"Water or not water: That is the question." Analysis of costs and consumption of the operating theaters in a greener perspective.

OBJECTIVE: To compare the amounts of water and plastic used in surgical hand washing with medicated soaps and with alcohol-based products and to compare costs and consumption in a year, based on scheduled surgical activity. METHOD: This retrospective study was carried out at Udine's Gynecology Operating Block from October to November 2022. We estimated the average amount of water with a graduated cylinder and the total cost of water usage based on euros/m3 indicated by the supplier; for each antiseptic agent we collected the data relevant to wash time, amount of water and product used per scrub, number of handscrubs made with every 500 mL bottle and cost of a single bottle. We put data into two hypothetical contexts, namely WHO guidelines and manufacturers' recommendations. Data were subjected to statistical analysis. RESULTS: The daily amount of water using povidone-iodine, chlorhexidine-gluconate and alcohol-based antiseptic agents was 187.6, 140.7 and 0 L/day (P value = 0.001), respectively; A total of 69 000 L/year of water would be saved if alcohol-based products were routinely used. A single unit of an alcohol-based product allows three times as many handscrubs as any other product (P value = 0.001) with consequent reduction in plastic packaging. CONCLUSION: Despite the cost saving being negligible, choosing alcohol-based handrub over medicated soap handrub - on equal antiseptic efficacy grounds - could lead to a significant saving of water and plastic, thus making our operating theaters more environmentally friendly.

The Cost Effectiveness of Dilute Betadine Lavage for Infection Prophylaxis in Total Joint Arthroplasty.

BACKGROUND: This article presents a break-even analysis for intraoperative Betadine lavage for the prevention of infection in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost effectiveness. RESULTS: At our institutional price of $2.54, dilute (0.35%) Betadine lavage would be cost effective if initial infection rates of both TKA (1.10%) and THA (1.63%) have an ARR of 0.01%. At a hypothetical lowest cost of $0.50, the ARR is so low as to be immediately cost effective. At a hypothetical high price of $40.00, Betadine is cost effective with ARRs of 0.16% (TKA) and 0.13% (THA). CONCLUSION: Intraoperative Betadine lavage, at typical institutional prices, can be highly cost effective in reducing infection after joint arthroplasty.

Cost-effectiveness analysis of chlorhexidine-alcohol versus povidone iodine-alcohol solution in the prevention of intravascular-catheter-related bloodstream infections in France.

OBJECTIVE: To perform a cost-effectiveness analysis of skin antiseptic solutions (chlorhexidine-alcohol (CHG) versus povidone iodine-alcohol solution (PVI)) for the prevention of intravascular-catheter-related bloodstream infections (CRBSI) in intensive care unit (ICU) in France based on an open-label, multicentre, randomised, controlled trial (CLEAN). DESIGN: A 100-day time semi-markovian model was performed to be fitted to longitudinal individual patient data from CLEAN database. This model includes eight health states and probabilistic sensitivity analyses on cost and effectiveness were performed. Costs of intensive care unit stay are based on a French multicentre study and the cost-effectiveness criterion is the cost per patient with catheter-related bloodstream infection avoided. PATIENTS: 2,349 patients (age≥18 years) were analyzed to compare the 1-time CHG group (CHG-T1, 588 patients), the 4-time CHG group (CHG-T4, 580 patients), the 1-time PVI group (PVI-T1, 587 patients), and the 4-time PVI group (PVI-T4, 594 patients). INTERVENTION: 2% chlorhexidine-70% isopropyl alcohol (chlorhexidine-alcohol) compared to 5% povidone iodine-69% ethanol (povidone iodine-alcohol). RESULTS: The mean cost per alive, discharged or dead patient was of €23,798 (95% confidence interval: €20,584; €34,331), €21,822 (€18,635; €29,701), €24,874 (€21,011; €31,678), and €24,201 (€20,507; €29,136) for CHG-T1, CHG-T4, PVI-T1, and PVI-T4, respectively. The mean number of patients with CRBSI per 1000 patients was of 3.49 (0.42; 12.57), 6.82 (1.86; 17.38), 26.04 (14.64; 42.58), and 23.05 (12.32; 39.09) for CHG-T1, CHG-T4, PVI-T1, and PVI-T4, respectively. In comparison to the 1-time PVI solution, the 1-time CHG solution avoids 22.55 CRBSI /1,000 patients, and saves €1,076 per patient. This saving is not statistically significant at a 0.05 level because of the overlap of 95% confidence intervals for mean costs per patient in each group. Conversely, the difference in effectiveness between the CHG-T1 solution and the PVI-T1 solution is statistically significant. CONCLUSIONS: The CHG-T1 solution is more effective at the same cost than the PVI-T1 solution. CHG-T1, CHG-T4 and PVI-T4 solutions are statistically comparable for cost and effectiveness. This study is based on the data from the RCT from 11 French intensive care units registered with www.clinicaltrials.gov (NCT01629550).

