Multifaceted Control Interventions for Healthcare-associated Infections in a Kidney Transplant Intensive Care Unit: Clinical Outcome Improvement and Bundle Adherence

Abstract

Background: Healthcare-associated infections (HAIs) are preventable complications that overwhelm the healthcare system. The implementation of multifaceted control intervention actions in the intensive care setting modifies clinical outcomes, but its effectiveness has not been specifically investigated for high-risk patients, such as kidney transplant recipients (KTRs).

Methods: This observational retrospective natural experiment evaluated the effectiveness of multifaceted control interventions (bundles) in reducing HAIs in a KTR intensive care unit. We also measured the bundle adherence rate during 16 mo in the after era.

Results: We included 1257 KTRs, 684 before and 573 in the postintervention period. After the bundle implementation, the incidence density of device-associated HAIs decreased from 8.5 to 3.9 per 1000 patient-days (relative risk [RR] = 0.46; 95% confidence interval [CI], 0.25-0.85; P = 0.01), primarily because of the reduction in central line-associated bloodstream infection from 8.0 to 3.4 events per 1000 catheter-days (RR = 0.43; 95% CI, 0.22-0.83; P = 0.012). Reductions in catheter-associated urinary tract infection (2.5 versus 0.6 per 1000 catheter-days; RR = 0.22; 95% CI, 0.03-1.92; P = 0.17) and ventilator-associated pneumonia (3.4 versus 1.0 per 1000 ventilator-days; RR = 0.29; 95% CI, 0.03-2.63; P = 0.27) were not significant. Central venous (P = 0.53) and urinary catheter (P = 0.47) insertion adherence were stable during 16 mo, whereas central venous (P < 0.001) and urinary catheter (P = 0.004) maintenance gradually increased. Finally, ventilator-associated pneumonia prevention bundle adherence slightly decreased over time (P = 0.06).

Conclusions: The implementation of comprehensive multifaceted control intervention actions in an intensive care unit dedicated to KTR care was effective in significantly reducing device-associated infections. The impact was in line with the reductions observed in populations that have not undergone transplantation, underscoring the effectiveness of these interventions across different patient groups.

FIGURE 1.

Population flowchart. ICU, intensive care unit; KTR, kidney transplant recipient.

FIGURE 2.

HAIs incidence rate stratified by era and by devices. The devices HAIs are expressed in infections per patients-day and stratified by the device in infections per device-day: CLASBI, per 1000 catheter-day; CAUTI, per 1000 catheter-day; VAP, per 1000 mechanical ventilation-day. CAUTI, catheter-associated urinary tract infection; CLASBI, central line-associated bloodstream infection; HAI, devices healthcare-associated infection; VAP, ventilator-associated pneumonia.

FIGURE 3.

The bundle adherence over time. M1 represents March 2018, and M16 represents June 2019. The month-to-month values are the median of all measurements captured by the observer, considering the approach of “all or nothing.” The solid grey line at 95% represents the ideal goal standardized by IHI. IHI, Institute for Healthcare Improvement.