This multi-targeted approach includes novel elements aimed at sustaining practice adherence and improving patient safety.

Many individuals receiving hemodialysis require a central venous catheter (CVC), which places them at risk for central-line associated bloodstream infections (CLABSIs). The Centers for Disease Control and Prevention (CDC) Making Dialysis Safer for Patients Coalition partnership with the American Society of Nephrology’s Nephrologists Transforming Dialysis Safety Initiative aims to eliminate CLASBIs in these patients. The CDC’s core interventions serve as the gold standard for preventing intravascular CLABSI. In addition, healthcare facilities continue to implement strategies to prevent hemodialysis-related CLABSIs by creating a culture of collaboration and safety for this vulnerable population. (See CLABSI data.)

The acute dialysis unit in a quaternary teaching hospital had four cases of hemodialysis-related CLABSI from January 2019 through May 2019 (compared to no CLABSIs in 2018). The dialysis team (nephrology nurse leaders, nephrology clinical RNs, and nephrologists) partnered with key stakeholders (infection prevention, vascular physicians, advance care providers, and hospitalists) to form an interprofessional CLABSI prevention team focused on examining the problem and developing a multi-targeted approach to prevent CLABSI in hospitalized patients receiving hemodialysis.

The literature review

Findings in a study by Shalaby and colleagues indicated that a CVC bundle can significantly reduce CLABSI rates from 6.7 cases per 1,000 catheter days to 4.1 cases. The bundle included hand hygiene; maximal barrier precaution; skin site cleaning with an alcoholic chlorhexidine solution (>0.5 chlorhexidine and 70% alcohol) before CVC insertion and during dressing changes; optimal access site selection; use of a sterile transparent, semipermeable dressing or gauze to cover the catheter site; and scrubbing the catheter ports and hub with an appropriate antiseptic.

Fisher and colleagues cited novel interventions for infection prophylaxis, including a chlorhexidine-coated impregnated transparent exit dressing, a chlorhexidine-coated rod hub device, and an antimicrobial lock. The researchers also reported the importance of a multi-targeted approach that incorporates active patient engagement, staff education, and strict adherence to the CDC’s core strategies for infection prevention.

A similar study by Hamid and colleagues attributed success at CLABSI reduction to an interprofessional team approach and bundled intervention, including patient and family/caregiver education as well as revalidation of nurse competency on CVC care and catheter access management. According to Parker and colleagues, implementing a standardized care and infection prevention program can reduce the risk of hemodialysis bloodstream infections. Staff behavior and practices impacted the success of these interventions, and leadership and teamwork facilitated infection prevention.

The structure and process

In May 2019, the CLABSI prevention team developed and implemented a multi-targeted approach aimed at preventing hemodialysis-associated CLABSIs. The nephrology nurse leaders created the educational module based on the CDC guidelines for the prevention of intravascular catheter–related infections as well as organizational and departmental policies and procedures. (See Multi-targeted approach.)

Before implementing the new approach, nephrology RNs completed mandatory education (via the organization’s learning management system) in initiating and discontinuing hemodialysis treatment and performing catheter care. Through direct observation (during initial orientation, ongoing, and annually), nephrology nurse leaders assess nephrology RN competency. (See Nurse competencies.)

Initiating and discontinuing treatment

Steps involved in initiating and discontinuing treatment include drawing the privacy or cubicle curtain, hand hygiene, and scrubbing the hemodialysis catheter hub with chlorhexidine gluconate (CHG) swabs for 5 seconds and allowing it to air dry during each access and de-access. RNs place a Food and Drug Administration-approved, needle-free, closed connector system at the initiation of each treatment and close it with a disinfecting cap upon completion. The device prohibits microbial entry.

RNs use a gauze sleeve to cover both lumens and place a neon green sticker on top of the sleeve labeled, “FOR HD [hemodialysis] USE ONLY.” Typically, nephrology RNs perform the sterile dressing change every 7 days and as deemed necessary (for example, if the dressing is wet, loose, soiled, or not intact).

Assessments and rounding

The standard of practice for patients receiving hemodialysis via a CVC includes a daily visual and tactile assessment of the insertion site, dressing, closed connector system, and disinfecting cap. Nephrology RNs assess for pain, tenderness, edema, redness, purulent drainage, malposition, migration, and obstructed or kinked tubing. To ensure thorough assessment, the CLABSI prevention team developed a checklist. RNs escalate abnormal findings to the nephrologists, primary medical–surgical RN, and nephrology nurse leaders. If necessary, they report clinical findings to the infection prevention team.

The nephrology nursing team developed a novel approach for proactive rounding assessments during non-dialysis days. Nephrology nurse leaders review the daily schedule of patients for hemodialysis treatment (typically 10 to 12) and create a list of those with CVC access for catheter rounding. They then provide that list for the nephrology RN assigned to conduct rounding that day.

Common assessment findings during non-dialysis days include loose dressings, skin irritation, and exit sites with drainage. The nephrology RNs document their assessments in the electronic health record (EHR) and escalate any non-tunneled catheter in place for more than 7 days to the nephrology provider for a line change or catheter removal.

CHG bathing

To reduce bacteria on the skin, all patients with a hemodialysis catheter receive daily CHG wipe baths (chest, abdomen, upper and lower extremities, back, and buttocks). CHG bathing is linked to significant reductions in infections caused by gram-positive pathogens. A study by Scheier and colleagues showed a decline in CLABSI incidence in ICUs that implemented daily CHG bathing.

