P379
ABOLISHING ACUTE HAEMODIALYSIS CATHETER ASSOCIATED BLOOD STREAM INFECTIONS
Alderson, H, Gorton, J, Corbett, A, Stirling, L, Brierley, B, Zada, T, Chavez, R, Anand, V, Luszcz, A, Smethurst,
L, Fereday, G, Hegarty, J
Salford Royal Hospital NHS Foundation Trust
PROBLEM: Central catheter associated blood stream infections cost money and increase patient morbidity and mortality.
As an acute kidney care facility we insert on average 8 temporary haemodialysis catheters per month (av 35 catheter days
pcm). In 2008 our department had the highest central catheter infection rates in the whole trust. In February 2009 we
joined a trust wide Quality Improvement Collaborative aiming to reduce catheter associated infections by 50% by
December 2009.
DESIGN: A multi-disciplinary improvement team was formed. The aims were to standardise line insertion, improve line
care and promote timely line removal. Designated team leaders used small group sessions to educate staff regarding best
practice around line insertion and care bundles. Multiple small tests of change (Plan, Do, Study, Act methodology) were
trialled to improve adherence to the bundles. Successful PDSAs resulted in standardised line insertion packs;
development of a detailed insertion checklist; introduction of daily review for removal and improved behaviour around
surveillance if line infection was suspected. Departmental presentations at CME, junior doctor lunchtime sessions and
nurse handover were all used to communicate ongoing challenges and progress. A consultant microbiologist flagged all
positive blood and line tip cultures each month. Patient case notes were systematically reviewed using an agreed
proforma (HELICS definition) to verify if it was a haemodialysis catheter associated infection. A random sample of 25%
of these episodes was reviewed by a second observer with 100% inter-observer concordance over the 9 month
collaborative period. For comparison, we carried out a retrospective analysis of the previous 6 months microbiology data.
FINDINGS: Adherence to processes of care began to improve after 4 months, but it took longer to establish near 100%
compliance with processes measurements, ie line insertion and care bundles. Analysis of microbiology data
demonstrated a significant and sustained fall in catheter associated infections with no line infections at the time of writing
for 7 months.
Haemodialysis catheter related infections
Number of episeodes of infection
4.5
4
3.5
3
2.5
Temporary
2
1.5
1
0.5
0
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr08
08
08
08
08
08
09
09
09
09
M
ay09
Jun09
Jul- Aug- Sep- Oct- Nov09
09
09
09
09
Month
CONCLUSIONS: It is possible to virtually abolish acute haemodialysis catheter associated infections if attention is paid
to correct line insertion, line care and timely line removal. Although published data is available to demonstrate reductions
of central catheter associated infections in ICU patients, the population of patients in an acute renal unit is quite different.
Many patients are mobile and a larger proportion of the lines inserted in our unit are inserted into femoral veins (80%), a
site generally avoided in other studies.
RELEVANCE: Haemodialysis catheter associated infections are costly and potentially lethal. With hard work, energy
and focus, it is possible to virtually abolish acute haemodialysis catheter associated infections using quality improvement
tenets which put the responsibility for improvement with frontline teams.