Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project

Abstract

Background: Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities.

Methods: The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool.

Results: The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff.

Conclusions: Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

Keywords: antisepsis; audit tool; bacteremia; catheter; checklist; dialysis; hemodialysis; infection; outpatients; quality improvement; vascular access.

Graphical abstract

Figure 1.

Dialysis care checklist. This is the appearance of the initial screen on the tool. The observer selects their title and which procedure they will be observing. APRN, advanced practice registered nurse; NTDS, Nephrologists Transforming Dialysis Safety; PA, physician assistant.

Figure 2.

Dialysis care checklist (second screen). Example of how one of several observations appear on the tool. This is the first observation for catheter connection procedure.

Figure 3.

Educational resources for patients are available to select on the tool for viewing. A variety of CDC infection prevention topics is included.

Figure 4.

Prepilot survey of patient knowledge about catheter-care procedures. Responses to the question “how would you rate your knowledge about the steps the staff take to connect and disconnect your catheter, and about the protocol for exit-site care?” Most patients report an "average" knowledge about catheter care procedures.

Figure 5.

Type of observer using the electronic catheter checklist for each pilot facility. In facilities A–E, nursing staff and technicians performed the majority of observations. In facilities F and G, most observations were performed by nursing staff, physician assistants or technicians.

Figure 6.

Catheter connection observation results (n=361). The step for which there was a lapse in technique was allowing for the "appropriate antiseptic dry time". All other catheter connection steps were performed as recommended in >99% of the time.

Figure 7.

Catheter disconnection procedures (N=305). The step for which there was a lapse in technique was allowing for the "appropriate antiseptic dry time". All other catheter disconnection steps were performed as recommended in >99% of the time.

Figure 8.

Catheter exit-site procedures (n=288). The steps for which there was a lapse in technique were "avoiding contact after antisepsis" and "applying antibiotic ointment". *One facility did not routinely use antibiotic ointment which explains this finding. All other steps were performed as recommended in >94% of the time.