Cost Efficacy of Methicillin-Resistant Staphylococcus aureus Decolonization With Intranasal Povidone-Iodine.

BACKGROUND: With increasing rates of virulent drug resistant organisms, MRSA (methicillin-resistant Staphylococcus aureus) decolonization has been demonstrated to decrease infection rates. Recent research has shown the antiseptic povidone-iodine to be equally effective and potentially cost saving compared to intranasal mupirocin. This study's purpose is to evaluate the incidence of MRSA colonization in a more rural community-based population, rates of infection on a mupirocin decolonization protocol, and develop a cost analysis model to compare costs of utilizing povidone-iodine. METHODS: Utilizing over 4 years of data, the incidence of MRSA decolonization of consecutive total knee and hip arthroplasties, as well as the rates of infection of patients uncolonized, colonized with successful decolonization, and unsuccessful decolonization were evaluated. Utilizing these data, cost data, and known infection rate utilizing povidone-iodine decolonization, a cost analysis model was developed. RESULTS: Of the 5584 cases with MRSA data at a single institution, only 3.5% tested positive for intranasal MRSA. Of those patients, 69% were successfully decolonized. Of the 3864 cases with infection data, 21 sustained a surgical site infection within 90 days (0.54%). Of these patients, all tested negative for intranasal MRSA initially and therefore did not undergo the decolonization protocol. The cost analysis predicts a potential savings of $74.72 per patient at our institution to use a global intranasal povidone-iodine protocol prior to total joint arthroplasty. CONCLUSION: Even with a lower incidence of MRSA than typically reported, utilization of intranasal povidone-iodine would potentially save $74.42 per patient.

Effectiveness of preoperative decolonization with nasal povidone iodine in Chinese patients undergoing elective orthopedic surgery: a prospective cross-sectional study.

Staphylococcus aureus colonization in the nares of patients undergoing elective orthopedic surgery increases the potential risk of surgical site infections. Methicillin-resistant S. aureus (MRSA) has gained recognition as a pathogen that is no longer only just a hospital-acquired pathogen. Patients positive for MRSA are associated with higher rates of morbidity and mortality following infection. MRSA is commonly found in the nares, and methicillin-sensitive S. aureus (MSSA) is even more prevalent. Recently, studies have determined that screening for this pathogen prior to surgery and diminishing staphylococcal infections at the surgical site will dramatically reduce surgical site infections. A nasal mupirocin treatment is shown to significantly reduce the colonization of the pathogen. However, this treatment is expensive and is currently not available in China. Thus, in this study, we first sought to determine the prevalence of MSSA/MSRA in patients undergoing elective orthopedic surgery in northern China, and then, we treated the positive patients with a nasal povidone-iodine swab. Here, we demonstrate a successful reduction in the colonization of S. aureus. We propose that this treatment could serve as a cost-effective means of eradicating this pathogen in patients undergoing elective orthopedic surgery, which might reduce the rate of surgical site infections.

Effectiveness, cost-effectiveness and cost-benefit of a single annual professional intervention for the prevention of childhood dental caries in a remote rural Indigenous community.

BACKGROUND: The aim of the study is to reduce the high prevalence of tooth decay in children in a remote, rural Indigenous community in Australia, by application of a single annual dental preventive intervention. The study seeks to (1) assess the effectiveness of an annual oral health preventive intervention in slowing the incidence of dental caries in children in this community, (2) identify the mediating role of known risk factors for dental caries and (3) assess the cost-effectiveness and cost-benefit of the intervention. METHODS/DESIGN: The intervention is novel in that most dental preventive interventions require regular re-application, which is not possible in resource constrained communities. While tooth decay is preventable, self-care and healthy habits are lacking in these communities, placing more emphasis on health services to deliver an effective dental preventive intervention. Importantly, the study will assess cost-benefit and cost-effectiveness for broader implementation across similar communities in Australia and internationally. DISCUSSION: There is an urgent need to reduce the burden of dental decay in these communities, by implementing effective, cost-effective, feasible and sustainable dental prevention programs. Expected outcomes of this study include improved oral and general health of children within the community; an understanding of the costs associated with the intervention provided, and its comparison with the costs of allowing new lesions to develop, with associated treatment costs. Findings should be generalisable to similar communities around the world. The research is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), registration number ACTRN12615000693527; date of registration: 3rd July 2015.

Betadine irrigation and post-craniotomy wound infection.

