needle accidentally knicks the pleural sac, which in turn can cause a lung to collapse). "When you’re trying to thread in a 16-gauge needle, you don’t like the thought of compromising lung function in these patients," Lightner says.
Unlike central lines, PICC lines can be placed by nurses. Once in position, the lines can stay in as long as six to eight months, Lightner says.
Complications are rare, and maintaining the lines involves little more than occasionally changing heparin locks and dressings. After 21¼2 years of using the lines, the outpatient clinic hasn’t documented a single case of line sepsis, Lightner says. There have been one or two instances of localized infection with purulent drainage, she adds, but the problem resolved itself within two to three days after the line was removed.
In one instance the onion-field worker, it turns out a PICC line did break off. But the broken line was removed without incident. In fact, Lightner adds, the only real problem was figuring out how to use the lines to deliver medicines usually given by other routes. (Luckily, she found guidelines from National Jewish Hospital.)
What makes Lightner’s outcomes especially impressive is the way her cases have grown more complex in recent years, from an average of four-drug resistance, to an average of six-drugs resistance now.
Giving anything but streamlined care isn’t really an option, Lightner says. "We practice in what amounts to a Third World country down here. We have to do our jobs more efficiently," she says. "If we can improve our outcomes at the same time, then it’s dollars well spent."
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