title: Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.
abstract: BACKGROUND
  The prevalence of central venous catheters (CVCs) for hemodialysis remains high and, despite infection-control protocols, predisposes to bloodstream infections (BSIs).
  
  
  METHODS
  Stratified, cluster-randomized, quality improvement initiative.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  The primary outcome was positive blood cultures for estimating BSI rates.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA.
authors.forename: Alex
authors.initials: A
authors.lastname: Rosenblum
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA.
authors.forename: Weiling
authors.initials: W
authors.lastname: Wang
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA.
authors.forename: Lynda K
authors.initials: LK
authors.lastname: Ball
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Latham
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA.
authors.forename: Franklin W
authors.initials: FW
authors.lastname: Maddux
authors.affiliation: Fresenius Medical Care, North America, Waltham, MA. Electronic address: elacsonj@fmc-na.com.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Lacson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D055499:Catheter-Related Infections / Q000175:diagnosis / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000379:methods / Q000592:standards; D002408:Catheters, Indwelling / Q000382:microbiology* / Q000592:standards*; D016000:Cluster Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement / Q000592:standards*; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods / Q000592:standards*
keywords: Hemodialysis; central line–associated bloodstream infections; central venous catheters (CVCs); chlorhexidine; chronic kidney disease (CKD); infection prevention; vascular access