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Intravenous therapy teams (IVTT) provide care, education and supervision of the patient with a central line, and his/her family. This article discusses the creation of an IVTT in the Hospital Clínico San Carlos of Madrid, Spain, demonstrating its effectiveness using cost-utility analysis and outcomes indicators. In 2009 the IVTT began using a high-flow peripherally inserted central catheter (PICC) with its target population of chronic patients dependent on central venous catheters or prolonged IV treatment. The team designed activity, welfare, educational and economic indicators. Of the 98 catheters placed, 80% of patients achieved a positive response; 42% of catheters were removed after death and 30% by the end of treatment. Four percent were removed due to infection. The average implantation duration was 45 days. The economic study showed an increasing cost saving compared to peripheral catheters after 90 days of implantation, and after 77 days compared to central venous catheters. This translated into an immediate saving of 161 euros (£133.70) and 303.83 euros (£252.31) per catheter over Hickman lines and ports, as well as reduced risks, length of hospital stays and costs. The study shows PICC to be cost-effective with reported benefits to patients, professionals and organizations. The creation of the IVTT has resulted in improvements to care and the management of resources.

Introduction: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area., Purpose: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results., Material and Methods: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared., Main Variables: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery., Results: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0)., Limits: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated., Conclusions: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

Infectious diseases are currently one of the major health problems worldwide. As a consequence, both nosocomial and community-acquired infections are responsible for a significant increase in workload and health costs for hospitals, particularly in Intensive Care Units (ICU), Internal Medicine and Surgery. The use of intravenous antimicrobial agents is common in hospitalized patients. In order to determine the use of antimicrobial agents and the most frequent procedures used for their administration in Spanish hospitals, a national multicenter survey was undertaken among ICU, Internal Medicine and Surgery health staff from 63 hospitals, in which data were collected on central and peripheral catheter manipulation and intravenous administration. Results showed that, in Spain, both catheter manipulation (insertion, maintenance and removal) and administration of antimicrobial agents are performed by the nursing staff following established protocols, particularly for central catheters. Moreover, the ICUs had the highest rates of catheter-bearing patients, as well as patients undergoing antimicrobial treatment, sometimes in combination. The use of intravenous antimicrobial agents in Spanish hospitals results in an increased workload for the nursing staff and higher health costs, not to mention the risk involved with the use of vascular catheters.

Objective: To evaluate the influence of late referral to nephrology of the patients with chronic renal failure in the morbimortality of the patients who start hemodialysis. SUBJETS AND METHODS: There were included in the study the patients who started hemodialysis (HD) as first form of treatment, and that survived at least three months in both hospitals of reference of the province of Huesca from january 1990 to december 2001. Patients who started HD after acute renal failure were excluded. Clinical and analytical data were determined for each patient at the start of HD and during the follow-up. Early (ER) and late referral (LR) were defined by the time of first nephrology encounter greather than or less than 4 months respectively, before HD initiation. Morbidity analysis (using multiple linear regression with rate of days of hospitalization as dependent variable) and global and anual during the first three years of follow-up survival analysis (using Cox proportional hazards regression) were carried out., Results: A total of 139 patients (78%) started HD in the ER group and 39 (22%) in LR group. Mean follow-up was similar in both (ER = 34.43 +/- 25.5 months; LR = 34.42 +/- 28.37 months). At the start of dialysis LR was associated to higher proportion of temporary catheters, lower level of hematocrit and albumin, higher comorbidity and higher levels of urea and creatinine. Risk factors selected by the model in the morbidity analysis were index of comorbidity (CI), late referral, serum albumin, urea reduction ratio (URR) and hematocrit (R2 = 0.334, F = 16.97, p < 0.005). The final equation of regression was: Rate of hospitalization's days = 101.12 + (2.45 x CI) - (12. 11 x LR) - (11.57 x Alb.) - (0.43 x PRU) - (0.83 x Hto). Variables selected by Cox's regression model that were associated with survival throughout complete follow-up were hematocrit (RR = -0,207, CI 95% 0.726-0.910, p < 0.0005), index of comorbidity (RR = 0,265, CI 95% 1.066-1.594, p = 0.007), PRU (RR = - 0,059, CI 95% 0.893-0.996, p = 0.038) and type of dialysis membrane (RR = 0,771, Cl 95% 0.260-0.822, p = 0.007). Nevertheless, in successive models fitting after 12, 24 and 36 months of follow-up the variable LR influenced in an independent way survival first two years, losing his significance later., Conclusion: In our study patients of the group LR presented a worse clinical and metabolic situation at the beginning of the HD. Later there was demonstrated in this group a higher long-term morbidity and a lower survival the first two years.

