Life-sustaining Treatment Research Articles

Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy.

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.

Circumstances surrounding end of life in a Swiss pediatric intensive care unit

PurposeTo describe the modes of death (MOD), the elements related to the decision to forgo life-sustaining treatments (LST) as well as the medical and parental environment surrounding time of death in our pediatric intensive care unit (PICU).MethodsThis is a retrospective, single-center study from a Swiss PICU. All patients between 30 days and 18 years of age who died in our PICU from 2006 to 2019 were eligible for inclusion. Data were collected from patients’ record and from a standardized death form containing information on circumstances surrounding end-of-life. Patients’ and families’ characteristics as well as trends over time of MOD were evaluated.ResultsOf 6930 PICU admissions during the whole study period, 121 (1.7%) died in our PICU. Mortality significantly decreased from 2.9% in 2006 to 1% in 2019 (p = 0.003). More than half of patients died after a decision to transition to comfort care (68.56%). Withdrawal and limitation of LST were the prevalent MOD (56%) with a significant increase in withdrawal over time. Primary diagnosis, limitation (vs. withdrawal) of LST, type of admission and families’ religious background are associated with longer latencies between admission to decision to comfort care and from decision to death. At least one parent was present in 94% of cases when LST were limited or withdrawn.ConclusionsMost of the deaths follow LST limitation or withdrawal with increasing rates of withdrawal over time. We also showed that time latencies between admission and decision and from decision to death varies depending on MOD, patients’ characteristics and families ‘religious background.

Advance Care Planning in South Korea

South Korea is an Asian country with a very low birth rate and a large elderly population. Nearly half of deaths are in the elderly over the age of 80, and cancer is the leading cause of all deaths. As the aging population increases, interest in end-of-life (EOL) care and quality of death is growing, but South Korea is one of the Asian countries that traditionally feels burdened by discussing death openly. In particular, even when a person is suffering from an incurable disease and is about to die, it is customary for the family members to make decisions without directly informing the patient of the disease status or discussing life-sustaining treatment (LST). However, due to a series of social events, the importance of individual autonomy, good death, discontinuation of LSTs, and advance care planning (ACP) gradually spread, and eventually the Life-Sustaining Treatment Decisions Act was implemented in 2018. With the enactment of this law, patients’ autonomy was enhanced in a short period of time, and a legal basis was established to discontinue LST at the EOL. However, there are still many areas to be improved, and it is fundamentally necessary to spread the concept of ‘ACP’ within society.

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

#4621 TREATMENT PREFERENCES TO SERIOUS ILLNESS IN PATIENTS RECEIVING PERITONEAL DIALYSIS

Abstract Background and Aims People with end-stage kidney disease receiving maintenance dialysis are more likely to receive intensive pattern of end-of-life care than those with other severe illness. It's important to understand the preferences to cardiopulmonary resuscitation (CPR) and other end-of-life care. However, no prior studies have investigated patients receiving peritoneal dialysis. This study aimed to explore the preference to CPR and patterns of end-of-life care in patient receiving peritoneal dialysis (PD), which had not been specifically investigated in the literature. Method This cross-sectional study of patients receiving PD was conducted in the National Taiwan University Hospital between Dec. 2021, and Mar. 2022. Patients were enrolled if they were 20 years or older, sufficiently fluent to complete surveys and cognitively able to provide written informed consent and had received maintenance peritoneal dialysis for at least 3 months. Enrollee were asked to the Chinese version of Physician Orders for Life-Sustaining Treatment questionnaire. Results Among 400 eligible patients, 364 (91%) responded to the questionnaire. The average age was 55.5 years; 50.3% were men. Among the 364 responders, 73.6% selected do not attempt resuscitation (DNR) and 26.4% preferred CPR. Multivariate logistic analysis revealed that age (OR = 0.96, 95% CI 0.94-0.98), male (OR = 2.44, 95% CI 1.45-4.1) and residual kidney Kt/V (OR = 2.45 95% CI 1.24-4.82) were associated with CPR. If they are facing on serious illness, 47.5% of participants prefer to “Focus on comfort”, 28.6% choose “try treatments, but do not suffer” and 23.9% request “live as long as possible”. Furthermore, 51.4% of participants selected “No artificial nutrient support” in the end of life and 87.1% select “comfort care” as their first priority. Paradoxically, only 13.5% of the patients who preferred CPR took “staying alive” as their first priority, while 71.9% focused on “comfort care”. Conclusion Around 75% of PD patients selected DNR when cardiopulmonary arrest. Age, gender, residual Kt/V were important factors associated with CPR preference. Most patients preferred supportive pattern of end-of-life care. Integrating patients' treatment preference to serious illness and values and goals of end-of-life care in shared decision making is important for patients receiving dialysis.

