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Prevention of hemodialysis central line-associated bloodstream infections in acutely ill individuals.


To provide an overview of tunneled, cuffed catheter use and quality improvement measures in one center's inpatient hemodialysis setting.


1. Explain the process of hemodialysis catheter care.

2. Discuss how a healthcare team can be motivated to make changes during a quality improvement project.

3. Describe the catheter evaluation and selection process as part of this institution's ongoing quality improvement project.


In an academic medical center in the Pacific Northwest, dialysis care is provided by an in-house dialysis team consisting of six dialysis technicians and approximately 65 hemodialysis-trained nurses. The dialysis technicians, with support from the clinical engineering department, are responsible for hemodialysis machine and portable reverse osmosis (RO) unit set-up, take-down, disinfection, dialysate preparation, water quality measures, and maintenance. The dialysis nurses are based in three intensive care units (cardiac, medical-surgical, and oncology), and one inpatient medical-surgical unit. The dialysis nurses are responsible for providing hemodialysis treatment and primary nursing care. Approximately 250 dialysis procedures are provided a month in the form of 4-hour hemodialysis, slow low-efficiency dialysis (SLED), and slow continuous ultrafiltration (SCUF).

Dialysis access care has been an ongoing quality improvement focus since the beginning of the program in 1960. To maintain quality care, the hemodialysis catheter is only accessed with an order from the nephrology team by a nurse who has successfully completed competency in dialysis access. Hemodialysis orientation is approximately 10 days and led by the nephrology clinical nurse specialist (CNS) and six unit-based dialysis nurse preceptors. Orientation includes lecture, reading, videos, simulated practice, and one-on-one supervised clinical experience. Education reinforcement is provided with yearly education, an annual competency quiz, and bi-monthly communication from the CNS. A multidisciplinary central venous access team reviews current literature and revises policies with a focus on standardizing care for all central venous catheters (CVCs), when possible, among specialties, such as oncology and dialysis. Surveillance of catheter infection rates is monitored by hospital epidemiology nurses.

Non-tunneled catheters are placed by the nephrology team in situations when hemodialysis is indicated urgently and removed within one week of placement (National Kidney Foundation [NKF], 2006). Non-tunneled catheter placement at the bedside is performed using a CVC bundle that includes a provider checklist and CVC insertion cart, and standardized supplies are determined by the multidisciplinary CVC team. If continued hemodialysis is necessary, a tunneled, cuffed catheter is placed by interventional radiology.

Catheter Care

Care of hemodialysis catheters has continued to evolve within the institution. Interventions that have been incorporated into policies to prevent catheter-related bloodstream infections are shown in Table 1. These interventions are consistent with the Centers for Disease Control (CDC) Guidelines for the Prevention of Catheter-Related Bloodstream Infections (CDC, 2010). More recent practice changes focus on dressings with chlorhexidine gel, needleless access devices that do not need to be removed during hemodialysis, and sodium citrate 4% catheter locks.

Care of the hemodialysis catheter is outlined in Table 2. Site care includes insertion site cleansing with chlorhexidine scrub for 30 seconds, allowing the area to dry, and application of a transparent dressing with chlorhexidine gel pad. After initial line placement, gauze with an occlusive dressing is applied. Approximately 24 hours after CVC insertion when hemostasis is achieved, a transparent dressing with a chlorhexidine gel pad is placed. The transparent dressing is then changed weekly and as needed when the gel pad becomes saturated or the dressing is compromised. Prior to the use of the transparent dressing with the chlorhexidine gel pad, hemodialysis catheter dressing consisted of povidine-iodine ointment and gauze, or a chlorhexidine sponge dressing. The decision to use a chlorhexidine product was based on current literature at the time and to align hemodialysis catheter care with standard CVC care in the institution. Due to the inconsistent practice of staff regarding appropriate application of the chlorhexidine sponge, the institution is currently utilizing the one-piece transparent dressing with chlorhexidine gel pad.

Since 2006, needleless access devices that do not need to be removed during hemodialysis have been used with all hemodialysis catheters within the institution. Needleless access devices may provide a physical and functional barrier against catheter infection by creating a closed system in between dialysis sessions. The needleless access devices allow flows up to 500 mL/minute, and therefore, do not need to be removed during hemodialysis (Eloot, DeVos, Hombrouchx, & Verdonck, 2007). Prior to catheter access, two 30-second scrubs are performed with alcohol wipes using aseptic technique, with both the provider and the patient wearing masks. The needleless access device is changed weekly for individuals dialyzing three times a week per institution standard on Thursday or Friday, and twice a week for individuals dialyzing more than three times a week on Monday and Thursday (McAfee, Seidel, Watkins, & Flynn, 2009).

