Central Line-Associated Bloodstream Infection Reduction in Hemodialysis Patients Across 9 Hospitals and 3 States

Abstract

Background

This quality improvement project was initiated to reduce hospital-acquired catheter-associated bloodstream infections (CLABSI) in hospitalized patients receiving dialysis. A team dedicated to reducing hospital-acquired infections led the implementation of evidence-based interventions across all the included hospitals. This innovative approach demonstrated substantial enhancements in outcomes for patients on hemodialysis.

Methods

To enhance patient safety in patients receiving hemodialysis, new strategies were implemented, including (1) transitioning from a vendor model to an internal model, enabling dialysis program standardization, (2) empowering intensive care nurses with increased autonomy and ownership, (3) transitioning to a standardized dialysis machine, and (4) introducing chlorhexidine gluconate (CHG) impregnated caps and CHG pads. To reduce CLABSI in hemodialysis lines, a multidisciplinary team was formed comprising physicians, nurses, a dialysis technician, pharmacists, the dialysis director, the chief medical officer, the chief nursing officer, the assistant chief nursing officer, the infection preventionist, and the quality director. The team implemented a standardized approach to caring for hemodialysis lines, provided just-in-time education to staff, and standardized policies simultaneously at 8 hospitals. Initially, 1 facility served as the pilot facility for facility-owned dialysis services, totaling 9 facilities providing in-house standardized dialysis services. Data was reported back for monthly evaluation.

Results

Overall, there was an 88% reduction in CLABSI occurrences in hemodialysis lines from pre-intervention (n = 8) to post-intervention (n = 1), X² (1, N = 4112) = 4.181, P = .0408. Collaboration on these initiatives improved communication and enhanced quality care and patient safety across the entire spectrum of care.

Conclusions

Implementing innovative tracking of standardized approaches to patient care and infection prevention and evidence-based interventions resulted in decreased CLABSI rates, improving outcomes in vulnerable patients. An unintended benefit of this project was the increase in multidisciplinary collaboration.

Introduction

Currently, in the United States (US), it is estimated that 1 in 31 patients admitted to the hospital are at risk for developing a hospital-acquired infection (HAI) during their hospital stay. These HAIs include catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), hospital-acquired Clostridioides difficile infections (CDIFFs), ventilator-associated pneumonia (VAP), hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in the blood, and hospital-acquired infection after colon or hysterectomy surgery. Many treatments in the hospital require the use of an invasive device, such as a catheter or ventilator, to aid in the patient’s healing. The potential for patients to acquire an HAI is of significant concern, as infections can prolong hospitalizations, heighten morbidity and mortality rates, contribute to antimicrobial resistance, and elevate patients’ risk of infection.^1,2 In 2020, US acute-care hospitals reported a substantial increase in bloodstream infections (BSIs) associated with central vascular catheters, totaling 28 370 cases. This was an 18% increase in BSIs compared to the previous years.¹

Individuals with either acute or chronic diseases of the kidney may require hemodialysis (HD) treatment. This treatment is used to filter wastes and water from the blood when the kidneys are unable to do so effectively. A person hospitalized with kidney disease or who develops kidney failure from another disease process may require HD while hospitalized, which requires the insertion of a special vascular or HD catheter. Nationally, patients undergoing HD treatment face an amplified risk of developing HAIs, particularly CLABSIs, due to repeated access to the line. While estimates vary, studies suggest that HD patients may be up to 100 times more likely to contract a CLABSI, underscoring the critical need for targeted preventive measures and interventions.³

In the inpatient hospital setting, HD-associated CLABSI infections can be attributed to a multitude of factors. These include but are not limited to insertion practices, catheter management, and device duration.^4,5 Ensuring appropriate protocols and maintenance plans are in place is imperative to ensure CLABSI prevention efforts are successful. Measures could include evaluating insertion sites, thorough antisepsis, catheter lumen management, barrier precautions, duration minimization, ensuring dressing integrity, maintaining aseptic technique, disinfecting connectors rigorously, daily chlorhexidine gluconate (CHG) bathing, and optimizing dressing change practices. By comprehensively addressing these measures, health care facilities can significantly reduce the incidence of CLABSI infections among patients on HD.

