Controlling Infection through a 3-Phase Approach

Impaired host immunity and bloodstream exposure to indwelling catheters or repeated cannulation renders dialysis patients prone to bloodstream infection (BSI). BSI is a leading cause of hospitalization and one of the leading causes of death among hemodialysis patients. According to the Centers for Disease Control and Prevention (CDC), an estimated 37,000 BSIs occur each year among dialysis patients with central venous catheters (CVCs). The estimated cost per hospitalization from a bloodstream infection among this population is $23,000. Thus, preventing and addressing BSIs is critical to patient safety and can also generate savings for the healthcare system as a whole.

The CDC has provided recommendations and tools that can help reduce dialysis bloodstream infections by 50 percent. DaVita developed the WipeOut Infection^® program to meet these CDC recommendations and serve as an effective, systematic approach to addressing infection prevention and control in a dialysis setting. The program has helped to prevent not only BSIs but also Hepatitis B, Hepatitis C, pneumonia and influenza—and ultimately has helped improve patient quality of life.

WipeOut was built on a comprehensive infection surveillance, prevention and response system.

1. Surveillance

Surveillance systems actively search to identify and report infections. For example, when a patient presents with fever, rigors and hypotension and prompts suspicion of a BSI or other serious, systemic infection, blood cultures are drawn and, frequently, IV antibiotics are started.  Positive blood culture results, in these instances, are appropriately reported to the CDC’s National Healthcare Safety Network as a dialysis-related BSI. Obtaining blood cultures before starting IV antibiotics for a suspected BSI is a fundamental principle of antibiotic stewardship, is essential in guiding decision-making in the care of the patient, and is crucial to generating trustworthy infection surveillance information. Among DaVita centers, both the blood culture rate (calculated as a percentage of IV antibiotic starts) and the rate of positive blood cultures are determined, and serve as the basis for a center performance measure.  An approach along these lines, to determine and report blood culture rates, would be helpful for the industry to adopt or for the CDC to formally recommend. Actively reporting infections can provide the entire industry with more data on infections so root causes can be identified and mitigated.

2. Prevention

Among hemodialysis patients, the risk of BSI is many-fold higher among those with a CVC than with either an arteriovenous graft or fistula. In practice, the BSI rate for a dialysis center depends mostly on the rate of CVC-related infection. The single most effective way to prevent BSI in a dialysis patient is to remove an existing CVC.

For those patients with an existing CVC, prevention of BSI depends on preventing touch contamination of the catheter hub. Most CVC-related BSIs are thought to begin with touch contamination of the catheter hub, followed first by bacterial colonization of the huband then by intra-lumenal colonization. Proper hand hygiene, careful preparation of the skin around the catheter insertion and deliberate scrubbing of catheter hubs—though simple—can be remarkably effective in preventing a catheter-related BSI. New technologies designed to block hub colonization, including alcohol-impregnated caps combined with needle-free connectors in use in DaVita centers, show promising results in BSI prevention.

Proper immunization is also an essential component of infection prevention in dialysis patients. The care team should be mindful of the seasonality of infections and work preventatively to protect patients from the increased threat of BSIs in the summer and respiratory infections in the winter.

3. Response

Once the root cause of infection is identified, it can be addressed in a meaningful way to deliver results and improve patient outcomes. It is important to work with accurate data to understand the scope of the problem, identify emerging patterns and craft an appropriate response. Proper antibiotic stewardship must involve testing patients with a suspected infection, providing the “right drug for the right bug,” and prescribing antibiotics for the appropriate amount of time.

The magnitude of the problem within the industry, and the serious outcomes that can result from BSIs in particular, warrant building an established structure with dedicated personnel assigned to infection control.

At a minimum, it is important to:

• Properly educate and train team members to identify, prevent and treat infection
• Institute proper protocols for infection prevention and control and ensure they are being consistently followed
• Foster a culture of infection prevention and awareness until protocols become established behaviors
• Monitor infection control practices through regular audits

Infection control is a responsibility that belongs to everyone, from the technicians, nurses, dietitians, social workers and physicians who work most closely with patients to center administrators and state and federal partners. We all have a role in infection detection, prevention and response—a role that requires consistency and dedication. As an industry we need to devote the time and attention necessary to better address the root causes of infection so that we can better protect and care for our patients.

Some of this content has been republished, with permission, from Nephrology News & Issues.