Catheter lock solutions have also been an area of interest in hemodialysis CVC care (Battistella, Vercaigns, Cote, & Lok, 2010). Regional anticoagulation with sodium citrate has been used in hemodialysis effectively for many years (Palsson & Niles, 1999). Sodium citrate 4% has been shown to be an effective lock solution that is cost effective, and it has a more favorable side effect profile than heparin (MacRae et al., 2007; Michaud, Komant, & Pfefferle, 2001). Due to increased concerns of bleeding and potential for heparin-induced thrombocytopenia (HIT), the institution began using sodium citrate 4% catheter locks with patients on hemodialysis in the oncology intensive care unit in 2007. Prior to 2007, heparin 1000 units per mL was the standard catheter lock solution for all hemodialysis catheters, unless an individual had the diagnosis of HIT. After one year of using sodium citrate 4% for hemodialysis catheter locks, there was no increase in the use of tissue plasminogen activator (tPA), catheter dysfunction rates, or infection rates. Sodium citrate 4% became the standard lock solution on the inpatient medical-surgical dialysis unit in 2008. However, there are instances when heparin may be used. If an individual requires tPA on two separate occasions and has no contraindications for heparin, then heparin 1000 units per mL is used instead of sodium citrate 4% for the catheter locks.

Since sodium citrate 4% is typically supplied in intravenous solution bags, a process was developed with the pharmacy to provide catheter locks for the dialysis units. Sodium citrate 4% has been found to be stable for 28 days in syringes when protected from light (Levesque, Girard, Leger, & Dorval, 2001). The pharmacy fills syringes with 3 mL of sodium citrate 4%, labels the syringes, and places them in a tinted container for delivery and storage in the medication dispensing machine on the dialysis units. When the syringes are removed from the tinted container, the sodium citrate 4% is used immediately, or if not used immediately, discarded. The pharmacy monitors use and re-stocks the prefilled syringes of sodium citrate 4% as needed.

Catheter Care: Discussion

Care of tunneled catheters will continue to change and evolve as new evidence becomes available. The challenge becomes incorporating practice changes within institutions to create a new standard of care. Kotter and Rathgeber (2005) describe an eight-step process for successful change, which includes:

* Creating a sense of urgency.

* Pulling together a guiding team.

* Developing a vision and strategy.

* Communicating for understanding.

* Empowering others to act.

* Producing short-term wins.

* Not letting up.

* Creating a new culture.

Educating and involving staff can help build momentum to support changing practice. Although the process takes time and planning, it is possible to achieve goals when staff understand the goals, feel empowered to make a difference, and have consistent feedback on progress. The recent changes described at this institution developed over the course of years and included trials, unit experts, procedure and form revisions, support from other disciplines, and repeated education for staff. Per hospital epidemiology staff in 2009, there were a total of five central line-associated blood stream infections (CLABSIs) in patients with hemodialysis catheters. The hemodialysis catheter infection rate was 1.08 per 1000 catheter days on the medical-surgical hemodialysis unit, and 0.2 per 1000 catheter days in the intensive care unit. Although these rates are relatively low (Beathard, 2003), continued efforts are necessary to maintain and enhance hemodialysis CVC care.

Catheter Selection

Practice changes do not only apply to catheter care but also toward developing a process to select a tunneled catheter for use in a facility. Since access function is essential for adequate dialysis treatment, the selection of a tunneled catheter also deserves focus (Frasca, Dahyot-Fizelier & Mimoz, 2010; Spector et al., 2008). Some challenges with dialysis catheters include inability to achieve goal blood flow (Qb) and potential for recirculation (NKF, 2006). In discussions with inpatient and community dialysis nurses, when goal Qb is not met, or if there are frequent arterial or venous pressure alarms, nurses reported it is not an unusual practice to reverse catheter lines. This practice is also described as "lines are reversed" (NKF, 2006) and is intended as a temporary solution to line dysfunction. In reversing catheter lines, there is an increased potential for recirculation, which can lead to decreased clearance. A systematic approach was developed to evaluate hemodialysis catheters to maximize solute clearance by evaluating ability of tunneled catheters to achieve Qb of 400 mL/minute and demonstrate a recirculation rate of less than 10%.

