Introduction, Analysis of Existing Evidence, and Quality Improvement Process
Hemodialysis patients are at high risks of infection due to their impaired immune defenses and repetitive access of the bloodstream via vascular access types. The treatment process of hemodialysis involves using different processes and equipment that sometimes worsen the patientsâ€™ conditions. For example, frequent antibiotics administration to these patients generates antimicrobial resistance and multidrug-resistant organisms. Central venous catheters (CVCs) are among the most commonly used vascular access types. While the use of CVCs is geared toward enhancing the health and wellbeing of hemodialysis patients, they enhance the risk of hospital-acquired infections. This paper provides a brief overview of the practice problem, analyzes existing evidence on this issue, and describes the quality improvement process and the Quality model that will be used to address this practice problem.
The lifeline for patients suffering from long-term hemodialysis is a well-functioning vascular access. This is primarily because hemodialysis patients are at significantly high risk of developing vascular access-related blood stream infections (VRBSI) that could generate severe complications. According to Thompson et al. (2017), infection is regarded as the second leading cause of death among hemodialysis patients and the leading cause of hospitalization. Similarly, Nguyen et al. (2017) states that infections in hemodialysis patients increase hospitalization, mortality, need for antimicrobials, and healthcare costs. Nguyen et al. (2017) further states that hemodialysis patients are at high risks of infections due to their impaired immune defenses and repetitive access of the bloodstream using vascular access sites and types like central venous catheters (CVCs). Over the past 25 years, numerous efforts have been undertaken to lessen the number of bloodstream infections cause by the use of CVCs in hemodialysis and end-stage renal disease patients. These efforts have proven relatively ineffective since the use of CVCs for hemodialysis patients continues to be a major contributor of high bloodstream infection rates, increased healthcare costs, mortality, and morbidity (Hymes et al., 2017). Even though CVCs remain unavoidable for hemodialysis patients in need of immediate dialysis access, they continue to have undesirable side effects with regards to increasing infections. The undesirable side effects of CVCs contributes to a major practice problem in hemodialysis care settings.
Analysis of Existing Evidence
CVC infections have attracted considerable attention in existing literature since they are undesirable side effects of using central venous catheters in providing care to hemodialysis patients. Existing literature have examined various aspects relating to this issue with the aim of generating evidence that would promote practice change. Gahlot et al. (2014) states that intravascular catheters such as the central venous catheters are critical in modern clinical practices with regards to providing care to hemodialysis and end-stage renal disease patients. These catheters are inserted in critically-ill patients to help in administration of medication, fluids, nutritional solutions, blood products, and hemodynamic monitoring. While CVCs are among the integral catheters for critically-ill patients like hemodialysis patients, they pose a high risk of device-related infections. As compared to other kinds of catheters and medical device, CVCs are major causes of mortality and morbidity. The findings of prospective studies indicate that majority of bloodstream infections among hemodialysis patients are associated with CVCs. These studies estimate the relative risks for bloodstream infections to be approximately 64 times higher as compared to peripheral venous catheters (Gahlot et al., 2014).
Saxena, Panhotra & Al-Mulhim (2005) state that hemodialysis patients are at high risks of vascular access-related blood stream infections (VRBSI) that contribute to severe complications. Severe VRBSI infections are mostly associated with central venous catheters rather than arteriovenous fistula. These researchers contend that CVCs remain unavoidable for critically-ill patients in need of instant dialysis access. The unavoidability of CVCs in hemodialysis patients is linked to the unpredictable course of chronic renal disease. For hemodialysis patients, CVCs are used to help in ensuring a well-functioning vascular access. However, these patients are affected by dialysis access-related infections and subsequent hospitalization, which affect their overall well-being. The undesirable side effects of central venous catheters makes them undesirable though they are unavoidable. CVC infections among hemodialysis patients increase the cost of healthcare, mortality, morbidity, need for antimicrobials, and hospitalization (Nguyen et al., 2017; Gahlot et al., 2014; Thompson et al., 2017; Sexena, Panhotra & Al-Mulhim, 2005).
Hymes et al. (2017) suggests that the undesirable side effects of central venous catheters has resulted in numerous efforts over the past 25 years to lessen CVC infections among hemodialysis and end-stage renal disease patients. Some of these efforts include education and training of healthcare workers, Centers for Medicare and Medicaid Services Fistula initiative, use of antimicrobial locks, and development of guidelines like Scrub-the-Hub protocol by the Centers for Disease Control and Prevention (CDC). However, these researchers contend that there is a need for change in clinical practice relating to the use of CVCs for hemodialysis patients because these efforts have been relatively ineffective. Regardless of these numerous efforts, the use of central venous catheters in treatment and care for hemodialysis patients continues to be a major cause of high rates of hospitalization, bloodstream infections, increased healthcare costs, mortality, and morbidity. Therefore, the healthcare setting is faced with the need for a change in clinical practice that would help address the undesirable effects of using CVCs for hemodialysis patients while enhancing the general health and wellbeing.
Apata et al. (2017) argues that the use of chlorhexidine-impregnated transparent dressings as part of CVC maintenance helps to lessen CVC related infections among hemodialysis patients. Such dressings lessen CVC infections through allowing ongoing antimicrobial exposure and easy visibility of the insertion site for the intravascular catheter. The use of chlorhexidine-impregnated transparent dressings has been found to be more effective in lessening CVC infections among hemodialysis patients in comparison to adhesive dry gauge dressing. Therefore, existing evidence-based practice suggests that CVC infections among hemodialysis patients can be significantly reduced through the use of chlorhexidine-impregnated transparent dressings as part of CVC maintenance.
Quality Improvement Process and the Quality Model
The proposed quality improvement process for this project is promoting CVC maintenance care through chlorhexidine-impregnated transparent dressings (CHG-transparent dressing). In this regard, CHG-transparent dressing will be introduced in the hemodialysis unit as part of clinical practice on the use of CVCs for hemodialysis patients. This process will entail conducting clinician education and training on CHG-transparent dressing for CVC maintenance. The training will help enhance cliniciansâ€™ knowledge on this change in practice in order to enhance hemodialysis patient experiences and general wellbeing. To help in effective implementation of this quality improvement plan, the quality model that will be utilized is Plan-Do-Study-Act Cycle. The model will be utilized since it will allow for testing of the proposed change in clinical practice prior to full implementation. Once the change has been developed, a plan for testing it will be developed and carried out before its consequences are observed and modifications made prior to full implementation.
Apata et al. (2017, April 2). Chlorhexidine-Impregnated Transparent Dressings Decrease Catheter-related Infections in Hemodialysis Patients: A Quality Improvement Project. The Journal of Vascular Access, 18(2), 103-108.
Gahlot et al. (2014, Apr-Jun). Catheter-related Bloodstream Infections. International Journal of Critical Illness & Injury Science, 4(2), 162-167.
Hymes et al. (2017). Dialysis Catheter-Related Bloodstream Infections: A Cluster-Randomized Control Trial of the ClearGuard HD Antimicrobial Barrier Gap. American Journal of Kidney Diseases, 69(2), 220-227.
Nguyen et al. (2017, June 29). National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clinical Journal of the American Society of Nephrology, 12, 1-8.
Saxena, A.K., Panhotra, B.R. & Al-Mulhim, A.S. (2005). Vascular Access Related Infections in Hemodialysis Patients. Saudi Journal of Kidney Diseases and Transplantation, 16(1), 46-71.
Thompson et al. (2017, December). Catheter-related Blood Stream Infections in Hemodialysis Patients: A Prospective Cohort Study. BMC Nephrology. doi: 10.1186/s12882-017-0773-5
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