The effect of applying central line insertion and maintenance bundles in a renal dialysis unit - an effort to reduce CRBSI rate

Catheter related blood stream infections (CRBSI) rates were determined before and after the application of central line (CL) insertion and maintenance bundles by means of a prospective surveillance study conducted on patients undergoing regular catheter haemodialysis in the Artificial Kidney Unit of Al-Leith General Hospital, over a period of 12 months. During Phase 1 (baseline period), active surveillance was performed without the implementation of the infection control bundles. CRBSI rates obtained in Phase 1 were compared with CRBSI rates obtained in Phase 2 (intervention period), after implementation of the CL insertion and maintenance bundles. During baseline period 2,854 CL days were recorded, while 2,611 CL days were recorded during the intervention period. The CRBSI rate was 4.9 per 1,000 CL days in baseline period, and in the intervention period the CRBSI rate decreased to 2.3 per 1,000 CL days. This study shows that the implementation of CVC insertion and maintenance bundles was associated with a significant reduction in the CRBSI rates in the renal dialysis unit of a small hospital. Based on our study, we recommend that these bundles and protocol be adopted in all renal dialysis units


Introduction
The survival and life quality of many patients with end stage renal disease (ESRD) are dependent upon the adequacy of dialysis through properly functioning vascular access. 1 Although central venous catheters (CVCs) are associated with several infections, mechanical and thrombotic complications, 2 they remain irreplaceable tools of vascular access in the modern dialysis delivery system. 3scular access-related blood-stream infections and their complications that require hospitalization, account for nearly one third of the cost of ESRD management with reported mortality rates of 12-25.9%. 1 Central line associated blood stream infections (CLABSIs) are serious but often preventable infections when evidence-based guidelines are followed for the insertion and maintenance of central lines.This preventability is even more acutely apparent in developing countries, where use of these devices may occur in the absence of the most basic infection prevention and control practices and limited availability of supplies. 4,5stitute for Health Care Improvement (IHI), USA has developed the concept of 'Bundle' to help clinician deliver bedside care more reliably and effectively. 6Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.The IHI Central Line (CL) Bundle consists of five interventions: hand hygiene; maximal barrier precautions; chlorhexidine skin antisepsis; optimal catheter site selection, with avoidance of the femoral vein for central venous access in adult patients; and daily review of the line necessity, with prompt removal of unnecessary lines. 7st previous studies concentrated mainly on the effect of insertion bundles on the incidence of CLABSI, much less studies addressed the effects of maintenance practices.The renal patient is a chronic patient and a considerable proportion rely on CVCs for dialysis blood access.In comparison with shortterm catheters, in long periods, the value of sound maintenance practices become more prominent.
We hypothesized that the development, implementation, and enforcement of central line insertion and maintenance bundles may result in a decrease in the rate of CLABSI.We therefore developed and implemented two CVC bundles, and evaluated the impact that such an intervention had on reducing the rate of CLABSI per 1,000 line days during the 6 months before and after implementation of the policy.

Setting and study design
This study was conducted on patients undergoing regular catheter haemodialysis in the Dialysis Unit of Al-Leith General Hospital at Al-Leith, Saudi Arabia, over a period of 12 months between April 2013 and March 2014.This is a prospective pre-and post-intervention study.It was performed in two phases: Phase 1 (baseline period) and Phase 2 (intervention period).The following data were collected in the six months prior to and the six months following the start of the policy: (1) number of central line days; (2) number of central venous catheter associated blood stream infections; (3) central venous catheter associated bloodstream infections per 1000 central line days; and (4) central line bundle compliance;

Definitions
A device day was defined by a patient having a single CVC for a whole or part 24 h period; two catheters for a part or whole 24 h period was defined as two device days and so on.
CRBSI is defined according to CDC as bacteraemia/ fungaemia in a patient with an intravascular catheter with at least 1 positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI except the catheter.One of the following should be present: a positive semiquantitative (15 CFU/catheter segment) or quantitative (10 3 CFU/catheter segment catheter) culture whereby the same organism (species and antibiogram) is isolated from the catheter segment and peripheral blood; simultaneous quantitative blood cultures with a 5:1 ratio CVC versus peripheral; differential period of not for citation purposes