Participation and Influencing Factors in the Decision-Making of Life-Sustaining Treatment: A Focus on Deceased Patients with Hematologic Neoplasms.

This study aimed to investigate the involvement of patients who died from hematologic neoplasms in the decision-making process surrounding the withdrawal of life-sustaining treatment (LST). A total of 255 patients diagnosed with hematologic neoplasms who ultimately died following decisions related to LST during their end-of-life period at a university hospital were included in the study. Data were retrospectively obtained from electronic medical records and analyzed utilizing the chi-square test, independent t-test, and logistic regression. In total, 42.0% of patients participated in the decision-making process regarding LST for their hematologic neoplasms, while 58.0% of decisions were made with family involvement. Among these patients, 65.1% died in general wards and 34.9% in intensive care units (ICUs) as a result of decisions such as the suspension of LST. The period from the LST decision to death was longer when the decision was made by the patient (average, 27.15 days) than when it was made by the family (average, 7.48 days). Most decisions were made by doctors and family members in the ICU, where only 20.6% of patients exercised their right to make decisions regarding LST, a rate considerably lower than 79.4% observed in general wards. Decisions to withhold or withdraw LST were more commonly made by patients themselves than by their families. The key to discussing the decision to suspend hospice care and LST is respecting the patient's self-determination. If a patient is lucid prior to admission to the ICU, considerations about suspending LST should involve the patient input.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

Factors That Influence Attitudes toward Advance Directives among Female Cancer Patients.

This study aimed to identify attitudes toward advance directives (ADs) among female cancer patients and factors related to ADs. The study was conducted at a university hospital in Seoul from September 19, 2020, to January 20, 2021. The participants were 153 patients diagnosed with gynecological cancer or breast cancer. Data were collected using questionnaires and included general characteristics, disease- and AD-related characteristics, knowledge and attitudes about ADs, and attitudes about dignified death. Data were analyzed using the t-test, analysis of variance, and multiple regression analysis. Only 2% of the participants completed ADs. The mean score for attitudes toward ADs was 3.30, indicating a positive knowledge and attitude toward dignified death. The factors related to attitudes toward ADs were attitudes toward dignified death (β=0.25, P=0.001), experience discussing life-sustaining treatment (β=0.17, P=0.037), preferred time to have a consultation about ADs (β=0.19, P=0.046), intention to write ADs (β= 0.15, P=0.038), and Eastern Cooperative Oncology Group Performance Status (β=-0.37, P<0.001). The explanatory power of these variables for attitudes toward ADs was 38.5%. Overall, patients preferred to have a consultation about ADs when they were still active, mentally healthy, and able to make decisions. Education about ADs should be provided to patients on the first day of hospitalization for chemotherapy or while awaiting treatment in an outpatient setting so patients can write ADs and discuss them with family and friends.

Using telehealth to conduct serious illness conversations (SIC) for patients with metastatic lung cancer during the COVID-19 pandemic.

e13687 Background: Engaging patients with advanced cancer in discussions about values and preferences in serious illness allows clinicians to deliver care that is consistent with their patients’ wishes and improves end-of-life outcomes. The COVID-19 pandemic necessitated serious illness conversations to occur via telehealth, yet little is known about how telehealth influences these conversations between patients and their oncology clinicians. Methods: We conducted a retrospective analysis of patients with metastatic lung cancer at a single academic center who had telehealth visits with their oncology clinicians. All outpatient and inpatient clinician notes for these patients were obtained from the electronic medical record during the first surge of COVID-19 in Massachusetts (03/10/2020 - 06/10/2020). Natural Language Processing (NLP) text identification software was used to conduct a semi-automated chart review and to identify documentation of discussion about five SIC domains (goals of care [GOC], limitation of life-sustaining treatment [LLST], prognostic awareness [PA], palliative care [PC] and hospice) and characterize the context of these conversations. We used unadjusted linear regression models to examine the relationship of SIC with (1) type of clinician (MD versus APP) (2) visit type (phone vs video), (3) cancer status, and (4) family involvement during the telehealth visit. Results: The study included 361 unique patients with 634 telehealth notes from 17 oncology clinicians. Most patients had non-small cell lung cancer (92%), and most telehealth notes were completed by physicians (88%). We identified 126 (34%) patients with documentation of discussion of at least one SIC domain. Of the 634 telehealth notes reviewed, 110 (17%) notes had documentation of one SIC domain while 78 notes (12%) documented two or more SIC domains. The most common SIC domain addressed was GOC (21%), followed by PA (16%). The domains of hospice (6%), PC (5%), and LLST (3%) were infrequently discussed. We found no association between clinician or visit type and SIC during telehealth visits. The presence of family at the visit (B=0.179, p=0.002) and progressive or newly diagnosed disease (B=0.58, p&lt;0.001) were associated with an increased number SIC domains addressed during telehealth visits. Conclusions: During the COVID-19 pandemic, oncology clinicians used telehealth to conduct SIC in patients with advanced cancer, but this study demonstrated considerable heterogeneity in the content of these conversations. The presence of family at the visit and progressive or newly diagnosed disease were associated with an increased number SIC domains addressed during telehealth visits. Future efforts should focus on how to optimize telehealth tools to conduct these important conversations between patients and their oncology clinicians.

