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Septicemia is one of the leading causes of death among dialysis patients. Long-term catheter use is often associated with hospitalizations due to increased infectious complications and mortality. Network 5 sought to decrease the use of catheters in place >90 days based on the Kidney Disease Outcomes Quality Initiative (K-DOQI) recommendation that less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters in use >90 days continuously as their permanent chronic dialysis access site.
A project goal was to reduce the quality deficit (RFR) by 25% for targeted facilities that met Medical Review Board (MRB)-approved selection criteria. In December 2008, after discovery of skewed baseline data from one (1) of the nine (9) targeted facilities, a revised baseline measure of CVC in use >90 days of 22.4% was calculated for May 2008, and a goal of 19.3% was reset for March 2009. Through multi-faceted strategies and interventions that included tracking tools, one-on-one technical assistance, CDC expert WebEx training, and data collection, targeted facilities surpassed the goal with a rate of CVC in use >90 days of 18.4% in March 2009.
An additional project aim was to increase the percent of blood cultures obtained prior to the administration of IV antimicrobials for treatment of septicemia through a reduction in quality deficit of at least 10%, from a baseline rate of 69.2%, by March 2009. Through data collection and individualized quality improvement technical assistance that addressed patient safety practices, targeted facilities surpassed the goal of 72.3% with a final measurement of 80.8%.
Background
Septicemia is a life-threatening infection that progresses rapidly. In 2004, septicemia was the 10th leading cause of death in the United States, accounting for 1.4% of total deaths (Heron, 2007). Among dialysis patients, septicemia is second to cardiovascular disease as a cause of death (United States Renal Data System, 2007).
Factors such as older age and diabetes have been identified as placing all dialysis patients at risk for septicemia (Ishani et al., 2005). Low serum albumin, temporary vascular access, and dialyzer reuse place hemodialysis patients at increased risk.
The most recent USRDS Atlas (2007) speculates that the continued high catheter use rate in this country may be a contributory factor to growing rates of infectious hospitalization and hemodialysis mortality rates. In the U.S., 81% of incident hemodialysis patients use a catheter at their first outpatient dialysis session. The average Network 5 facility has an annual rate of hospitalization with a diagnosis of septicemia present that is higher than that of the average U.S. facility, 15% compared to 11.6%. Averages do not tell the full story, however. Hospitalizations with septicemia vary across the Network. About 9% (n=24) of Network facilities, excluding nursing homes, military treatment facilities, Veterans Health Administration units and prisons, have septicemia hospitalization rates of 24.4% or greater. Approximately 18% have septicemia hospitalization rates of 20% or greater.
In 2008-2009, MARC targeted eight (8) facilities in Network 5 to help them identify root causes and to provide them with technical assistance to stimulate changes designed to impact the aims of the initiative, which were
- To reduce the quality deficit for the pooled use of catheters > 90 days among project participants by 25%.
- To reduce the quality deficit for the pooled percentage of blood cultures obtained prior to facility-initiated administration of IV antimicrobials among project participants by 10%.
Data Sources
CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections
United States Renal Data System (USRDS) 2007 Annual Data Report/Atlas
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