Exit Site Infection: Central Venous Catheter Care of Dialysis Patients

Student A

West Chester University

Abstract

This analysis was done to collect data on infection control in the outpatient dialysis setting for those with a central venous catheter as their hemodialysis access device by comparing two prospective studies done by Beathard (2003) and Young (2005). Both researchers implemented strict infection control protocol into hemodialysis catheter care procedure which resulted in decreased exit site infections and catheter-related bacteremia. Beathard (2003) saw an average difference in exit site infections of 5.29 per 1,000 catheter-days over a 33-month data collection period while Young (2005) reported a 2.1% rate of exit site infections in a 21-day study period, a significant change from previously reported 3-13% rate in her studies. Both studies required education and compliance of procedure by staff for outcomes to be successfully measured.

Exit Site Infection: Central Venous Catheter Care of Dialysis Patients

The use of central venous catheters (CVCs) in hemodialysis patients has become a widely used practice in the chronic care dialysis setting. Although the use of a graft or fistula is superior and a longer lasting access route, many patients end up with a permanent CVC access (Beathard, 2003). This evidenced-based analysis examines infection risks associated with the care of central venous catheters. According to Beathard (2003), CVCs that are maintained correctly lead to a decrease in catheter-related bacteremia (CRB), which requires that health care providers are informed of CVC care guidelines and strictly follow the set standards. In her study, Young (2005) examined exit site infection (ESI) rates in double and triple lumen catheters and concluded that strict adherence to sterile precautions for CVC procedures leads to a decrease in ESI.

The Center for Disease Control has guidelines for maintenance of CVCs for the outpatient setting, including staff education and training and the use of a fistula or graft for chronic renal failure (O’Grady et al., 2011). Currently in the chronic care dialysis setting, CVCs are maintained using clean technique – this means that gloves and supplies used to remove the old dressing and clean the access that leads directly into their right atrium are not aseptic or sterile. The proposed change for nursing practice is to elevate the standard of care for CVCs and require that all CVCs be maintained using full sterile procedure. This inquiry into evidenced based practice seeks to find if, for patients on hemodialysis, a clean versus an aseptic CVC technique will result in a decreased CRB or ESI rates.

Search Study

To conduct research for this review, Boolean phrases such as “central venous catheter infection and dialysis” and “exit site infection of central venous catheters” were processed using the EBSCOhost databases. Criteria for the search included peer reviewed articles with available pdf full text since 2005. The results were expanded by allowing search for like terms and in-text search for terminology. Google scholar was first used to identify relevant studies and assist in narrowing search terminology. Ovid database returned results that needed to be narrowed and then EBSCOhost database was successfully utilized.

Literature Review

Beathard (2003) examined infection rates of hemodialysis patients with central venous catheters over a period of 24 months and compared his findings to data from charts documented during the “control period,” nine months before initiation of the study. Young (2005) examined how elevating the standard of care by implementing protocol for exit sites of CVCs decreases exit site infections (ESI) of hemodialysis patients over 21 days. Both studies took place at outpatient dialysis facilities and were prospective; Beathard’s (2003) population size was 700 patients while Young’s (2005) study consisted of 473. Beathard (2003) used the clinic’s existing CVC policy and procedure plus implemented a set of new “prophylaxis protocol” designed to prevent CRB. Young (2005) implemented exit-site care using sterile field with sterile supplies and cautions that sterile technique must be maintained. Central and peripheral blood samples were drawn two hours before CVC insertion, filled both tubes with minimum 5 milliliters (mL) of blood, and sent all specimens to the same lab; the lab was trained on handling of the specimens and only a registered nurse (RN) who had been trained to collect labs was able to collect the blood samples. Young’s (2005) study used the same blood collection method when the CVC was removed and more blood cultures were drawn, both centrally and peripherally.

To analyze the data, Beathard (2003) and Young (2005) both use a chi-square test with a 0.05 or less significance value. Beathard’s (2003) ex post facto control group showed an average CRB incidence of 6.97 per 1,000 catheter-days while the study group showed an average incidence of 1.28 per 1,000 catheter-days; the study met the significance with p < 0.05, showing that the CRB prophylaxis protocol was effective. Young’s (2005) study revealed a 3 per 1,000 catheter-day incidence, with 2.1% (10 out of 473) of the population contracting an ESI, an incidence lower than the 3-13% of previous studies.

Limitations. Young’s (2005) study did not specify an antibiotic for treatment of positive pre-insertion blood culture, which is listed as a variable in her work. The results reveal that some CVCs were removed after 5 days, which could have led to falsely low ESI results of 2.1%. Beathard (2003) No study limitations were offered in either research article.

Conclusion

Beathard’s (2003) CVC prophylaxis protocol includes using face masks and clean gloves, iodine to clean CVC hubs, and limited hub exposure to air; this set of standards requires an educated nurse and proper CVC maintenance by staff, leading to decreased CRB rates. The study supports the idea that for hemodialysis patients, a clean versus sterile procedure is necessary and leads to a decrease in CRB incidence. The entire essence of his study depended upon staff education and compliance with CVC protocol. Per Beathard (2003), the study “demonstrates that it is possible to reduce the incidence of CRB to a relatively low level and maintain it there using basic principles directed toward the protection of the catheter hubs at the time of use in the dialysis facility” (p. 4005).

Unlike Beathard (2003), Young (2005) further compared ESI rates to CVC insertion site location (femoral, subclavian, jugular) resulting in a 0.54 probability and concluding that location of a CVC is not related to ESI. Intuitively one can gather that this leaves other factors in play to cause infections, such as catheter maintenance and care. Young’s (2005) study demonstrates that CVC care using sterile technique and proper education and training of staff results in a lower incidence of infection for hemodialysis patients with CVCs. Current nursing practice for CVC care needs to be elevated with a set standard of care using sterile technique to decrease ESI and CRB incidence.

References

Beathard, G. A. (2003). Catheter management protocol for catheter-related bacteremia prophylaxis. Seminars In Dialysis, 16(5), 403. doi:10.1046/j.1525-139X.2003.16087.x

O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S., Lipsett, P., Masur, H., Mermel, L., Pearson, M., Raad, I., Randolph, A., Rupp, M., Saint, S. (2011). Guidelines for the prevention of intravascular catheter-related infections. PsycEXTRA Dataset,1-82. doi:10.1037/e548442006-001

Young, E. J., Contreras, G., Robert, N. E., Vogt, N. J., & Courtney, T. M. (2005). Incidence and influencing factors associated with exit site infections in temporary catheters for hemodialysis and apheresis. Nephrology Nursing Journal, 32(1), 41-50.