Ethical Issue of Physician-Assisted Suicide and Euthanasia.

With the implementation of Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life, interests of the general public on self-determination right and dignified death of patients have increased markedly in Korea. However, "self-determination" on medical care is misunderstood as decision not to sustain life, and "dignified death" as terminating life before suffering from disease in terminal stage. This belief leads that physician-assisted suicide should be accommodated is being proliferated widely in the society even without accepting euthanasia. Artificially terminating the life of a human is an unethical act even though there is any rational or motivation by the person requesting euthanasia, and there is agreement thereof has been reached while there are overseas countries that allow euthanasia. Given the fact that the essence of medical care is to enable the human to live their lives in greater comfort by enhancing their health throughout their lives, physician-assisted suicide should be deemed as one of the means of euthanasia, not as a means of dignified death. Accordingly, institutional organization and improvement of the quality of hospice palliative care to assist the patients suffering from terminal stage or intractable diseases in putting their lives in order and to more comfortably accept the end of life physically, mentally, socially, psychologically and spiritually need to be implemented first to ensure their dignified death.

Patterns of Pediatric Palliative and End-of-Life Care in Neonatal Intensive Care Patients in the Southern U.S.

Despite high rates of mortality among infants in the Southern U.S., little is known about the timing of pediatric palliative care (PPC), the intensity of end-of-life care, and whether there are differences among sociodemographic characteristics. To describe PPC patterns and treatment intensity during the last 48 hours of life among neonatal intensive care unit (NICU) patients in the Southern U.S. who received specialized PPC. Medical record abstraction of infant decedents who received PPC consultation in two NICUs (in Alabama and Mississippi) from 2009 to 2017 (n = 195) including clinical characteristics, palliative and end-of-life care characteristics, patterns of PPC, and intensive medical treatments in the last 48 hours of life. The sample was racially (48.2% Black) and geographically (35.4% rural) diverse. Most infants died after withdrawal of life-sustaining interventions (58%) and had do not attempt resuscitation orders documented (75.9%); very few infants enrolled in hospice (6.2%). Initial PPC consult occurred a median of 13 days after admission and a median of 17 days before death. Infants with a primary diagnosis of genetic or congenital anomaly received earlier PPC consultation (P = 0.02) compared to other diagnoses. In the last 48 hours of life, NICU patients received intensive interventions including mechanical ventilation (81.5%), CPR (27.7%) and surgeries or invasive procedures (25.1%). Black infants were more likely to receive CPR compared to White infants (P = 0.04). Overall, PPC consultation occurred late in NICU hospitalizations, infants received high-intensity medical interventions in the last 48 hours of life, and there are disparities in intensity of treatment interventions at end of life. Further research is needed to explore if these patterns of care reflect parent preferences and goal concordance.

