Using a Targeted Process to Reduce Subsequent Bloodstream Infections Related to Environmental Sources in Dialysis

Abstract

Background Focus on pathogens in water reservoirs in the hemodialysis setting has largely concentrated on the internal/closed system as indicated by the Association for the Advancement of Medical Instrumentation standards (AAMI), with environmental sources generally unnoticed as potential issues. In 2016, an outbreak of gram-negative bloodstream infections (BSIs) occurred in three clinics. The cause was determined to be the dialysis station wall box and inadequate infection control practices. This study examines if a targeted Infection Preventionist (IP) driven process is effective in reducing subsequent unusual pathogen BSIs within a clinic. Methods A retrospective comparison of the frequency of unusual pathogen BSIs within dialysis clinics was performed. National Healthcare Safety Network (NHSN) Dialysis Event data was utilized to track cases of unusual pathogen BSIs; cases where attribution was identified as “other” were excluded. Cases were defined as BSIs with any mycobacterium, fungus and/or gram-negative pathogen, with the exception of Proteus. A decrease was defined as a reduction in the number of subsequent cases following an initial case. The frequency of subsequent cases was compared from 2016-2017 before the implementation of the targeted process to 2018-2019 after the implementation. Results Data from approximately 700 dialysis clinics were assessed. A baseline review revealed 990 cases in 401 clinics with an average of 2.47 cases per clinic with a range of subsequent cases of 1 to 30. A post-process implementation review revealed 657 cases in 368 clinics with an average of 1.74 cases per clinic with a range of 1 to 6. The median decreased from 2 cases to 1. Conclusions This study found that targeted interventions and education with individual dialysis clinics resulted in improved infection control practices and a decrease in subsequent bloodstream infections with unusual pathogens. Focus on pathogens in water reservoirs in the hemodialysis setting has largely concentrated on the internal/closed system as indicated by the Association for the Advancement of Medical Instrumentation standards (AAMI), with environmental sources generally unnoticed as potential issues. In 2016, an outbreak of gram-negative bloodstream infections (BSIs) occurred in three clinics. The cause was determined to be the dialysis station wall box and inadequate infection control practices. This study examines if a targeted Infection Preventionist (IP) driven process is effective in reducing subsequent unusual pathogen BSIs within a clinic. A retrospective comparison of the frequency of unusual pathogen BSIs within dialysis clinics was performed. National Healthcare Safety Network (NHSN) Dialysis Event data was utilized to track cases of unusual pathogen BSIs; cases where attribution was identified as “other” were excluded. Cases were defined as BSIs with any mycobacterium, fungus and/or gram-negative pathogen, with the exception of Proteus. A decrease was defined as a reduction in the number of subsequent cases following an initial case. The frequency of subsequent cases was compared from 2016-2017 before the implementation of the targeted process to 2018-2019 after the implementation. Data from approximately 700 dialysis clinics were assessed. A baseline review revealed 990 cases in 401 clinics with an average of 2.47 cases per clinic with a range of subsequent cases of 1 to 30. A post-process implementation review revealed 657 cases in 368 clinics with an average of 1.74 cases per clinic with a range of 1 to 6. The median decreased from 2 cases to 1. This study found that targeted interventions and education with individual dialysis clinics resulted in improved infection control practices and a decrease in subsequent bloodstream infections with unusual pathogens.