Our pilot institutions’ CLABSI rates reached an all-time high, registering at a Standardized Utilization Rate of 0.68, which, while still below the national average, was 27% higher than the previous years’ scores, with nearly 40% of CLABSI-related infections attributed to HD lines. The increase in CLABSIs raised awareness of the issue in our pilot institution as well as in the 8 other institutions. This project was undertaken as a quality improvement (QI) project and as such does not require oversight by an Institutional Review Board.

Methods

Project Setting, Design, Context, and Sample

The setting for this project included a multi-hospital division spanning 3 states that made the transition from contracted HD services to all in-house services. A director was hired to manage the transition, and they noted an increase in CLABSIs, with several instances associated with HD lines. With all new staff performing HD at the 9 hospitals during the phasing from outsourced to in-house services, the director embarked on a QI project aimed at eliminating HD-line-associated CLABSIs. A systematic approach to handling HD catheters was essential to standardize maintenance and care of the catheters to eliminate potential infection through the HD catheter. Thorough education and training of all staff performing HD was needed.

Routine data monitoring revealed an increase in CLABSI cases after the implementation of in-house dialysis services in the 9 hospitals that offered in-house dialysis and had all new staff performing treatments. The director of HD programs reviewed the data and realized that action needed to be taken. Given the span of hospitals, the director assembled an interdisciplinary team of nephrology physicians, nurses, a dialysis technician, a pharmacist, the chief medical officer (CMO), the chief nursing officer (CNO), the assistant chief nursing officer (ACNO), the infection preventionist, the director of critical care, the intensivist medical director, and the director of quality to tackle the issues. The team investigated all reported CLABSIs across the 9 hospitals, which revealed that infections involving HD catheters accounted for an estimated 40% of all HAIs, including 8 reported cases within a year. Recognizing the urgency of the situation, the director of HD programs directed the interdisciplinary team to identify and implement a set of standardized interventions to be rolled out across the 9 hospitals offering HD services to mitigate infections associated with HD catheters.

The team identified 1 hospital to be the pilot facility for the QI project. In Q3 2020, the pilot hospital moved from an external dialysis program to an in-house program. By Q3 of 2021, all remaining facilities made the transition from external to in-house, with a focus on standardizing protocols, interventions, and policies across sites. By Q1 of 2022, policies and procedures had been uniformly established, including the standardization of supplies and equipment for HD and intensive care unit (ICU) treatments.

During Q1 2022, as the HD CLABSI reduction program shifted to an in-house model, the interdisciplinary team developed a set of standard interventions and protocols that all nurses would follow. The entirety of the protocols and interventions deployed are presented in Table 1. Standard infection prevention interventions were implemented during the initial development of the program. These measures were focused specifically on the front-line staff. In addition, these methods align directly with guidelines issued by the Centers for Disease Control (CDC), the Association for Advancement of Medical Instrumentation (AAMI), and The Joint Commission (TJC), among others.^6–8 The team identified a lead nurse at the facility who ensured that all interventions were in place and being followed. The lead nurse monitored practices in real-time, observed HD treatments, and audited cleaning logs to ensure proper infection control practices were followed. On-the-spot remediation was conducted as appropriate. The nurse also reported back monthly to the interdisciplinary team on compliance with all interventions.

Table 1.

Standardized Program and Interventions Implemented at 9 Hospitals to Reduce HD CLABSIs (2020 to 2023)

(1) Appropriate disinfection of dialysis spaces

(2) Rigorous monitoring of water and dialysate quality

(3) Employ single-patient use equipment

(4) Surveillance and de-escalation protocols for line monitoring

(5) Regular audits of hand hygiene and line access

(6) Patient and staff education initiatives

(7) Use of chlorhexidine gluconate (CHG) impregnated dressings on central lines

(8) Provide feedback on infection rates, with a focus on frontline staff engagement

Next, the team determined that surveillance of central vascular catheters was needed daily, including the necessity of the line, the condition of the dressing covering the line, and the documented date for the next dressing change (steps 4–5 of Table 1). Before and after HD treatment, the HD nurse would conduct and document the assessment; however, given the variability in treatments, it was determined that rigorous monitoring of the catheters was needed. Each facility conducted daily reviews of every central line, assessing its necessity and potential for de-escalation. The line surveillance results were reported daily at the facility’s previously established daily safety huddle. All concerns were addressed by the facility CMO, CNO, or ACNO as needed.

