Hemodialysis Catheter Care Strategies: A Cluster-Randomized Quality Improvement Initiative

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 exitsite 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 (w27% 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. (C) 2014 by the National Kidney Foundation, Inc.