Discussion

We demonstrated that implementing ISDD resulted in a substantial reduction in BCC. This aligns with findings from other institutions employing similar techniques. ^{Reference Al Mohajer and Lasco1–Reference Callado, Lin and Thottacherry3} However, our results showed no improvement in LOS, DOT, or the number of false-positive CLABSI.

Only a few studies utilizing ISDD have reported clinical outcomes. Callado et al. ^{Reference Buzard, Evans and Schroeder6} showed that hospital LOS, ICU LOS, and vancomycin DOT remained similar post-ISDD despite improved BCC. Conversely, Nielsen et al. ^{Reference Nielsen, Nguyen and Wahl7} demonstrated a 31.4% reduction in vancomycin DOT after ISDD implementation. Tompkins et al. ^{Reference Tompkins, Tien and Madison2} reported lower false-positive CLABSI post-ISDD, though the standardized infection ratio had already been declining before the intervention. The difference in these studies’ results could be attributed to heterogeneity in designs, diversion techniques, and patient populations.

In our study, the percentage of TP decreased after the intervention. Conversely, another study demonstrated no change in TP after ISDD. ^{Reference Zimmerman, Karameh, Ben-Chetrit, Zalut, Assous and Levin8} This could be explained by the additional interventions at Center 1 restricting BCx to specific services (e.g., ICU) and selected indications.

An assumption of no realized cost reduction post-ISDD can be made, given the absence of improvement in measured outcomes. We hypothesize that the known association between LOS and BCC, ^{Reference Al Mohajer and Lasco1} which was also seen in our study (Table 1), could be attributed to unmeasured confounding effects (e.g., other comorbidities) rather than true consequences of BCC since a reduction in contamination did not lead to a decrease in LOS. Similarly, we did not see a reduction in DOT for vancomycin and daptomycin, as these antibiotics were likely given for indications other than BCC.

Several studies estimated cost savings using ISDD solely based on BCC reduction. ^{Reference Jackman, Tahk, Zeileis, Maimone, Fearon and Meers5} Skoglund et al. ^{Reference Skoglund, Dempsey, Chen and Garey9} provided a cost-benefit analysis projecting a cost saving of $272 per device, primarily by reducing LOS. Consequently, given the commercial ISDD cost, ISDD would not be cost-beneficial if the LOS reduction is not realized.

To our knowledge, this is the second study that assessed more than one ISDT. Arenas et al. ^{Reference Arenas, Boseman, Coppin, Lukey, Jinadatha and Navarathna10} found that both commercially available devices had lower contamination than the open technique. Similarly, our study showed lower BCC in the commercial device arm; however, it is possible that the difference in BCC was due to the rigorous training on aseptic techniques provided by the Steripath team rather than the diversion technique itself.

Our study has several limitations. The non-randomized design renders it unlikely to conclude a causal association. Although we have accounted for the role of external factors by providing a control group and adjusting for several confounders, there remain unmeasured confounding effects. We did not assess for echocardiogram utilization; however, they are rarely employed in patients with BCC. Moreover, we did not evaluate other relevant outcomes, such as the device’s ease of use or patient satisfaction. Finally, our study was restricted to Southeast Texas, limiting generalizability.