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Published on: July 13, 2019
Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter-Related Bloodstream Infections: A
Benjamin Lazarus1, Elisa Bongetti2, Jonathan Ling2
1Department of Medicine, Monash University, Melbourne; Department of Nephrology, Monash Medical Centre, Monash Health, Melbourne; George Institute of Global Health, Sydney.
Insights
Multifaceted quality improvement interventions show potential for preventing hemodialysis catheter-related bloodstream infections (HDCRBSI) outside intensive care units. However, current evidence is of low quality, necessitating further rigorous research to confirm effectiveness.
Area of Science:
- Nephrology
- Infectious Disease Prevention
- Healthcare Quality Improvement
Background:
- Central venous catheters (CVCs) are essential for hemodialysis but are associated with significant bloodstream infections.
- Hemodialysis catheter-related bloodstream infections (HDCRBSI) pose a substantial clinical and economic burden.
- Previous quality improvement interventions have shown success in intensive care units, but their efficacy in community-based hemodialysis settings is uncertain.
Approach:
- A systematic review was conducted, searching PubMed, EMBASE, and CENTRAL for relevant studies.
- Included were randomized trials, time-series analyses, and before-after studies evaluating multifaceted quality improvement interventions for HDCRBSI or access-related bloodstream infections (ARBSI) in non-ICU hemodialysis patients.
- Data extraction and risk of bias assessment were performed independently by two reviewers.
Key Points:
- Twenty-one studies were included in the analysis.
- Evidence for the effectiveness of quality improvement interventions was mixed, with higher-quality studies yielding discordant results.
- The overall quality of evidence was low for HDCRBSI and very low for ARBSI, with significant heterogeneity in definitions and study designs.
Conclusions:
- Multifaceted quality improvement interventions may help prevent HDCRBSI in hemodialysis units outside the ICU.
- The current evidence base is limited by low quality and methodological heterogeneity.
- Further high-quality research is crucial to definitively establish the effectiveness of these interventions.
Rationale & Objective:
Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI).
Study Design:
Systematic review.
Setting & Study Populations:
PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU).
Data Extraction:
Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools.
Analytical Approach:
Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described.
Results:
We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI.
Limitations:
Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility.
Conclusions:
Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted.
Registration:
Registered at PROSPERO with registration number CRD42021252290.
Plain-Language Summary:
People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.
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