Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative

Am J Kidney Dis. 2014 Feb;63(2):259-67. doi: 10.1053/j.ajkd.2013.08.019. Epub 2013 Dec 2.

Abstract

Background: The prevalence of central venous catheters (CVCs) for hemodialysis remains high and, despite infection-control protocols, predisposes to bloodstream infections (BSIs).

Study design: Stratified, cluster-randomized, quality improvement initiative.

Setting & participants: All in-center patients with a CVC within 211 facility pairs matched by region, facility size, and rate of positive blood cultures (January to March 2011) at Fresenius Medical Care, North America.

Quality improvement plan: Incorporate the use of 2% chlorhexidine with 70% alcohol swab sticks for exit-site care and 70% alcohol pads to perform "scrub the hubs" in dialysis-related CVC care procedures compared to usual care.

Outcome: The primary outcome was positive blood cultures for estimating BSI rates.

Measurements: Comparison of 3-month baseline period from April 1 to June 30 and follow-up period from August 1 to October 30, 2011.

Results: Baseline BSI rates were similar (0.85 vs 0.86/1,000 CVC-days), but follow-up rates differed at 0.81/1,000 CVC-days in intervention facilities versus 1.04/1,000 CVC-days in controls (P = 0.02). Intravenous antibiotic starts during the follow-up period also were lower, at 2.53/1,000 CVC-days versus 3.15/1,000 CVC-days in controls (P < 0.001). Cluster-adjusted Poisson regression confirmed 21%-22% reductions in both (P < 0.001). Extended follow-up for 3 successive quarters demonstrated a sustained reduction of bacteremia rates for patients in intervention facilities, at 0.50/1,000 CVC-days (41% reduction; P < 0.001). Hospitalizations due to sepsis during 1-year extended follow-up were 0.19/1,000 CVC-days (0.069/CVC-year) versus 0.26/1,000 CVC-days (0.095/CVC-year) in controls (∼27% difference; P < 0.05).

Limitations: Inability to capture results from blood cultures sent to external laboratories, underestimation of sepsis-specific hospitalizations, and potential crossover adoption of the intervention protocol in control facilities.

Conclusions: Adoption of the new catheter care procedure (consistent with Centers for Disease Control and Prevention recommendations) resulted in a 20% lower rate of BSIs and intravenous antibiotic starts, which were sustained over time and associated with a lower rate of hospitalizations due to sepsis.

Keywords: Hemodialysis; central line–associated bloodstream infections; central venous catheters (CVCs); chlorhexidine; chronic kidney disease (CKD); infection prevention; vascular access.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Aged, 80 and over
  • Catheter-Related Infections / diagnosis
  • Catheter-Related Infections / prevention & control*
  • Catheterization, Central Venous / methods
  • Catheterization, Central Venous / standards
  • Catheters, Indwelling / microbiology*
  • Catheters, Indwelling / standards*
  • Cluster Analysis
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Quality Improvement / standards*
  • Renal Dialysis / adverse effects
  • Renal Dialysis / methods
  • Renal Dialysis / standards*