The interdisciplinary team next deployed education for the staff who were handling HD catheters (step 6, Table 1). Intensive care nurses and dialysis nurses were educated in appropriate manipulation of dialysis catheters. Education was provided regarding dressing changes, proper access and de-access of HD lines, and effective monitoring and assessment practices. Furthermore, all nurses received training on dressing changes and appropriate line assessment, to ensure ongoing dressing integrity. Policy adjustments ensured all registered nurses were proficient in HD dressing changes. During this education, each hospital’s infection preventionist rounded daily on patients with HD catheters as a secure check for the integrity of the line.

A common finding during training and reviews was the lack of adherence to an adequate dry time when accessing central lines. Consequently, an infection preventionist conducted a literature review on alternative line disinfection products. Following this review, the team discussed transitioning to chlorhexidine gluconate (CHG) pads for cleaning around the hub, due to their shorter dry time (5 seconds) and CHG-impregnated caps on HD lines.^9,10 To assess the feasibility of the proposed change at scale, CHG pad costs were compared to alcohol pads. The cost analysis justified the switch to CHG pads, balancing infection expenses with potential improved patient safety. Each facility followed a timeline to implement the new caps. Eight out of 9 facilities transitioned to CHG caps during Q3 of 2022, with the remaining facility converting in Q4 of 2022 due to concurrent dialysis performance improvement projects (Figure 1). The CHG pads and caps were made available in all areas where dialysis lines were accessed. Education was provided for all staff trained in dialysis line access and with 100% verbalized understanding. The intervention was executed and CHG pads were readily available in the ICU and HD departments to ensure usage when changing dressings or accessing lines (step 7 of Table 1).

Figure 1.

This chart tracks CLABSI counts, highlighting interventions such as the start of ICU treatments, shifts to in-house dialysis, and the implementation of chlorhexidine/alcohol pads and dialysis caps. Pre- and post-intervention periods are marked for comparison.

Furthermore, during this time, standardized procedures for dialysis care across all facilities were implemented to enhance consistency and efficiency. All policies were revised to division-based standards, aligning with corporate policies to ensure uniformity. Comprehensive education on policy changes was provided to all dialysis staff and intensive care personnel trained in dialysis procedures. To streamline operations, dialysis-related products and equipment were standardized throughout the hospitals, ensuring consistent availability and usage protocols for HD staff. Additionally, we conducted an audit of the electronic health record system to ensure uniformity in charting and dialysis treatment orders. Adjustments were made to harmonize the electronic health record systems across both platforms utilized within the division, promoting consistency and accuracy in documentation and workflow processes.

Once education was completed and to strengthen the program, the scope and frequency of line audits were increased to at least once per week, involving a broader spectrum of individuals. These audits engaged the infection preventionist, dialysis director, and critical care director to focus on evaluating the environment of care, dressing changes, line access and de-access procedures, and adherence to policies and procedures. Specifically, tailored to HD staff, the audits provided opportunities for education and performance enhancement (step 8, Table 1). This continuous monitoring of CLABSI rates continued throughout the year and into 2023. Notably, during 2023, no new policies or procedures related to CLABSI prevention were introduced.

To ensure the QI project was effective, each HD-associated CLASBI event underwent a comprehensive review by the medical team, including joint discussions with nursing staff, physicians, the infection preventionist, the dialysis director, unit managers, CNO, quality leadership, and any other pertinent team members. After each CLABSI event, a structured analysis was conducted. The aim of the review was to identify potential lapses in infection prevention practices or staff education that needed to be addressed to ensure the correct techniques were being employed by all staff members administering and caring for HD lines. The multidisciplinary team reviewed all CLABSI events monthly.

Analysis and Results

Descriptive statistics were collected on patient and HD CLABSI data to gain deeper insights into the population and infection trends. A chi-square test was chosen as the statistical method to compare pre- and post-intervention CLABSI rates, as it met the assumptions required for the analysis, including frequency data, mutually exclusive categories, and independence. The test was performed with a 95% confidence interval. All statistical analyses were executed using Python and Excel. No power analysis was conducted as the data analysis was carried out retrospectively. Data were extracted from the hospitals’ electronic health records systems and infection prevention logs and analyzed.