Introduction: The importance of accidental catheter removal (ACR) lies in the complications caused by the removal itself and by catheter reinsertion. To the best of our knowledge, no studies have analyzed accidental removal of various types of catheters in the intensive care unit (ICU). The objective of the present study was to analyze the incidence of ACR for all types of catheters in the ICU., Methods: This was a prospective and observational study, conducted in a 24-bed medical/surgical ICU in a university hospital. We included all consecutive patients admitted to the ICU over 18 months (1 May 2000 to 31 October 2001). The incidences of ACR for all types of catheters (both per 100 catheters and per 100 catheter-days) were determined., Results: A total of 988 patients were included. There were no significant differences in ACR incidence between the four central venous access sites (peripheral, jugular, subclavian and femoral) or between the four arterial access sites (radial, femoral, pedal and humeral). However, the incidence of ACR was higher for arterial than for central venous catheters (1.12/100 catheter-days versus 2.02/100 catheter-days; P < 0.001). The incidences of ACR/100 nonvascular catheter-days were as follows: endotracheal tube 0.79; nasogastric tube 4.48; urinary catheter 0.32; thoracic drain 0.56; abdominal drain 0.67; and intraventricular brain drain 0.66., Conclusion: We found ACR incidences for central venous catheter, arterial catheter, endotracheal tube, nasogastric tube and urinary catheter that are similar to those reported in previous studies. We could not find studies that analyzed the ACR for thoracic, abdominal, intraventricular brain and cardiac surgical drains, but we believe that our rates are acceptable. To minimize ACR, it is necessary to monitor its incidence carefully and to implement preventive measures. In our view, according to establish quality standards, findings should be reported as ACR incidence per 100 catheters and per 100 catheter-days, for all types of catheters.

Vascular access disfunction causes a therapeutic emergency with different implications in patients and care givers. The aim of this study was to know the distribution of different kinds of vascular access between prevalent hemodialysis patients, the proportion of incident patients that holds a permanent vascular access, the monthly hospital ratio for access repair and the use of surveillance systems of vascular access adequacy in the different Centers. This is a National survey that shows results of a questionnaire sent to all hemodialysis units in Spain on september 1999. Eighty-eight units answered the questionnaire (42%) providing information about 5,476 prevalent patients. Of these patients, 81% receives treatment through an arteriovenous fistula, 10% uses a central catheter and 9% a graft. Only 56% of incident patients have a permanent vascular access. Reasons for catheter use between prevalent patients were exhaustion of vascular sites in 42%, maduration of permanent access in 24%, thrombosis of the access in 14% and another reasons in 19%. Patients monthly hospitalization ratio for vascular repair was 3%, that might represent more than 5,600 hospital ingress by year. More than 80% of the Units releases different surveillance programs of access adequacy, 69% by fiscal detection problems, 47% by dynamic alterations and 18% by dilution and imaging procediments. The conclusions of this survey are that arteriovenous fistula is the most used vascular access in Spain. Almost half of the patients do not have vascular access in use for the beginning of hemodialysis. Exhausted vascular sites is the primary reason for central catheter using. A great proportion of Units are employing programs for access monitoring.

Unlabelled: The aim of the study which we present is to analyze the incidence of late complications, clinical and sub-clinical, of venous reservoirs implanted through two access routes, subclavian (group A), and brachial (group B). It is a multi-centric clinical study, initiated in 1992, in which the general surgery departments of three general hospitals of the Valencian Community were involved. It is made up of 87 patients, 48 men and 39 women, with a mean age (SD) of 57.1 (12.6) years, of whom we made a late review of 41 patients (29 from group A and 12 from group B). They were subjected to a physical examination, bacterial cultures of the entrance, and phlebograms of the upper extremities through the dorsal veins of the hands., Results: The incidence of clinical complications was 39% in group A and 77% in group B (p = 0.0507). The main clinical complications were minimally symptomatic venous thrombosis, catheter thrombosis, infection, and miscellaneous (migration, paresthesias, articular movement alterations, etc.). And the prevalence of phlebographic venous thrombosis was 18% in group A and 40% in group B (p = 0.051)., Conclusions: The subclavian access for the implantation of venous reservoirs has a lower incidence (with a tendency towards clinical significance) of clinical complications and subclinical venous thrombosis (Phlebogram) than the brachial access.