가톨릭 의료기관 임상윤리자문 활성화를 위한 지침과 방안에 대한 고찰

In the pluralistic society where the medical technology is highly advanced, the role of clinical ethics consultation that helps to solve the ethical conflicts in health care is getting important. Clinical ethics consultation is an activity to support informed, deliberative decision making on the part of patients, families, and the health care team in the patient care. In Korea, clinical ethics consultation was regulated as an activity of the institutional ethics committee with the enforcement of the 「Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life」 in 2018, However, most health care institutions in Korea do not provide clinical ethics consultation, and this situation is the same even for Catholic health care institutions, which account for 8 percent of health care in Korea. In particular, Catholic health care institutions should be able to provide effective ethical consultation with specific ethical guidelines and activation plans that are consistent with Catholic spirituality, even in the midst of rapid medical development and social/institutional changes. Therefore, it is judged appropriate to apply the 『Ethics and Religious Directive for catholic Health Care Service : ERDs』 published by United Conference of Catholic Bishops as an appropriate model for the corresponding ethical guidelines. In addition, the specific case of the Catholic Medical Center, which is making progress in activating clinical ethics consultation, can suggest a direction for the activation of clinical ethics consultation in other Catholic healthcare institutions and can be a exemple worth sharing with all medical institutions pursuing holistic health care. If clinical ethics advice is activated and properly operated in Catholic health care institutions, it will become the conscience of the institution communicating to realize the best interests of patients, and high quality health care services will be achieved by protecting the rights and conscience of medical staff. This will be of great help in protecting the identity of a Catholic health care institution serving human dignity and value in the increasingly industrialized medical field.

Intensive Care Clinicians' Perspectives on Ethical Challenges Raised by Rapid Genomic Testing in Critically Ill Infants.

Rapid genomic testing (rGT) enables genomic information to be available in a matter of hours, allowing it to be used in time-critical settings, such as intensive care units. Although rGT has been shown to improve diagnostic rates in a cost-effective manner, it raises ethical questions around a range of different areas, including obtaining consent and clinical decision-making. While some research has examined the perspectives of parents and genetics health professionals, the attitudes of intensive care clinicians remain under-explored. To address this gap, we administered an online survey to English-speaking neonatal/paediatric intensivists in Europe, Australasia and North America. We posed two ethical scenarios: one relating to obtaining consent from the parents and the second assessing decision-making regarding the provision of life-sustaining treatments. Descriptive statistics were used to analyse the data. We received 40 responses from 12 countries. About 50-75% of intensivists felt that explicit parental consent was necessary for rGT. About 68-95% felt that a diagnosis from rGT should affect the provision of life-sustaining care. Results were mediated by intensivists' level of experience. Our findings show divergent attitudes toward ethical issues generated by rGT among intensivists and suggest the need for guidance regarding ethical decision-making for rGT.

Functional Neuroimaging in Patients With Disorders of Consciousness: Caution Advised.

Functional Neuroimaging in Patients With Disorders of Consciousness: Caution Advised.

Recommendation-making in the emergency department: A qualitative study of how Canadian emergency physicians guide treatment decisions about resuscitation in critically ill patients.

Emergency physicians are frequently responsible for making time-sensitive decisions around the provision of life-sustaining treatment. These decisions can involve goals of care or code status discussion, which will often substantially alter a patient's care pathway. A central part of these conversations that has received relatively little attention are recommendations for care. By proposing a best course of action or treatment via a recommendation, a clinician can ensure that their patients receive care that is concordant with their values. The objective of this study is to explore emergency physicians' attitudes toward recommendations about resuscitation in critically ill patients in the emergency department (ED). We recruited Canadian emergency physicians via multiple recruitment strategies to ensure maximum variation sampling. Semi-structured qualitative interviews were conducted until thematic saturation occurred. Participants were asked about their perspectives and experiences with respect to recommendation-making in critically ill patients and to identify areas for improvement in this process in the ED. We used a qualitative descriptive approach and thematic analysis to identify themes around recommendation-making in the ED for critically ill patients. Sixteen emergency physicians agreed to participate. We identified four themes and multiple subthemes. Major themes included identification of the roles and responsibilities of the emergency physician (EP) with respect to making a recommendation, the logistics or process of making a recommendation, barriers to making a recommendation, and how to improve recommendation-making and goals of care conversations in the ED. Emergency physicians provided a range of perspectives on the role of recommendation-making in critically ill patients in the ED. Several barriers to the inclusion of a recommendation were identified and many physicians provided ideas on how to improve goals of care conversations, the recommendation-making process, and ensure that critically ill patients receive care that is concordant with their values.

The attitudes about life-sustaining treatment among cardiac surgery ICU patients and their families.