COVID-19 Excluded Data

Patients who tested positive for COVID-19 were excluded from the analysis to eliminate potential confounding variables.¹¹ Among CLABSI patients, the number of COVID-19-positive cases was 24 pre-intervention and 1 post-intervention (P = .0163). When COVID-19-positive CLABSI patients were excluded, the cases decreased from 19 infections preintervention to 1 post-intervention (P = .0408). Although both evaluations yielded statistically significant results, our analysis focused on the data set with COVID-19-positive patients excluded.

Change in HD-CLABSI Rates

Over an approximately 4-year period from January 2020 to December 2023, data on HD CLABSI rates were collected from the 9 hospitals in the project across 3 states. HD CLABSI rates during the 32-month pre-intervention period (January 2020 to September 2022) and 14-month post-intervention period (October 2022 to December 2023) are summarized in Figure 1. Results showed a statistically significant decrease in HD CLABSI rate across the intervention period X² (1, N = 4112) = 4.181, P = .0408. During the pre-intervention phase, the 9 institutions administered a total of 21 141 HD dialysis treatments, approximately 649 HD treatments a month, with a total of 19 HD CLABSI occurrences (0.09%). During the post-intervention phase, the 9 institutions administered 9017 HD dialysis treatments, approximately 601 HD dialysis treatments a month, with 1 HD CLABSI occurrence (0.011%). This was an 88% reduction in CLABSI occurrences in HD lines from pre-Intervention (January 2020 to September 2022) to post-intervention (October 2022 to December 2023). Results of the analysis also revealed a 71% decrease in CLABSI occurrences from all 9 hospitals originating from HD lines, with HD lines accounting for 38.10% of all CLABSIs in 2020, compared to only 11.11% of CLABSIs in 2023 (Figures 2 and 3).

Figure 2.

The graph shows the decline in institutional CLABSI cases (orange line) and the percentage of CLABSIs attributed to hemodialysis lines (blue line) from 2020 to 2023. Roderman et al. (2024)

Figure 3.

The graph displays monthly HD CLABSI counts before and after the program’s implementation, showing a decrease in occurrences over time.

Discussion

While performing root cause analysis we observed HD catheter maintenance variability among clinicians. Examples of the variability included catheter access procedures, insertion techniques, and dressing maintenance. This finding led to increased staff education and training to standardize practice. In addition, the facilities moved to in-house management allowing each facility to standardize practice across all hospitals. Also, daily line surveillance ensured all interventions became hardwired. To scale across 9 hospitals, having member representatives from each hospital on the interdisciplinary team ensured buy-in from all hospitals. The infection preventionists enhanced the project with on-the-spot remediation and education. This team approach aided in the successful reduction of HD CLABSIs.

Unexpected benefits emerged from this project. In the second quarter of 2020, 1 facility decided to have ICU nurses manage all extended treatments, which increased nurse autonomy and reduced treatment costs by eliminating vendor services. This success led other facilities in the division to adopt the same approach. Policies and procedures were adopted to support the change, order sets were added to the electronic health record, and ICU nurses received training to ensure competency. By the third quarter of 2020, the facility had transitioned all dialysis services to an in-house model, which included hiring dialysis-specific nurses and providing thorough training. This pilot program expanded to 2 other facilities, successfully standardizing treatments without increasing CLABSIs.

Another noteworthy finding from this project was the implementation of infection reduction measures related to the use of CHG pads and CHG-impregnated caps. While all interventions may have aided in the process of the reduction of CLABSIs in this hospital group, the most significant decrease in CLABSIs was noted after the implementation of CHG-impregnated caps and CHG pads. This decrease could be linked to the continued presence of CHG in the catheter lumen due to the design of the catheter caps. In addition, the improved compliance with dry times associated with the CHG pads potentially led to decreased infection rates. In Q4 of 2022, the full implementation of CHG pads and CHG-impregnated caps was completed. Following this implementation, we observed a significant (89%) reduction in HD CLABSI cases in 2023, with only 1 case reported in 2023 compared to 8 cases in 2022.

Conclusion

At the time of this writing (May 2024), the HD CLABSI reduction program has yielded quality results each quarter. Specifically, implementing and tracking standardized approaches and high-quality infection prevention interventions has demonstrated continuous low CLABSI rates. Moving forward, it is imperative to maintain a continuous cycle of evaluation and reevaluation of evidence-based infection prevention practices. This includes implementing monitoring protocols in acute settings for HD lines, as these patients frequently transition in and out of hospital environments, exposing them to heightened risks of infection.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.