Catheter Selection: Method

The current tunneled catheter product and four new tunneled catheters were selected by a multidisciplinary group of physicians, nurses, and technicians from nephrology and interventional radiology. The renal CNS was notified by interventional radiology when a tunneled catheter was placed. Interventional radiology randomly selected the catheter type for placement. When the individual was scheduled for dialysis, the dialysis technicians set up the machine with twister tubing. The renal CNS and a small of group of trained staff nurses programmed an online clearance test. The Q b of 400 mL/minute was obtained, and arterial and venous pressures were recorded. The Qb was decreased to 300 mL/minute, and the online clearance was measured. When prompted by results from the dialysis machine, lines were reversed using twister tubing, which does not require opening the hemodialysis system, and online clearance was measured. Recirculation was calculated (see Figure 1), and results reviewed by the renal CNS. The goal was to evaluate five catheters of each catheter type in five different individuals. Characteristics of the tunneled catheters trialed are shown in Table 3 (labeled A through E).
Figure 1
Recirculation Calculation

Recirculation is calculated:

Online clearance pre-line switch - Online clearance post-line switch /
Online clearance pre-line switch X 100%

Cather Selection: Results

The goal of evaluating five catheters of each type was not achieved due to the inability of some catheters to be tested because of catheter dysfunction, availability of the CNS or trained nurses when catheters placed emergently, inability to test online clearance during SLED when the Qb was below 300 mL/minute, or when SCUF was ordered. Catheter D was placed in two individuals. The catheter had a mean Qb of 300 mL/minute and was unable to be tested on four separate occasions due to high arterial and venous pressures, and frequent alarms. Both individuals required the catheter changed in interventional radiology. The multidisciplinary group decided to discontinue catheter D from the trial.

The multidisciplinary team evaluated the results of the first five catheters reviewing the mean Q b, range Qb with acceptable arterial and venous pressures (less than [+ or -] 250 mmHg), range of recirculation rates, and mean recirculation rates. The current product, catheter A, was found to have a mean Qb of 367 mL/minute and mean recirculation rate of 23.2%, which did not meet criteria, and supported the decision to change catheters in the institution. Catheter B performed second best of the trial catheters in regard to recirculation, with a mean rate of 14.4%, and a mean Qb of 341 mL/minute. Catheter C was found to be the most consistent performer, with a mean Qb of 400 mL/minute and mean recirculation rate of 1.2%. Catheter C also had the highest fiscal burden of the five catheters trialed. Catheter E was discontinued from the trial due to mean recirculation rate of 24% and the widest range of recirculation rates from 11.5 to 35.5%. The committee decided to add two newly available catheters, catheters F and G, to the trial and continue the process.


The multidisciplinary group met again after completing additional evaluations of catheters B, C, F, and G. Catheter F was found to have a mean Qb of 350 mL/minute and a mean recirculation rate of 29%. Catheter G had a mean Qb of 313 mL/minute and a mean recirculation rate of 20%, with a wide range of recirculation rates between 10% to 36.6%. The group determined that catheter C continued to meet criteria consistently, and catheter B was able to meet criteria some of the time and had less fiscal burden than catheter C. After discussions regarding cost, ease of insertion, clearance, Qb, recirculation, and function, the multidisciplinary group agreed that Catheter F and G would be discontinued from the trial. Catheters B and C continue to be used in the facility, with ongoing evaluation to determine if consistency in performance outweighs concerns regarding fiscal burden. The results for mean Qb and mean recirculation rate for each catheter are summarized in Figure 2.

Catheter Selection: Discussion

Although this quality improvement project is in a single center with limited numbers, the process of determining objective measurable outcomes, using resources within a facility, and evaluating products to maximize dialysis outcomes is applicable to any institution. Balancing patient outcomes and financial responsibility can be facilitated with measurable, agreed-upon outcomes. The multidisciplinary group was able to discuss objective findings guided by standards for patient care in addition to subjective experience of the staff. Further study across multiple institutions may provide greater insight into the applicability of this process for evaluating catheter selection to maximize hemodialysis outcomes.


Battistella, M., Vercaigns, L., Cote, D., & Lok, C.E. (2010). Antibiotic lock: Invitro stability of gentamicin and sodium citrate stored in dialysis catheters at 37 C. Hemodialysis International, 74(3), 322-326.

Beathard, G.A. (2003). Catheter management protocol for catheter-related bacteremia prophylaxis. Seminars in Dialysis, 16(5), 403-405.

Centers for Disease Control and Prevention (CDC). (2010). CDC guideline for the prevention of intravascular catheter-related bloodstream infections: Final issue review. Retrieved from _guideline_IssuesMay17final.pdf

Eloot, S., De Vos, J., Hombrouckx, R., & Verdonck, P. (2007). How much is catheter flow influenced by the use of closed luer lock access devices? Nephrology Dialysis and Transplant, 22(10), 3061-3064.

Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related infection in the intensive care unit. Critical Care, 74, 212.

Kotter, J., & Rathgeber, H. (2005). Our iceberg is melting: Changing and succeeding under any conditions. New York: St. Martin's Press.

Levesque, N., Girard, L., Leger, J., & Dorval, M. (2001). Stability of trisodium citrate 4.0% and 46.7% in polyvinyl chloride syringes. Canadian Journal of Hospital Pharmacy, 54(4), 264-268.

MacRae, J.M., Dojcinovic, I., Djurdev, O., Jung, B., Shalansky, S., Levin, A., & Kiaii, M. (2008). Citrate 4% versus heparin and the reduction of thrombosis study (CHARTS). Clinical Journal of American Society of Nephrology, 3, 369-374.

