Using the Model for Improvement to Reduce Line Related Infections in an Adult Renal UnitS Chohana, JP Traynorb, C Nolanb, L Gourlayb, Y Campbellb, CA Andrewsb

a Dept Intensive Care, Monklands Hospital; b Dept Renal Medicine, Monklands Hospital, NHS Lanarkshire

CTP.LRIARU.89271.L

It’s part and parcel of having a line “

“

Patient Quote

BackgroundPatients with acute and chronic renal failure frequently develop hospital acquired infections. Baseline data showed a mean 3.1 days between bacteraemias which required treatment, and 21.7 days between S Aureus Bacteraemias (SABs), the majority from long term and temporary central venous dialysis catheters (CVC). Use of CVC care bundles reduce infection rate in intensive care1. Use of antimicrobial lock (AL) solutions may reduce infections in long term dialysis CVCs2, supported by some local data.

AimTo reduce the frequency of CVC related infections to greater than 300 days between infections in an adult renal unit by August 2013.

MethodA multi professional quality improvement team was formed. Baseline infection data were used to form hypotheses for potential interventions. These were tested using PDSA cycles. Process compliance data were gathered by staff not involved with the processes, using random sampling methods, and analysed using statistical process control charts.

Process ChangeCompliance with line bundles improved with the use of checklist stickers for insertion, and a prompt to use a checklist on the medicines kardex for CVC maintenance. Measurement showed that use of the correct AL was universal at first introduction as it was a prescribed medication.

Figure 1

Team

Improvement Expertise

ICU Consultant

Subject Expertise2 Renal Medicine

ConsultantsSenior Charge Nurse

Nurses

Hypotheses Select Processes

Initial Tests of Change• CVC Bundles

(temporary CVCs)• Antimicrobial Lock

(TauroHep) (tunnelled CVCs)

Later Test of Change• Use of

2%Chlorhexidine Wipes during connection

to HD

Reduce dialysis-line related infections

to median 300 days between infections

by August 2013

Measures to reduce recurrence

CONSIDER change in treatment eg, Flucloz

instead of vanc

Manipulation when taking

OFF HD

Manipulation

Exit site care

Temporary Lines

Maintenance Bundle

Insertion Bundle

Exit site care

Locks

Manipulation when putting ON HD-

chloroprep wipes of tunnelled line

Haemodialysis TCVC

Figure 2

ResultsNon SAB infections decreased from 3.4 days between infections to 41.3 days. Segmentation of patients’ by vascular access (long term vs. temporary CVC) suggest both ALs and CVC bundles have a beneficial effect (charts not shown here).

Figure 3

SAB rates were unchanged, but arose from many sources including CVCs. It is too early to measure an effect on CVC related SABs. We hypothesised that the process of connection and disconnection from haemodialysis affected SAB risk, and are testing the effect of process reliability.

Figure 4

ConclusionsReliable processes reduce CVC related infection in patients with renal disease. Reduction in infection rate, data analysis and team learning allows testing of other key processes affecting outcome.

References

1. Berenholtz SM, Pronovost PJ, Lipsett PA et al. Crit Care Med: Eliminating catheter-related bloodstream infections in the intensive care unit. 2004:32;10:2014-2020

2. Solomon LR, Cheesbrough JS, Ebah L et al. Am J Kid Dis: A randomized double-blind controlled trial of taurolidine-citrate catheter locks for the prevention of bacteraemia in patients treated with hemodialysis. 2010 Jun;55(6):1060-8