Reducing blood stream infection in patients on hemodialysis: Incorporating patient engagement into a quality improvement activity.

Introduction Infection in our immunocompromised patients is the second leading cause of death, according to the Centers for Disease Control and Prevention (CDC). In an effort to improve quality of care, engage patients in their own care, and reduce morbidity and mortality secondary to infection, the Network designed a joint quality improvement/patient engagement activity to decrease bloodstream infection (BSI) rates. Methods Dialysis facilities were ranked utilizing 2014 National Healthcare Safety Network (NHSN) data. Selection included 20% of Network 13 facilities (n = 58) with the highest BSI rates, which captured 31% of the patient population. Findings Statistically significant (P < 0.001) improvement was reached in the reduction of BSIs; increasing patient engagement in the infection control process; and, correct completion of hand hygiene audits. Significant (P < 0.01) improvement was reached in correct completion of cannulation audits. There was also improvement in the catheter audits, but results were not significant. Discussion Involving patients in the infection control process contributed to our successful outcomes and could be replicated to meet the needs of the end stage renal disease community as a whole.

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 exit-site 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 (∼27% 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.

Fatal vascular access hemorrhage: reducing the odds.

Vascular access hemorrhage is not a frequently occurring complication associated with hemodialysis fistulas and grafts, but when it occurs, it can be fatal to patients and devastating to patients' families and dialysis unit staff members. The End Stage Renal Disease Notification of Death CMS-2746 forms indicated that between the years 2000 and 2006 (the most recent national data available), there were 1654 fatal vascular access hemorrhages. Specific issues that place patients at high risk for access rupture have been identified, and some are directly related to access physical assessment and cannulation. Recognizing at-risk accesses during physical assessment and improving site selection for needle placement can modify some risk factors for fatal vascular access hemorrhage and improve patient outcomes.

Who should be teaching patients to self-cannulate?

When teaching self-cannulation, a number of variables come into play, beyond whether patients have the dexterity or visual acuity to perform the task. To solidify learning, such as self-cannulation, it is imperative for nurses to know how to teach adult learners, identify each patient's learning style, and possess cannulation expertise. Cannulation is an invasive procedure, and it is a very personal and emotional learning experience that requires a knowledgeable, experienced educator.

Improving the fistula rate: the northwest renal network experience.

In November 2010, Northwest Renal Network was the first of the 18 ESRD Networks to reach the Fistula First goal of greater than 66% prevalent hemodialysis patients using an arteriovenous fistula (AVF). The network has sustained that goal over time and as of August 2011, has achieved an AVF rate of 67.7%. The Northwest Renal Network has been successfully motivating facilities to embrace change using thorough root cause analyses and targeted quality improvement projects throughout the Network's five-state region.

The buttonhole technique: strategies to reduce infections.

The buttonhole technique has gained popularity over the last decade in the United States. The fact that it is a relatively new technique, which requires a change to current cannulation practice, has contributed to several unforeseen complications that have led to increased infection rates in AV fistulae. To keep this technique a viable option for patients, it will be necessary to understand the potential infection risks and implement strategies to reduce the incidence of infection.

Forty years of vascular access.

March 9, 1960, was a milestone marker in end stage renal disease history - the date when a patient received the very first arteriovenous Scribner shunt. This began the era of maintenance or chronic hemodialysis. With long-term dialysis a reality, various new types of vascular access were developed. As the American Nephrology Nurses' Association celebrates its 40th anniversary, this article looks back to see just how far vascular access has come and what might be in store for the future.