CVC insertion and maintenance bundles
Fouad et al.
CVC culture versus peripheral blood culture positivity of 2 hours.(5) following hub decontamination procedure before each hub access.The access hub is rubbed for at least 15 seconds using an antiseptic containing 70% isopropyl alcohol ('scrub the hub').
The process of implementing these bundles involved (1) staff education sessions using PowerPoint presentations; (2) the distribution of a CVC Bundle handbook that explain the bundle elements to all staff; (3) some Posters were put in the work area that motivate staff to follow the bundle elements to save lives; (4)   creating catheter insertion pack and maintenance pack; (5) feedback of surveillance data.
The compliance rates for both bundles were measured in phase 2 using checklists which were filled by the nurse during or after the procedure.Compliance with a bundle was defined as completion of all elements of the bundle.

Statistical methods
Patient characteristics during the baseline and intervention periods were compared using Fisher's exact test for dichotomous variables and unmatched Student's t-test for continuous variables.Relative risk (RR) ratios with 95% confidence intervals (CIs) were calculated using SPSS for comparisons of rates of CRBSI at baseline and the subsequent intervention period.P-values < 0.05 by two-sided tests were considered to be significant.

Results
Over the whole 12 months study period from April 2013 to March 2014, a total of 22 patients were enrolled with 5465 CL days.
Regarding CRBSI rates, during Phase 1 (baseline period), there were 2,854 documented CL days.There were 14 CRBSIs, for an overall baseline rate of 4.9 CRBSIs per 1,000 CL days.In Phase

Discussion
End stage renal disease patients are dependent on their permanent vascular access to receive life-sustaining dialysis.Unfortunately, vascular access is associated with many complications that significantly increase mortality and morbidity among this population.Central Venous catheters (CVCs) remain indicated in many renal dialysis patients either temporarily or permanently.CVCs however are associated with relatively higher infection risk than other methods of vascular access. 9,10Therefore, many efforts had been exerted to try to reduce CVC related infection risk, and one apparently successful approach was the 'Bundle' approach.
Although bundle of care approach was studied extensively in ICUs 7,11-13 and paediatric wards, 14,15 no studies were conducted in renal dialysis patients.The objective of this study was to apply the infection control bundle approach to renal haemodialysis patients to estimate its effectiveness in reducing CRBSI rate.The baseline CRBSI rate observed was 4.9/1,000 catheter days which is relatively high when compared to other reports from other developed countries, for CRBSI: catheter related blood stream infection example 0.85/1,000 CVC-days was reported in north America 16 and 1.46/1,000 CVC-days was reported in Australia. 17is study achieved a 52% reduction in CRBSI rate.
Although no previous studies applied the bundle approach to the haemodialysis patients, one study applied 2 elements found in our insertion bundle which were the use of 2% chlorhexidine with 70% alcohol swab sticks for exit-site care and the use of 70% alcohol pads to perform "scrub the hubs" in dialysis-related CVC care procedures.That study achieved around 22% reduction in BSI rates. 16 this study the high reduction in CRBSI rate may be partially attributable to the relatively high baseline CRBSI rate which may reflect some malfunctioning in the existing infection control program in the facility.Similar high reduction rates were achievable in other studies when the pre-existing basal infection rate was high. 12The high reduction in infection rate may be also attributable to the simultaneous application of two bundles, in other study the simultaneous application of CVC insertion and maintenance bundles in a paediatric intensive care unit resulted in an astonishing 70% reduction in central line-associated bloodstream infection rate from 7.8 infections per 1000 catheter-days to 2.3 infections per 1000 catheterdays. 15ny studied concentrated on one bundle alone, usually the insertion bundle, 13 but in renal dialysis patients, the maintenance gains more importance due to the chronic nature of the disease and prolonged catheter use period.
During this study, a relatively high level of compliance was achieved, the compliance level was better for Maintenance bundle (92.88%) than the insertion bundle (81.82%).
Gram positive cocci were the most common organisms isolated from CRSBI cases (56%).In another study, Gram positive cocci accounted for 52% of vascular access-related infections. 18The most common isolated organism was Staphylococcus aureus, which agrees with the results of another study, performed in the same country which Staphylococcus aureus was responsible for 29% of cases among haemodialysis patients. 19 summary, this study showed that the application of CL insertion and Maintenance bundles was successful in reducing CRSBI rates among renal dialysis patients.