McAfee, N., Seidel, K., Watkins, S., & Flynn, J. (2009). Use of Tego connectors to prevent hemodialysis catheter infections in children. American Journal of Kidney Disease, 53(4), B37.

Michaud, D., Komant, T., & Pfefferle, P. (2001). Four percent trisodium citrate as an alternative anticoagulant for maintaining patency of central venous hemodialysis catheters: Case report and discussion. American Journal of Critical Care, 10(5), 351-354.

National Kidney Foundation (NKF). (2006). KDOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: Hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Guideline 2--Selection and placement of hemodialysis access. American Journal of Kidney Disease, 48(1, Suppl.), S248-S273.

Palsson, R., & Niles, J.L. (1999). Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with high risk of bleeding. Kidney International, 55, 1991-1997.

Spector, M., Mojibian, H., Elisea, D., Pollack, J.S., Reiner, E., Arici, M., & Tal, M.G. (2008). Clinical outcome of the Tal Palindrome chronic hemodialysis catheter: Single institution experience. Journal of Vascular and Interventional Radiology, 19(10), 1434-1438.

Nancy Colobong Smith, MN, ARNP, CNN, is a Renal and Transplant Clinical Nurse Specialist, University of Washington Medical Center, Seattle, WA, and a Member of ANNA's Greater Puget Sound Chapter. She may be contacted via e-mail at

Acknowledgment: The author would like to thank Annie W. Tu, Sohail Ahmad, and Patrick Willis for their suppoer and participation in the Catheter Trial project.

Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Table 1 Interventions to Prevent Intravascular Catheter-Related
Bloodstream Infections

* Prepare skin with chlorhexidine-based preparation before central
venous catheter insertion and during dressing changes.

* Maximal sterile barrier precautions during insertion of central
venous catheters.

* When needleless systems are used, split system valve may be

* Minimize contamination risk by scrubbing the access port with an
appropriate antiseptic.

* Replace dressings at least every 7 days for transparent

Table 2
Hemodialysis Catheter Care

Dressing Changes

* Tunneled catheter care includes
hand hygiene, aseptic technique,
wearing masks and gloves

* Non-tunneled catheter care is
performed using sterile technique
per hospital protocol

* Cleanse insertion site with
chlorhexidine for 30 seconds

* Allow site to dry prior to applying
new dressing

* Apply clear dressing with
chlorhexidine gel pad (Tegederm
CHG[R]) per manufacturer's instructions

* Change dressing weekly, and as
needed when gel pad saturated or
dressing compromised

Hub Care

* Hand hygiene, aseptic technique
with masks and gloves

* Needleless access devices (Tego[R])
are placed on all hemodialysis

* Needleless access device is
changed weekly (Thursday or Friday)
for individuals who dialyze 3 times a

* Needleless access device is
changed twice a week, on Monday
and Thursday, for individuals who
dialyze more than 3 times a week

* Prior to accessing needleless access
device, scrub hub with alcohol pad
for 30 seconds x 2 (60 seconds total)

Table 3
Tunneled Hemodialysis Catheter Descriptions
(The information below is from product brochures.)

    Material                Tip Design

A   Carbothane[R]           Staggered lumen tips
    Alcohol compatible

B   Carbothane[R]           Staggered lumens
    Alcohol compatible      spaced 3.1 cm
    Biocompatible           apart

C   Carbothane[R]           Spiral-z tip design--
    Alcohol compatible      bi-directional and
    Biocompatible           symmetric
                            Laser slots
                            Wide openings

D   Bodysoft[R] Plus        3 cm stepped tip

E   Carbothane[R]           Stepped tip
    Alcohol compatible      "Non-restrictive"

F   Durathane[R]            Hydro-Tip[R]
    Alcohol and iodine

G   Radiopaque              Coaxial design--
    polyurethane material   360-degree flow
    Alcohol and iodine

    Special Features

A   Double-D design to improve
    cross-sectional area and
    blood flow
    Enhanced polyester cuff
    Large lumen
    Tapered, round single shaft

B   Double-D design
    Polyester cuff
    Rotating suture wing

C   Double-D design
    Polyester cuff

D   Double-D design
    Polyester cuff
    Large lumens--2.3 mm

E   Double-D design
    Polyester cuff
    Large lumens

F   Polyester cuff
    Rotating suture wing

G   Polyester cuff
    Rotating suture wing

Note: Catheters A through E were included in the initial trial.
Catheters F and G were added when catheters D and E were removed from
the trial. At this time, both catheters B and C are being used in this
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Title Annotation:Continuing Nursing Education
Author:Smith, Nancy Colobong
Publication:Nephrology Nursing Journal
Date:Sep 1, 2010
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