Hemodialysis Catheter Infection Reduction Kathleen Maloney, RN State University of New York Institute of Technology Department of Nursing Introduction Model PICO Abstract Literature Review References Objectives Implementation Conclusion According to the Joint Commission, intravascular catheter-related infections are a significant patient safety concern in health care today and are among the leading causes of morbidity and mortality in US hospitals. Both tunneled (permcath) and non-tunneled (temporary) hemodialysis catheters are included in this infection concern as they are direct routes to the bloodstream. Research of current standards of practice for the appropriate use of semi- permanent hemodialysis catheters, proper placement technique and catheter care revealed increased risk of infectious complications. The purpose of this project is to help reduce the incidence of blood-stream infections associated with hemodialysis catheters, identify if one catheter places patients at higher risk for catheter-related infection and to help establish a clinical pathway that guides providers in ordering the most appropriate hemodialysis catheter for their patients. Objective # 1: Review research literature focused on infection rates among tunneled permanent dialysis catheters and non-tunneled temporary dialysis catheters. Objective # 2: Initiate data collection on dialysis catheter placement within IR department to track infection rates related to hemodialysis catheters within the hospital. Objective # 3: Analyze data from literature reviews and data collected from hospital based research to assess infection risks among patients requiring hemodialysis catheters. Objective # 4: Use all research information to help establish a clinical pathway to aid physicians in ordering the appropriate dialysis catheter to help reduce infection rates among patients. Introduction Central line-associated bloodstream infections are monitored closely by the Joint Commission in an effort to reduce the potentially deadly outcomes associated with these infections, as well as the financial burden placed on the healthcare system as a result of the necessary treatment of these infections. Bloodstream infections not only complicate the course of treatment, but also increase morbidity and mortality among effected patients. According to Saxena & Panhotra, the use of central venous catheters as vascular access for HD has become more widespread, with an inevitable inherent risk of catheter-related bloodstream infections and ensuing mortality. We have seen an increase in the request for permanent dialysis catheters or permcaths in our department as well as a number of requests for permcath removals related to questionable catheter- related infection. After discussing this with the Interventional Radiologists, it was decided that we would not only track the placement and removal of all permcaths in the department, but also research clinical pathways that lead to the decision to order permcaths versus temporary dialysis catheter. Patient Population: Hospital In-Patients >25 years old with acute renal failure requiring dialysis Intervention: Placement of hemodialysis catheter by Interventional Radiology Comparison: Placement of tunneled permanent dialysis catheter versus placement of non-tunneled temporary dialysis catheter Outcome: Reduction in dialysis catheter infections requiring removal of dialysis catheter -Overview of Dialysis Outcomes Quality Initiative publication on vascular access and proper placement of tunneled catheters was completed. Preventing these complications will in turn reduce long- term morbidity and mortality of patients, and lower costs associated with catheter complications. (Banerjee, 2011). -This literature review discusses epidemiology and pathogenesis of hemodialysis catheter- related infections. According to this study, the incidence of catheter-related infection ranges between 0.6 and 6.5 episodes per 1000 catheter days (Lok & Mokrzycki, 2011). -Clinical study completed to assess the incidence of bacteremia and bacterial colonization reported incidence of bacteremia varies greatly, however in this study, the catheter colonization rate was 23.4/1000 catheter/days, with an incidence of 9.2 episodes bacteremia 1000/catheter days and 68.9% of the patients presented at least one catheter with colonization evidence during the course of the study (Freitas, Neto, Nascimento & Figueiredo, 2008). -Study to evaluate the clinical and cost effectiveness of implementing published guidelines that pertain to patient son HD. The incidence of catheter-related infections in the U.S. ranges from 0.2 to 7.2 per 1000 catheter days (Bakke, 2010). The model that guided this project was that of Faye Abdellah’s Twenty-one Nursing Problems. She describes the achievement of health as the purpose of nursing services. According to Abdellah’s model, quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems (Gonzalo, 2011). These requirements can be met by the problem-solving process which involves identifying the problem, selecting pertinent data, formulating hypotheses, testing hypotheses through the collection of data, and revising hypotheses when necessary on the basis of conclusions obtained from the data (Gonzalo, 2011). A pilot “research” program has begun at St. Peter’s Hospital in the Interventional Radiology (IR) department following a discussion regarding the seemingly high incidence of permcath placements and removals versus temporary dialysis catheter placements, and the possibility of associated bacteremia. This committee is composed of doctors, nurses and vascular technologists working in the IR department placing dialysis catheters with a shared interest in better patient outcomes. The concept of the program is to follow the patient from the time of the placement of the dialysis catheter, either tunneled permcath or non-tunneled temporary dialysis catheter, until the time of removal. Data gathered will help indicate if the removal is related to catheter infection, maturation of an AV fistula or if the patient no longer requires hemodialysis. According to the literature review, there is evidence that a higher incidence of blood-stream infections are related to non-tunneled temporary dialysis catheters than tunneled permanent dialysis catheters. However, it is challenging to find an adequate amount of studies that delineate tunneled versus non-tunneled statistics referring to infection rates. Research and data collection within our facility at St. Peter’s hospital is still in progress. The data we collect will then allow us to compare our results to those of the national averages and hopefully help us identify patterns or behaviors that are causing these infections. Overwhelmingly, the research shows that proper patient, nursing and technician care of these dialysis catheters impact associated infection rates. Emphasis on proper catheter care and maintenance in the hospital will soon be addressed not only with medical providers, but with the patients as well. Please see back of poster for a list of all resources used for this research project. Acknowledgments Implementation I would like to thank the following people for their involvement and dedication to this research project: -Jonathan D. Mishkin, MD Chief of Radiology at St. Peter’s Hospital -Stephanie Bull, RPCA Interventional Radiology P.A. -Peggy Hallam, RN Medical Imaging Nursing Supervisor