Randomized Controlled Trial

. 2022 Apr 12:377:e069634.

doi: 10.1136/bmj-2021-069634.

Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial

Sradha Kotwal^{1

2}, Alan Cass³, Sarah Coggan⁴, Nicholas A Gray^{5

6}, Stephen Jan⁴, Stephen McDonald^{7

8

9}, Kevan R Polkinghorne^{10

11}, Kris Rogers^{4

12

13}, Girish Talaulikar¹⁴, Gian Luca Di Tanna⁴, Martin Gallagher^{4

15}; REDUCCTION Investigators

Affiliations

¹ George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia skotwal@georgeinstitute.org.au.
² Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia.
³ Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
⁴ George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
⁵ Sunshine Coast University Hospital, Birtinya, QLD, Australia.
⁶ Department of Health and Behavioural Science,University of the Sunshine Coast, Sippy Downs, QLD, Australia.
⁷ ANZDATA Registry, South Australia Health and Medical Research Institute, Adelaide, SA, Australia.
⁸ Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
⁹ Renal Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
¹⁰ Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia.
¹¹ Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, VIC, Australia.
¹² Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
¹³ School of Population Health, University of New South Wales, Sydney, NSW, Australia.
¹⁴ Renal Services, ACT Health, Canberra, ACT, Australia.
¹⁵ South Western Sydney Clinical School, University of New South Wales, NSW, Sydney, Australia.

PMID: 35414532
PMCID: PMC9002320
DOI: 10.1136/bmj-2021-069634

Randomized Controlled Trial

Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial

Sradha Kotwal et al. BMJ. 2022.

. 2022 Apr 12:377:e069634.

doi: 10.1136/bmj-2021-069634.

Authors

Affiliations

¹ George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia skotwal@georgeinstitute.org.au.
² Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia.
³ Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
⁴ George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
⁵ Sunshine Coast University Hospital, Birtinya, QLD, Australia.
⁶ Department of Health and Behavioural Science,University of the Sunshine Coast, Sippy Downs, QLD, Australia.
⁷ ANZDATA Registry, South Australia Health and Medical Research Institute, Adelaide, SA, Australia.
⁸ Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
⁹ Renal Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
¹⁰ Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia.
¹¹ Departments of Nephrology and Medicine, Monash Medical Centre, Monash University, VIC, Australia.
¹² Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
¹³ School of Population Health, University of New South Wales, Sydney, NSW, Australia.
¹⁴ Renal Services, ACT Health, Canberra, ACT, Australia.
¹⁵ South Western Sydney Clinical School, University of New South Wales, NSW, Sydney, Australia.

PMID: 35414532
PMCID: PMC9002320
DOI: 10.1136/bmj-2021-069634

Abstract

Objective: To identify whether multifaceted interventions, or care bundles, reduce catheter related bloodstream infections (CRBSIs) from central venous catheters used for haemodialysis.

Design: Stepped wedge, cluster randomised design.

Setting: 37 renal services across Australia.

Participants: All adults (age ≥18 years) under the care of a renal service who required insertion of a new haemodialysis catheter.

Interventions: After a baseline observational phase, a service-wide, multifaceted intervention bundle that included elements of catheter care (insertion, maintenance, and removal) was implemented at one of three randomly assigned time points (12 at the first time point, 12 at the second, and 13 at the third) between 20 December 2016 and 31 March 2020.

Main outcomes measure: The primary endpoint was the rate of CRBSI in the baseline phase compared with intervention phase at the renal service level using the intention-to-treat principle.

Results: 1.14 million haemodialysis catheter days of use were monitored across 6364 patients. Patient characteristics were similar across baseline and intervention phases. 315 CRBSIs occurred (158 in the baseline phase and 157 in the intervention phase), with a rate of 0.21 per 1000 days of catheter use in the baseline phase and 0.29 per 1000 days in the intervention phase, giving an incidence rate ratio of 1.37 (95% confidence interval 0.85 to 2.21; P=0.20). This translates to one in 10 patients who undergo dialysis for a year with a catheter experiencing an episode of CRBSI.

Conclusions: Among patients who require a haemodialysis catheter, the implementation of a multifaceted intervention did not reduce the rate of CRBSI. Multifaceted interventions to prevent CRBSI might not be effective in clinical practice settings.

Trial registration: Australia New Zealand Clinical Trials Registry ACTRN12616000830493.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the organisations listed in the funding statement for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

**Fig 2**
Box plot of raw rate of confirmed haemodialysis catheter related bloodstream infection (CRBSI) per 1000 catheter days, at service level, across the study. Time points are defined: 0 is all services in baseline phase; 1 is first tranche (12 services) of intervention implemented; 2 is second tranche implemented with total of 24 services in intervention phase; 3 is final tranche implemented with all services in intervention phase. Dots are weighted to size of renal services (according to local dialysis registry). Box represents interquartile range and line represents median rate during trial phase

See this image and copyright information in PMC

References

1. Klevens RM, Edwards JR, Andrus ML, Peterson KD, Dudeck MA, Horan TC, NHSN Participants in Outpatient Dialysis Surveillance . Dialysis Surveillance Report: National Healthcare Safety Network (NHSN)-data summary for 2006. Semin Dial 2008;21:24-8. 10.1111/j.1525-139X.2007.00379.x - DOI - PubMed
1. Zimlichman E, Henderson D, Tamir O, et al. . Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-6. 10.1001/jamainternmed.2013.9763 - DOI - PubMed
1. Nuckols TK, Keeler E, Morton SC, et al. . economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review. JAMA Intern Med 2016;176:1843-54. 10.1001/jamainternmed.2016.6610 - DOI - PMC - PubMed
1. O’Grady N, Alexander M, Burns L, et al. . Guidelines for the prevention of intravascular catheter-related infections 2011: https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf. - PubMed
1. Resar R, Griffin FA, Haraden C. Nolan TW. Using care bundles to improve health care quality. IHI Innovation Series white paper. Institute for Healthcare Improvement, 2012.

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Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial

Affiliations

Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical