Original Investigation
Dialysis
Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report

https://doi.org/10.1053/j.ajkd.2013.03.011Get rights and content

Background

Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN).

Study Design

Quality improvement project.

Setting & Participants

Patients in 17 outpatient hemodialysis facilities that volunteered to participate.

Quality Improvement Plan

Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff.

Outcomes

Crude and modeled BSI and access-related BSI rates.

Measurements

Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods.

Results

Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period.

Limitations

Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project.

Conclusions

Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Section snippets

CDC Dialysis BSI Prevention Collaborative and Interventions

Participation in the CDC Dialysis BSI Prevention Collaborative project (the Collaborative) was voluntary and open to any US outpatient hemodialysis facility. Core activities of the Collaborative included participation in the CDC's NHSN surveillance system, implementation of the Collaborative interventions, and participation in monthly conference calls and yearly in-person meetings. The CDC provided participant training and assistance on NHSN enrollment and reporting procedures. Participants

Results

Of the 17 facilities included in the analysis, most facilities were not for profit (n = 15), hospital affiliated (n = 11), not part of a corporate chain (n = 16), and located in the Northeast (n = 11; Table 1). Facilities reported a median of 17 months of data to the NHSN during the evaluation period.

During the preintervention period, pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months, respectively. During the postintervention period, these rates were

Discussion

The mostly hospital-based hemodialysis facilities participating in this collaborative project were able to demonstrate substantial intervention-associated decreases in their BSI and access-related BSI rates, adding evidence that multicenter initiatives can effectively prevent vascular access infections. BSI reductions of this magnitude have the potential to markedly advance patient safety and produce cost savings.18 Previous initiatives have reduced central catheter–associated BSIs in inpatient

Acknowledgements

The authors thank all members of the CDC Dialysis BSI Prevention Collaborative, Ms Barbara Bond for support, and Dr Katherine Ellingson for providing technical guidance.

These findings were presented in part at the National Kidney Foundation Spring Clinical Meetings in Washington DC, May 10, 2012.

Support: The collaborative project described in this article was funded by the US CDC. The findings and conclusions in this report are those of the authors and do not necessarily represent the official

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    This is a US Government Work. There are no restrictions on its use.

    Originally published online May 15, 2013.

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