Embracing collaboration: A novel strategy for reducing bloodstream infections in outpatient hemodialysis centers

doi:10.1016/j.ajic.2012.07.015

American Journal of Infection Control

Volume 41, Issue 6, June 2013, Pages 513-519

https://doi.org/10.1016/j.ajic.2012.07.015 Get rights and content

Background

The incidence of access-related bloodstream infections (AR-BSIs) in US outpatient hemodialysis centers is unacceptably high. This paper presents the implementation and results achieved from a multi-pronged strategy to reduce AR-BSIs in 1 outpatient hemodialysis center.

Methods

The intervention, which took place between 2009 and 2011, involved membership in the Centers for Disease Control and Prevention Hemodialysis Bloodstream Infection Prevention Collaborative, implementation of a panel of infection prevention interventions, and use of positive deviance (PD) to engage staff. Changes in the incidence of AR-BSIs and infection prevention process measures between the pre- and postintervention time periods, as well as alterations in the center's social networks, were examined to assess impact.

Results

The incidence of all AR-BSIs dropped from 2.04 per 100 patient-months preintervention to 0.75 (P = .03) after employing the Collaborative interventions and to 0.24 (P < .01) after augmenting the Collaborative interventions with PD. Adherence rates increased significantly in 4 of 5 infection prevention process measure categories. The dialysis center's social networks became more inclusive and connected after implementation of PD.

Conclusion

Participating in a Collaborative, employing a panel of infection prevention strategies, and engaging employees through PD resulted in a significant decline in AR-BSIs in this facility. Other hemodialysis facilities should consider a similar approach.

Section snippets

Facility

The AtlantiCare Regional Medical Center Bruce A. Eidelson, MD, Dialysis Unit is a 12-station hospital-based outpatient hemodialysis center serving patients in the Atlantic City, NJ, region. The dialysis center provides care mostly to the community's underinsured end-stage renal disease population. Prior to the interventions described in this paper, the center deployed several strategies to reduce BSIs: dialysis infection-related events surveillance through the CDC's National Healthcare Safety

Outcome measures

AR-BSIs incidence rates for the preintervention, Collaborative, and Collaborative with PD time periods ranged from 2.04 per 100 patient-months to 0.24 per 100 patient-months and varied for AR-BSIs in catheter patients from 2.94 per 100 patient-months to 1.32 per 100 patient-months. The incidence rate for AR-BSIs was significantly lower in both postintervention periods than in the preintervention period. Incidence rates for AR-BSIs in catheter patients dropped from postintervention period 1

Discussion

At AtlantiCare's outpatient hemodialysis center, implementation of a package of interventions and membership in a collaborative supported by a defined behavioral change process resulted in a lower incidence of overall AR-BSIs and AR-BSIs in patients with catheters. Notably, this included only 1 AR-BSIs for the final 12 months of the evaluation period. In addition, following implementation of PD, there were significant improvements in important infection prevention process measures. Social

Acknowledgments

The authors express deep appreciation to Alex Kallen, Priti Patel, and Ronda Sinkowitz-Cochran from CDC for their assistance with the manuscript; to CDC for establishing the BSI Prevention Collaborative and supporting the positive deviance effort at AtlantiCare; and to Jeffrey Cohn for his positive deviance consulting assistance at AtlantiCare.

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Cited by (26)

