Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach

Abstract

Background: Driveline infections (DLIs) are a common adverse event in patients on ventricular assist devices (VADs) with incidence ranging from 14% to 59%. DLIs have an impact on patients and the healthcare system with efforts to prevent DLIs being essential. Prior to our intervention, our program had no standard driveline management presurgery and postsurgery. The purpose of this Quality Improvement (QI) initiative was to reduce DLIs and related admissions among patients with VAD within the first year post implant.

Methods: In anticipation of the QI project, we undertook a review of the programs' current driveline management procedures and completed a survey with patients with VAD to identify current barriers to proper driveline management. Retrospective data were collected for a pre-QI intervention baseline comparison group, which included adult patients implanted with a durable VAD between 1 January 2017 and 31 July 2018. A three-pronged care pathway (CP) was initiated among patients implanted during August 2018 to July 2019. The CP included standardised intraoperative, postoperative and predischarge teaching initiatives and tracking. Using statistical process control methods, DLIs and readmissions in the first year post implant were compared between patients in the CP group and non-CP patients. P-charts were used to detect special cause variation.

Results: A higher proportion of CP group patients developed a DLI in the first year after implant (52% vs 32%). None developed a DLI during the index admission, which differed from the non-CP group and met criteria for special cause variation. There was a downward trend in cumulative DLI-related readmissions among CP group patients (55% vs 67%). There was no association between CP compliance and development of DLIs within 1 year post implant.

Conclusion: The CP did not lead to a reduction in the incidence of DLIs but there was a decrease in the proportion of patients with DLIs during their index admission and those readmitted for DLIs within 1 year post implant. This suggests that the CP played a role in decreasing the impact of DLIs in this patient population. However, given the short time period of follow-up longer follow-up will be required to look for sustained effects.

Keywords: Healthcare quality improvement; Performance measures; Quality improvement; Statistical process control.

Figure 1

Control chart displaying the cumulative proportion of implanted patients with a DLI, with n representing the cumulative number of implanted patients. Only first DLIs were included. The central red line represents the mean with upper and lower limits set at 3 SDs from the mean (dashed lines). CP. care pathway; DLI, driveline infection; VAD, ventricular assist device.

Figure 2

Control chart displaying the cumulative proportion of DLIs that occurred during index admission, with n representing the number of DLIs that occurred by the end of the quarter (Q). The central red line represents the mean with upper and lower limits set at 3 SDs from the mean (dashed lines). CP, care pathway; DLI, driveline infection; VAD, ventricular assist device.

Figure 3

Control chart displaying the cumulative proportion of DLIs that required Hospital readmission, with n representing the number of readmissions in the quarter (Q). Each patient was censored following their first admission to hospital (excludes those DLIs occurring during index admission). CP, care pathway; DLI, driveline infection; VAD, ventricular assist device.

Figure 4

Run chart displaying compliance scores with the CP protocol for each patient with median displayed in blue. Red dots represent patients implanted in that quarter (Q) that developed a DLI within a year of VAD implant. CP, care pathway; DLI, driveline infection; VAD, ventricular assist device.