OBJECT: The purpose of this study is to evaluate the efficacy of betadine irrigation in preventing postoperative wound infection in cranial neurosurgical procedures. METHODS: A total of 473 consecutive cranial neurosurgical procedures, including craniotomies and burr hole procedures were retrospectively reviewed. Patients had either antibiotic irrigation or dilute betadine plus antibiotic irrigation prior to skin closure. Infection was determined by purulence noted on reoperation and confirmed with bacterial growth culture. One and three month postoperative infection rates were calculated. Statistical analysis was performed using Chi-squared tests. RESULTS: This study included 404 patients. Betadine was used in 117 (29.0%). At 1 month after surgery, there was no difference in the rate of wound infection between the two groups (1.7% each). However, at 90 days, the betadine group had a 2.6% infection rate compared with 3.8% in the antibiotic group, indicating a 33% decrease in infection rates with the addition of betadine (p=.527). The small sample size of the study produced a low power and high beta error. CONCLUSIONS: In this small preliminary study, betadine decreased postoperative infection rates compared with antibiotic prophylaxis alone at 90 days but not 30 days. This was not statistically significant, but a larger sample size would lower the beta error and decrease confounding bias associated with group heterogeneity. The potential for betadine, a cheap, low toxicity antimicrobial, to decrease infection rates and reoperations for infection warrants a larger multicenter trial.

Evaluation of a non-adherent, povidone-iodine dressing in a case series of chronic wounds.

Here we report a product evaluation for a non-adherent, povidone-iodine (PVP-I) dressing, determining the clinical need for the product, performing a literature review, clinical evaluation and cost-analysis, and developing a recommendation. This evaluation included 20 patients who experienced dressing pain with the previous antimicrobial dressing. Two patients discontinued the evaluation and four ulcers were non-healing; the remaining wounds closed with the PVP-I dressing. Patients indicated a preference for the PVP-I dressing, primarily due to lack of dressing pain. The PVP-I dressing was also the most cost-efficient.

Observational study on preoperative surgical field disinfection: povidone-iodine and chlorhexidine-alcohol.

BACKGROUND AND OBJECTIVES: Surgical site infection (SSI) rate is reported to range around 16%. Preoperative skin disinfection is keystone for SSI reduction. Chlorhexidine-alcohol has been reported to be more effective than Povidone-iodine (PVI). However, in many countries established habits and the inferior costs of PVI restrain the employment of chlorhexidine disinfection kits (ChloraPrep®) for the preparation of the surgical field. MATERIALS AND METHODS: The costs of surgical field preparation in clean-contaminated surgery utilizing PVI (Betadine) and chlorhexidine alcohol and the evaluation of surgeon compliance and satisfaction, were studied by a observational study on 50 surgical operations in which surgical field was prepared with PVI checking established guidelines, and on 50 surgical operations in which chlorhexidine-alcohol (ChloraPrep) was employed. The use of auxiliary material was tabulated as well as the timing of the phases of disinfection and the surgeon's opinions. RESULTS: The use of auxiliary material (gloves, gauzes, paper towels, surgical instruments, small swabs for umbilical cleaning) is associated with the type of disinfectant, with major use of auxiliary materials recorded in PVI disinfection. PVI disinfection does not follow stringent guidelines, in particular waiting for the disinfectant to dry. PVI guidelines are more demanding than those relative to ChloraPrep. The time necessary for the preparation of the field is significantly longer for PVI. Auxiliary material and guideline compliance must be taken into account when calculating costs; the former are direct costs (even though marginal) and the latter can determine major infective risk. CONCLUSIONS: Chlorhexidine in kits is easier and faster to use than PVI, requires less auxiliary material and has been shown previously to reduce SSI in clean contaminated surgery.

Alcoholic povidone-iodine or chlorhexidine-based antiseptic for the prevention of central venous catheter-related infections: in-use comparison.

PURPOSE: To make a field comparison of the effectiveness, ease of use, and cost of a chlorhexidine antiseptic solution (CBA) and an alcohol-based povidone-iodine solution (PVP-IA) for the prevention of central venous catheter (CVC)-related infections in an intensive care unit, with the aim of identifying the superior antisepsis agent. MATERIALS AND METHODS: We measured the CVC colonization and infection incidence for PVP-IA (Betadine alcoolique(®)) and for CBA (Biseptine(®)) during two successive 1-year periods of routine surveillance (REA RAISIN network). A questionnaire on the ease of CBA use was administered. Consumption data were obtained from the hospital pharmacy. RESULTS: The study included 806 CVC (CBA period: 371). Upon switching from PVP-IA to CBA, we recorded a significant reduction in colonization incidence/100 catheter days (1.12 vs. 1.55, p=0.041), nonsignificant differences concerning CVC-related infection incidence/100 catheter days (0.28 vs. 0.26, p=0.426), and a nonsignificant reduction in CVC-related bacteremia/100 catheter days (0.14 vs. 0.30, p=0.052). PVP-IA users were at significantly higher risk of CVC colonization or infection based on a multivariate Cox model analysis (relative risk [95% CI]: 1.48 [1.01-2.15], p=0.043). The main drawbacks of CBA use were its low cleansing activity and its colorless solution. No cost advantage was found. CONCLUSIONS: Our field study revealed no major clinical advantage of CBA use in CVC infection and no cost advantage in addition to limited ease of use.

Treatment of paediatric burns with a nanocrystalline silver dressing compared with standard wound care in a burns unit: a cost analysis.

Burns are a leading cause of non-natural death in South African infants and children. Conventional care of partial-thickness burns often requires painful, time consuming and costly twice-daily dressing changes to clean the wound and apply antimicrobial topical agents. A new topical nanocrystalline silver-coated NS dressing (Acticoat; Smith & Nephew) has been developed and is the first-line treatment of choice in many burn centres. However, because of its cost the Department of Health has been reluctant to introduce it as a standard of care. We retrospectively studied 4 randomly selected paediatric burn patients, calculating the cost associated with the use of NS dressings and comparing this with the projected costs of three previously standard burn wound treatment regimens. NS dressings were changed every 3 days based on their sustained and slow release of silver ions over 72 hours. Using NS clearly saved costs compared with the three other regimens. The demonstrated cost savings resulted primarily from the decreased number of dressings, and the presumed shorter hospital stay.

[Comparative study of the cost/effectiveness of surgical wash with various antiseptics].

BACKGROUND: "Surgical scrub" of the hands and arms is a fundamental procedure for reducing infection risk. We undertook this study in order to compare different antiseptics and their microbicidal effects, costs and times of the procedures. METHODS: Thirty students followed the surgical scrub procedure using benzalkonium chloride. Seven days later the students used povidone-iodine and, 7 days after that, they used chlorhexidine/alcohol. After the surgical scrub, cultures were obtained from the palms of their hands and from their nail beds. The students wore sterile gloves, which were removed 30 min later to obtain new cultures from the same sites. The cost of the products was calculated in Mexican pesos and the time of each procedure was measured in minutes. RESULTS: There was a statistically significant difference in the number of colony-forming units (CFUs). The number of CFUs was lower in the groups of students who used chlorhexidine/alcohol and povidone-iodine as compared to the benzalkonium chloride group. There was no difference between chlorhexidine/alcohol and povidone-iodine. Costs were higher for povidone-iodine and benzalkonium chloride compared to chlorhexidine/alcohol. Procedure times were similar with povidone-iodine and benzalkonium chloride but the time was reduced approximately five times when using chlorhexidine/alcohol. CONCLUSIONS: It is a proven fact that the lack of surgical scrub favors wound infections, longer hospital stays and increased costs. Therefore, further studies are needed to determine the best antiseptic according to cost/benefit. Chlorhexidine/alcohol proved to be the superior antiseptic in terms of cost/benefit compared to povidone-iodine and benzalkonium chloride.

Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine.

The use of chlorhexidine gluconate solution for vascular catheter insertion site care reduces the risk of catheter-related bloodstream infection by one-half, compared with povidone iodine. Our objective was to evaluate the cost-effectiveness of chlorhexidine gluconate versus povidone iodine. We used data from randomized, controlled trials, meta-analyses, and epidemiologic studies to construct a decision analysis model. We estimated that use of chlorhexidine, rather than povidone, for central catheter site care resulted in a 1.6% decrease in the incidence of catheter-related bloodstream infection, a 0.23% decrease in the incidence of death, and savings of 113 dollars per catheter used. For peripheral catheter site care, the results were similar, although the differences were smaller. The results were found to be robust on multivariate sensitivity analyses. Use of chlorhexidine gluconate in place of the current standard solution for vascular catheter site care is a simple and cost-effective method of improving patient safety in the hospital setting.

Comparison of preoperative skin preparation products.

We compared application, drying, and removal times as well as user satisfaction of four preoperative skin preparation products. All products were applied to 25 subjects, allowed to dry, and removed. Operating room personnel who applied the products were asked to complete a user-satisfaction survey. Application and drying times were longest with the povidone iodine paint and scrub product (p<0.05). That product had the highest rating for overall user satisfaction. Cost-minimization analysis revealed that although alcohol-containing products had lower overall costs, savings may not outweigh associated safety risks.