Effect of a Multifaceted Intervention on the Incidence of Hemodialysis Catheter Dysfunction in a National Stepped-Wedge Cluster Randomized Trial
2023, Kidney International Reports
Effective strategies to prevent hemodialysis (HD) catheter dysfunction are lacking and there is wide variation in practice.
In this post hoc analysis of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a national (REDUCCTION) stepped-wedge cluster randomized trial, encompassing 37 Australian nephrology services, 6361 participants, and 9872 catheters, we investigated whether the trial intervention, which promoted a suite of evidence-based practices for HD catheter insertion and management, reduced the incidence of catheter dysfunction, which is defined by catheter removal due to inadequate dialysis blood flow. We also analyzed outcomes among tunneled cuffed catheters and sources of event variability.
A total of 873 HD catheters were removed because of dysfunction over 1.12 million catheter days. The raw incidence was 0.91 events per 1000 catheter days during the baseline phase and 0.68 events per 1000 catheter days during the intervention phase. The service-wide incidence of catheter dysfunction was 33% lower during the intervention after adjustment for calendar time (incidence rate ratio = 0.67; 95% confidence interval [CI], 0.50–0.89; P = 0.006). Results were consistent among tunneled cuffed catheters (adjusted incidence rate ratio = 0.68; 95% CI, 0.49–0.94), which accounted for 75% of catheters (n = 7403), 97.4% of catheter exposure time and 88.2% of events (n = 770). Among tunneled catheters that survived for 6 months (21.5% of tunneled catheters), between 2% and 5% of the unexplained variation in the number of catheter dysfunction events was attributable to service-level differences, and 18% to 36% was attributable to patient-level differences.
Multifaceted interventions that promote evidence-based catheter care may prevent dysfunction, and patient factors are an important source of variation in events.
Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter–Related Bloodstream Infections: A Systematic Review
2023, American Journal of Kidney Diseases
Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI).
Systematic review.
PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU).
Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools.
Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described.
We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI.
Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility.
Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted.
Registered at PROSPERO with registration number CRD42021252290.
People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.
Epidemiology of infections and antimicrobial use in Australian haemodialysis outpatients: findings from a Victorian surveillance network, 2008–2015
2017, Journal of Hospital Infection
Citation Excerpt :
Finally, infection prevention practices at participating centres were not evaluated to determine the impact upon infection risk. The use of multi-modal care bundles has been shown to reduce risk of infection in haemodialysis patients, including interventions such as staff education, observation of vascular access/catheter care, use of chlorhexidine for skin antisepsis, auditing of hand hygiene practices, patient education, and catheter use reduction strategies [32–34]. In Australia, a multi-site study is currently underway to implement evidence-based and systematic interventions for reducing the risk of catheter-related bloodstream infections in dialysis patients [35].
Patients with chronic renal failure who require haemodialysis are at high risk for infections.
To determine the burden of bloodstream and local access-related infections and the prescribing patterns for intravenous antibiotics in Australian haemodialysis outpatients.
A surveillance network was established following stakeholder consultation, with voluntary participation by haemodialysis centres and data collation by the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre. Definitions for infection and intravenous antimicrobial starts were based upon methods employed by the Centers for Disease Control and Prevention. Longitudinal mixed-effects Poisson regression was used to model time-trends for the period 2008–2015.
Forty-eight of 78 Victorian dialysis centres participated in the network, with 3449 events reported over 78,826 patient-months. Rates of bloodstream infection, local infection and intravenous antimicrobial starts were much higher for patients with tunnelled central lines (2.60, 1.41, and 3.37 per 100 patient-months, respectively), compared to those with arteriovenous fistulae (0.27, 0.23, and 0.73 per 100 patient-months, respectively) and arteriovenous grafts (0.76, 1.08, 1.50 per 100 patient-months, respectively). Staphylococcus aureus was the most frequent pathogen, with meticillin-resistant isolates (MRSA) responsible for 14.0%. Access-related infections diminished significantly across all vascular-access modalities over time. Vancomycin contributed nearly half of all antimicrobial starts consistently throughout the study period.
Risk for bloodstream and local access-related infections is highest in Australian haemodialysis patients with tunnelled central lines. S. aureus is the most frequent cause of infection, with a low incidence of MRSA. Future programmes should evaluate infection prevention practices and appropriateness of antibiotic prescribing in this population.
What is the evidence for intraluminal colonization of hemodialysis catheters?
2014, Kidney International
Hemodialysis catheter–related bloodstream infections are potentially devastating, leading to increased morbidity, mortality, and cost of care. Prospective studies published over the past 15 years shed light on the pathogenesis of these infections. The data suggest that the intraluminal microbial colonization of hemodialysis catheters often precedes bloodstream infection. This finding supports strategies aimed at preventing or eradicating intraluminal colonization.
New technologies to monitor healthcare worker hand hygiene
2014, Clinical Microbiology and Infection
Citation Excerpt :
This allowed calculation of the number of alcohol rub aliquots dispensed per number of nurse visits to patient rooms [12], and ultimately improved HH compliance. Recent evidence from social network analysis confirms that we are influenced not only by people close to us (parents, siblings, or friends), but also by friends of friends [25]. In a similar vein, HCWs can be influenced by patients and visitors.
Compliance with hand hygiene is a good quality indicator for hospital patient safety programmes. Hand hygiene is a major infection control prevention intervention, but in many medical centres compliance rates are only c. 50%. Given the enormous number of hand hygiene opportunities in hospitals, direct observation to monitor compliance is very inefficient. However, technologies are emerging to obviate the need for direct observation. These new technologies for monitoring hand hygiene compliance are discussed in this article.
Positive deviance in infection prevention and control: A systematic literature review
2022, Infection Control and Hospital Epidemiology

View all citing articles on Scopus

: CDC provided financial support for the Collaborative, the social network analysis, and the positive deviance consulting assistance.

: Study was conducted at AtlantiCare Regional Medical Center, Bruce A. Eidelson, MD, Dialysis Unit, Atlantic City, NJ.

: Conflicts of interest: C. Lindberg consults with health care organizations on Positive Deviance. V. Krebs consults with organizations on social network analysis. All other authors report no conflicts.

View full text

Major articleEmbracing collaboration: A novel strategy for reducing bloodstream infections in outpatient hemodialysis centers

Background

Methods

Results

Conclusion

Section snippets

Facility

Outcome measures

Discussion

Acknowledgments

Am J Kidney Dis

Am J Surg

Am J Infect Control

USRDS 2009 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States

Centers for Disease Control and Prevention. Vital signs: central line associated bloodstream infections, United States, 2001, 2008, and 2009

MMWR Morb Mortal Wkly Rpt

Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis

Infect Control Hosp Epidemiol

Kidney International: bacterial infection in the hemodialysis patient: pathogenesis and prevention

Kidney Int

Reducing bloodstream infections in an outpatient hemodialysis center: New Jersey, 2008-2011

Morb Mortal Wkly Rpt

Your company’s secret change agents

Harvard Bus Rev

The power of positive deviance: how unlikely innovators solve the world’s toughest problems

Positive deviance in child nutrition: with emphasis on psychosocial and behavioral aspects and implications for development

Sustained positive deviant child care practices and their effects on child growth in Viet Nam

Food Nutr Bull

The power of positive deviance

BMJ

Sustained reduction in the clinical incidence of methicillin-resistant Staphylococcus aureus colonization or infection associated with a multifaceted infection control intervention

Infect Control Hosp Epidemiol

Letting go, gaining control: positive deviance and MRSA prevention

Clin Leader

Staff-driven cultural transformation diminishes MRSA

Prev Strategist

Major article
Embracing collaboration: A novel strategy for reducing bloodstream infections in outpatient hemodialysis centers