Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report


      Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN).

      Study Design

      Quality improvement project.

      Setting & Participants

      Patients in 17 outpatient hemodialysis facilities that volunteered to participate.

      Quality Improvement Plan

      Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff.


      Crude and modeled BSI and access-related BSI rates.


      Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods.


      Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period.


      Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project.


      Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

      Index Words

      To read this article in full you will need to make a payment


      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Collins A.J.
        • Foley R.N.
        • Herzog C.
        • et al.
        US Renal Data System 2012 annual data report.
        Am J Kidney Dis. 2013; 61: e1-e480
        • Klevens R.M.
        • Edwards J.R.
        • Andrus M.L.
        • Peterson K.D.
        • Dudeck T.C.
        • Horan T.C.
        Dialysis surveillance report: National Healthcare Safety Network—data summary for 2006.
        Semin Dial. 2008; 21: 24-28
        • Taylor G.
        • Gravel D.
        • Johnston L.
        • et al.
        Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients.
        Am J Infect Control. 2004; 32: 155-160
        • Dopirak M.
        • Hill C.
        • Oleksiw M.
        • et al.
        Surveillance of hemodialysis-associated primary bloodstream infections: the experience of ten hospital-based centers.
        Infect Control Hosp Epidemiol. 2002; 23: 721-724
        • Stevenson K.B.
        • Hannah E.L.
        • Lowder C.A.
        • et al.
        Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data: predicting the impact of NKF:KDOQI clinical practice guidelines for vascular access.
        Am J Kidney Dis. 2002; 39: 549-555
        • Stevenson K.B.
        • Adcox M.J.
        • Mallea M.C.
        • Narasimhan N.
        • Wagnild J.P.
        Standardized surveillance of hemodialysis vascular access infections: 18-month experience at an outpatient, multifacility hemodialysis center.
        Infect Control Hosp Epidemiol. 2000; 21: 200-203
        • CDC
        Vital signs: central line–associated blood stream infections—United States, 2001, 2008, and 2009.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 243-248
        • Ramanathan V.
        • Chiu E.J.
        • Thomas J.T.
        • Khan A.
        • Dolson G.M.
        • Darouche R.O.
        Healthcare costs associated with hemodialysis catheter-related infections: a single-center experience.
        Infect Control Hosp Epidemiol. 2007; 28: 606-609
        • US Department of Health and Human Services
        National action plan to prevent healthcare-associated infections: roadmap to elimination.
        (Accessed May 2, 2012)
        • CDC
        Reduction in central line-associated bloodstream infections among patients in intensive care units—Pennsylvania, April 2001-March 2005.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 1013-1016
        • Pronovost P.
        • Needham D.
        • Berenholtz S.
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
        • Berenholtz S.M.
        • Pronovost P.J.
        • Lipsett P.A.
        • et al.
        Eliminating catheter-related bloodstream infections in the intensive care unit.
        Crit Care Med. 2004; 32: 2014-2020
        • Centers for Disease Control and Prevention
        National Healthcare Safety Network dialysis event protocol.
        (Accessed March 15, 2012)
        • Centers for Disease Control and Prevention
        Dialysis Safety: audit tools, protocols & checklists.
        (Accessed April 10, 2013)
        • Wagner A.K.
        • Soumerai S.B.
        • Zhang F.
        • Ross-Degnan D.
        Segmented regression analysis of interrupted time series studies in medication use research.
        J Clin Pharm Ther. 2002; 27: 299-309
        • Gebski V.
        • Ellingson K.
        • Edwards J.
        • Jernigan J.
        • Kleinbaum D.
        Modelling interrupted time series to evaluate prevention and control of infection in healthcare.
        Epidemiol Infect. 2012; 16: 1-11
        • Geography Division, U.S. Census Bureau
        Census Regions and Divisions of the United States.
        (Accessed April 9, 2013)
        • Hong Z.
        • Wu J.
        • Tisdell C.
        • et al.
        Cost-benefit analysis of preventing nosocomial bloodstream infections among hemodialysis patients in Canada in 2004.
        Value Health. 2010; 13: 42-45
        • CDC
        Guidelines for the prevention of intravascular catheter-related infections.
        2011 (Accessed April 10, 2013)
        • Centers for Disease Control and Prevention
        CDC's core interventions for dialysis BSI prevention.
        (Accessed March 3, 2012)
        • Kallen A.J.
        • Patel P.R.
        • O'Grady N.P.
        Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention to new settings.
        Clin Infect Dis. 2010; 51: 335-341
        • Guerin K.
        • Wagner J.
        • Rains K.
        • Bessesen M.
        Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle.
        Am J Infect Control. 2010; 38: 430-433
        • Beathard G.A.
        Catheter management protocol for catheter-related bacteremia prophylaxis.
        Semin Dial. 2003; 16: 403-405
      1. Fistula First Breakthrough Initiative.
        (Accessed March 3, 2012)
        • Centers for Disease Control and Prevention
        Device-associated module: central line-associated bloodstream infection (CLABSI) event protocol.
        (Accessed March 15, 2012)
        • National Quality Forum
        National Voluntary Consensus Standards for End Stage Renal Disease (ESRD): A Consensus Report.
        (Accessed April 10, 2013)
        • US Department of Health and Human Services, Centers for Medicare & Medicaid Services
        Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive Program; ambulance fee schedule; durable medical equipment; and competitive acquisition of certain durable medical equipment, prosthetics, orthotics and supplies. 42 CFR Parts 413 and 414.
        (Accessed March 15, 2012)
      2. Rosenblum A, Hall J, Weiling W, Latham C, Maddux F, Lacson E. Comparative effectiveness of hemodialysis catheter care protocols to prevent bacteremia. Poster presented at: American Society of Nephrology 2012 Kidney Week; October 30-November 4, 2012; San Diego, CA.

        • Lincoln M.
        Preventing catheter-related bloodstream infections in hemodialysis centers: the facility perspective.
        Nephrol Nurs J. 2011; 38: 411-415
        • CDC
        Reducing bloodstream infections in an outpatient hemodialysis center—New Jersey, 2008-2011.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 169-173