In addition to documenting CHG baths in the EHR, nurses also note them in the infection prevention CHG bath report, which provides vital information about the completion of baths in the last 24 hours and aids practice sustainment. All clinicians and leaders can access the auto-generated report. Hemodialysis patients without a CHG bathing order won’t appear on the report; nurses escalate these cases to the primary provider so an order can be placed.

Ongoing instruction and observation

Nephrology nurse leaders reinforce the multi-targeted approach via daily briefs, huddles, and staff meetings to improve and enhance nurses’ knowledge of infection prevention practices and central venous access care and maintenance. In turn, the RNs provide patient education. Tools for staff education include the clinical practice guidelines for catheter care embedded in the EHR as well as audit tools and checklists designed to ensure consistent adherence to guidelines, policies, and procedures. (See Audit Tools)

During implementation of the new approach, nephrology nurse leaders performed 10 observations per month (the standard recommendation from hospital quality management) to assess protocol adherence. These observations allowed nurse leaders to provide real-time feedback while reinforcing evidence-based practices. In addition, clinical RNs engaged in real-time peer-to-peer monitoring and feedback. After rounding, the assigned nephrology RN shared their findings with the patients’ primary RNs, who described them as learning opportunities and welcomed the teaching moment.

The data and results

Each day, the nephrology nurses track the number of CVCs and device days. The infection prevention team submits those numbers to the CDC’s National Healthcare Safety Network each month. In addition, clinical department managers and directors share monthly data with the clinical staff during unit meetings, nursing quality council meetings, and patient care services leadership meetings, as well as through the hospital performance improvement coordinating group. CLABSI data and direct observation by nephrology nurse leaders indicate that this process has helped improve staff adherence to key processes and increased understanding of trends and gaps in care.

At their monthly meeting, dialysis staff review the CLABSI multi-targeted approach, CVC rounding, CLABSI data, and improvement opportunities. Staff members share ideas, suggestions, and challenges in sustaining strict adherence to the CDC’s core interventions. These reviews have helped team members gain a deeper understanding of the importance of hardwiring the interventions and maintaining these infection prevention efforts.

The hospital reported zero CLABSIs for 7 consecutive months (June 2019 through December 2019) after implementation of the multi-targeted approach. This significant reduction continued in 2020 and 2021 with no hemodialysis catheter-related CLABSIs. So far in 2025, one case of CLABSI has occurred. These results have led to substantial cost savings of $384,864 related to treating infections. Additional cost reductions occurred as a result of decreased lengths of stay. The CDC estimates an additional savings of $48,108 per CLABSI case, above and beyond the cost associated with an inpatient stay for a similar patient without a CLABSI.

The challenges

Although proactive rounding proved beneficial, it also created team stress. Initially, some clinical staff voiced reluctance due to additional rounding work, which averaged 2 hours per day and resulted in staff overtime of approximately 0.32 FTE. Ultimately, the practice change incurred additional costs of $9,400 annually related to CVC supplies needed for more frequent dressing changes requested by nephrology RNs.

Understanding and addressing the causes of resistance, communicating the importance of the practice change, and engaging clinical staff in the process created a more receptive environment. The CLABSI prevention team initiated various strategies to acknowledge staff efforts and address stress, such as reward and recognition points, real-time feedback, a kudos board, and staff wellness programs.

Nephrology RNs encountered difficulty assessing patients due to scheduled tests and procedures. To avoid conflict with catheter rounding, the nephrology RNs communicated directly with primary RNs about test and procedure scheduling.

Early phases of implementation presented challenges with adherence to CHG bathing, primarily due to lack of provider orders. To address this barrier to success, the infection prevention team reviewed the CHG bath report daily for missing orders. Escalating the missing bath order to providers increased awareness and adherence to placing CHG bath orders for every patient receiving hemodialysis.

A supportive workplace culture, clear and inclusive communication, and a reliable feedback loop helped identify areas for improvement and ultimately resulted in positive outcomes, including zero CLABSIs and staff and leader engagement in the project.

Next steps

In 2025, to hardwire evidence-based CLABSI prevention practices for all patients with CVCs, the team created a multidisciplinary CLABSI champion program, with frontline clinical RNs serving as resources for colleagues and peers as they develop expertise and participate in or lead QI projects on their units. In addition, the organization’s annual mandatory RN skills fair will now include the multi-targeted CLABSI prevention approach.

Review of the correlation of the three novel strategies (proactive daily catheter rounding, cubicle curtain for patient safety, and visual cue “FOR HD USE ONLY”) with heightening situational awareness of clinicians will help the CLABSI prevention team better understand the impact on infection prevention practices specific to the hemodialysis population.

Positive impact

Despite prevention efforts, risk of CLABSI among patients receiving hemodialysis remains a concern. This performance improvement project demonstrated the positive impact of a dedicated and engaged team, effective leadership, timely feedback, and a multi-targeted approach to achieving success.

The authors work at North Shore University Hospital in Manhasset, New York. Elena Memoracion is senior director of patient care. Janis Paulose is assistant manager. Maria Bernal is a nurse manager.

American Nurse Journal. 2025; 20(8). Doi: 10.51256/ANJ082520

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Key words: hemodialysis catheter, bloodstream infections