Outbreak of Bloodstream Infections in Hemodialysis Patients Highlight the Importance of a Working Partnership Between Infection Prevention and Interventional Departments

Abstract

<h3>Background</h3> Research shows that collaboration between Infection Prevention (IP) and procedural personnel is vital to optimum patient outcomes. In the summer of 2019, a 350 bed acute care hospital experienced an outbreak of Central Line Associated Bloodstream Infections (CLABSI) in patients with implanted hemodialysis (HD) catheters. All infections had an onset of 10 days or less from device insertion in Interventional Radiology (IR). Only one CLABSI in three years was related to a dialysis catheter. Before June 2019, no issues within IR had been identified by Infection Prevention. <h3>Methods</h3> In July 2019, a multidisciplinary team with representation from: Surgical Services, IR, IP, Nephrology, and Environmental Services (ES) was convened. The project spanned July to October of 2019 in a five step process: Observe, research, define, implement, and monitor. A goal of decreasing CLABSI in HD patients with implanted devices in IR to the baseline of zero was established. National Healthcare Safety Network (NHSN) standards were used to define CLABSI. Observations to identify improvement opportunities and findings were divided into five categories: Physical barriers, aseptic technique, attire, environmental cleaning, and policies. Literature reviews, professional guidelines, and staff interviews helped to establish procedural guidelines and gain insight to perceived barriers. A solid improvement plan was then developed. Remediation on aseptic technique, environmental cleaning, and attire were provided. Weekly audits of hand hygiene and attire were conducted after improvement processes had been established. <h3>Results</h3> Four CLABSIs were identified in the outbreak. The goal of zero CLABSI, in the target month of November 2019, was achieved with no CLABSI identified in the focus population. <h3>Conclusions</h3> Each observation consistently revealed sub-optimal environmental cleaning and aseptic technique. Staff interviews highlighted gaps in understanding surrounding policies and best practice. Proactive efforts and collaboration between IR and IP are necessary to prevent outbreaks such as this from occurring.