To investigate the attitudes among cardiac surgery ICU patients and their families regarding life-sustaining treatment. A total of 172 pairs of patients in the cardiac surgery ICU of Nanjing First Hospital and their family members were enrolled in this study that examined their attitudes toward life-sustaining treatment using a willingness to care for life-sustaining treatment questionnaire. The consistency of the attitudes of patients and family members toward life-sustaining treatment was analyzed by the chi-square test with a paired design. The most popular life-sustaining treatment for cardiac ICU patients was noninvasive mechanical ventilation (79.1%); the most unpopular was intra-aortic balloon counterpulsation (48.3%). Most patients and their families had not considered electric defibrillation (65.7%), but most understood and were willing to permit cardiopulmonary resuscitation (76.2%). Few family members agreed that patients should receive a pacemaker (25.0%). The consistency of life support attitudes of patients and their families ranged from 12.8% to 60.5% for procedures both would agree to, 1.2% to 19.8% for procedures they were unwilling to permit, and 0.6% to 39.0% for procedures they had not considered. Kappa values ranged from 0.218 to 0.597 (P < 0.05), with general consistency. Cardiac surgery ICU patients families are generally consistent in their attitudes toward life-sustaining treatment, and family members' choices are not representative of patients' wishes.

Dialysis Patient Experiences During the COVID-19 Pandemic: A Survey Study

The coronavirus disease 2019 (COVID-19) pandemic imposed several changes in the care of patients with kidney failure receiving dialysis. We explored patient care experiences during the pandemic. The study team verbally administered surveys including Likert scale multiple-choice questions and open-ended questions and recorded responses. Surveys were administered to adults receiving dialysis through an academic nephrology practice after the first wave of the COVID-19 pandemic. Outpatient dialysis treatment during the COVID-19 pandemic. Perceptions of care and changes in health. Multiple-choice responses were quantified using descriptive statistics. Thematic analysis was used to code open-ended responses and derive themes surrounding patient experiences. A total of 172 patients receiving dialysis were surveyed. Most patients reported feeling "very connected" to the care teams. Seventeen percent of participants reported transportation issues, 6% reported difficulty obtaining medications, and 9% reported difficulty getting groceries. Four themes emerged as influencing patient experiences during the pandemic: 1) the COVID-19 pandemic did not significantly affect participants' experience of dialysis care; 2) the COVID-19 pandemic significantly impacted other aspects of participants' lives, which in turn were felt to affect mental and physical health; 3) regarding dialysis care experience more generally, participants valued consistency, dependability, and personal connection to staff; and 4) the COVID-19 pandemic highlighted the importance of external social support. Surveys were administered early in the COVID-19 pandemic, and patient perspectives have not been reassessed. Further qualitative analysis using semi-structured interviews was not performed. Survey distribution in additional practice settings, using validated questionnaires, would increase generalizability of the study. The study was not powered for statistical analysis. Early in the COVID-19 pandemic, perceptions of dialysis care were unchanged for most patients. Other aspects of participants' lives were impacted, which affected their health. Subpopulations of patients receiving dialysis may be more vulnerable during the pandemic: those with histories of mental health conditions, non-White patients, and patients treated by in-center hemodialysis. Patients with kidney failure continue to receive life-sustaining dialysis treatments during the coronavirus disease 2019 (COVID-19) pandemic. We sought to understand perceived changes in care and mental health during this challenging time. We administered surveys to patients receiving dialysis after the initial wave of COVID-19, asking questions on topics including access to care, ability to reach care teams, and depression. Most participants did not feel that their dialysis care experiences had changed, but some reported difficulties in other aspects of living such as nutrition and social interactions. Participants highlighted the importance of consistent dialysis care teams and the availability of external support. We found that patients who are treated with in-center hemodialysis, are non-White, or have mental health conditions may have been more vulnerable during the pandemic.

The Connecticut MOLST: Lessons for Policy and Practice

In accordance with national directives from POLST.org, Connecticut’s Department of Public Health formed a working group to review the literature and new directives for a Medical Orders for Life-Sustaining Treatment program in the state in 2013 that was signed into law in 2017. Five years later, many barriers have kept the program from becoming well-known and accessible to medical providers and the public. These policy lessons are important for the developing programs of other states to keep in mind as they further develop their own Medical Orders for Life-Sustaining Treatment (MOLST)/Physician Orders for Life-Sustaining Treatment (POLST) programs that ensure end-of-life wishes for life-sustaining treatments are honored on a form that is transferrable between institutions. Additionally, the goals of care conversation, teaching, and advocacy for better policies affecting end-of-life care remain critical skills for the nurse practitioner.

Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement

BackgroundNeonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death − after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care − was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents’ perceptions of end-of-life care according to death context.MethodsProspective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant’s death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death.ResultsOf 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview.ConclusionsContext of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.

Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter–Related Bloodstream Infections: A Systematic Review

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). Systematic review. 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). Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools. Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described. 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. 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. 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. Registered at PROSPERO with registration number CRD42021252290. 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.