P1324targeting Zero Infections in Hemodialysis Patients. An Experience of Only Two Catheter-Related Bloodstream Infection (Cr-Bsi) Over a Period of 1430 Days

Abstract

Background and Aims Patients undergoing hemodialysis (HD) through a tunneled central venous catheter are exposed to several risks. Catheter-related bloodstream infection (CR-BSI) is the second major cause of death in this population. To reduce the incidence of CR-BSI we conducted a non-randomized pre-post intervention study aimed to eliminate all preventable CR-BSI. Method A quasi-experimental study was conducted in an intra-hospital hemodialysis unit with 15 HD machines and attending 70 patients until March 2019, and 24 machines and 90 patients from that date until today. The CDC, CR-BSI criteria for dialysis event surveillance protocol, defined as the presence of a positive blood culture with the suspect source report as the vascular access or uncertain was used to define CR-BSI. A sequential implementation of evidence-based interventions, associated in literature with the reduction of CR-BSI rate, were developed between January 2011 and January 2020. The intervention package included: 1. Alcohol based gel delivery system fixed in every HD machine to enhance hand hygiene adherence 2. A new strict aseptic protocol for connecting/disconnecting HD lines that included: 2.1 Wrapping catheter rubs for 1-2 minutes with alcoholic chlorhexidine-saturated gauze before removal catheters caps 2.2 Nurses and patients wear masks during catheter manipulation 2.3 Apply a sterile fenestrate drape with sterile gloves before removing the caps 2.4 The scrub-the-hub aseptic technic after removing the caps with alcoholic chlorhexidine-saturated gauze 2.5 Precocious use of Tissue Plasminogen Activator (rTPA) to correct inadequate blood flow, avoiding excess of catheter manipulation 3. Use of chlorhexidine-impregnated dressing changed once a week 4. Training all nurse staff admitted, catheter care skill evaluation semiannually, re-training when necessary and monthly infection rate feedback 5. Use of citrate 30% as lock solution. Results During the follow-up period (January 2011 to January 2020) a mean of 45 patients (range 30-55) used tunneled catheter as vascular access each year. The mean age was 69±15 years (range 11-96 years), with 60% of patients been diabetic. After implementation the of the new strategies we observed a continuous reduction in the CR-BSI rate: 2010 the year before strategies implementation CR-BSI rate was 1.1/1000 catheter-days; 2011 CR-BSI rate 0.6/1000 catheter-days; 2012 CR-BSI rate 0.6/1000 catheter-days; 2013 CR-BSI rate 0.1/1000 catheter-days; 2014 CR-BSI rate 0.1/1000 catheter-days; 2015 CR-BSI rate 0.2/1000 catheter-days; 2016 CR-BSI rate 0.2/1000 catheter-days; 2017 CR-BSI rate 0.0/1000 catheter-days, 2018 CR-BSI rate 0.08/1000 catheter-days, and 2019 CR-BSI rate 0.06/1000 catheter-days. Between April 10th of 2016 and January 10th of 2020, a 1430 days period, we observed only 2 CR-BSI. Between April 10th of 2016 and January 3rd of 2018 there was a period of 633 days with no CR-BSI. Conclusion Implementation of several evidence-based practices and continuous education can reduce CR-BSI in HD patients to a very low level. Targeting zero infection proposing to eliminate all preventable infection should be the routine practice of all dialysis units.