Background: The investigators developed a Shower Technique protocol (STP) for hemodialysis (HD) patients with healed central venous catheter (CVC) exit sites, designed to permit showering but not increase infection risk. Research question: Is it feasible to conduct a randomized control trial comparing the rate of CVC related bacteremia (CRB) in adult satellite HD patients using STP versus standard CVC care alone with 6 month follow up? Study Design: This pilot study is a multi-centre randomized control trial. Eligible participants will be randomized to STP versus standard care after meeting predefined criteria to confirm healed tunneled CVC exit site. Primary Outcome: Feasibility will be determined based on 5 outcome measures: accuracy of the CRB rate documentation in the satellite setting, percentage of patients screened, recruited, educated successfully in the STP (intervention arm), and aspects of STP (% of contaminated patients in the control arm). Study Setting: In satellite units affiliated with 2 academic and 3 community centres in south central Ontario, Canada. Patient Population: Adult satellite HD patients dialyzing via CVC with healed CVC exit sites. Intervention: STP and standard CVC care; or Control: standard CVC care; Analysis: Each measure of feasibility has its statistical threshold for success. If the threshold is reached in 4 of the 5 measures, the full HIPPO SAT study will be deemed feasible. Discussion: A pilot feasibility study of the larger study is critical due to the potential challenges associated with recruitment, compliance and contamination.
CVC related infections are associated with increased morbidity and hospitalization rates, high treatment costs, and poor survival compared to use of an arteriovenous access. To prevent infection, patients should preserve the integrity and dryness of their CVC dressings. Showering should be avoided, as it is difficult to attain full protective coverage of the exit site using dressings and barriers. Wet dressings place patients at increased infection risk, especially if their CVC exit site is not fully healed. However, in a survey of 274 CVC dependent HD patients, 64% indicated that the recommended prohibition to shower was moderately to extremely inconvenient and reduced their quality of life. Additionally 77% of patients admitted to showering at least once while they had a CVC. While submersion of the CVC in water is discouraged by clinical practice guidelines, they also state that if precautions can be taken to reduce the likelihood of bacterial CVC entry then showering may be acceptable. However, this guidance is opinion based with no evidence to support specific precautions. Thus, to address the patients' desire to shower safely, at least 2 separate dialysis facilities in Ontario, Canada have developed a showering procedure as an alternative method of CVC care. Preliminary data from a small proof-of-concept study of 65 patients suggests acceptable CRB rates (0.46/1000 CVC days) using such showering procedures. The study was conducted in satellite HD units on a select population of patients who were infection-free for 6 months using the same CVC. Satellite units offer dialysis in an outpatient setting for those patients who are stable and require less intensive care than in-centre patients. The satellite HD population is typically younger and healthier, and likely more able to perform showering procedures than in-centre patients. With increasing patients in satellite HD, it is crucial that a pragmatic, yet effective, prophylactic CVC infection strategy be formally tested and established for this setting. Following the proof-of-concept study, nephrologists, vascular access coordinators, and HD centres from five dialysis centres across Ontario, collaborated to create a formal Shower Technique Protocol (STP) which includes chlorhexidine applicators after showering to minimize the risk of bacterial entry at the CVC exit site. STP is designed specifically for patients with a fully endothelialized CVC tunnel and healed exit site. Participants allocated to STP are able to shower and change their dressing up to 3 times per week. Prior to more widespread implementation of the STP, it is critical to determine whether it is safe for use in patients with healed CVC exit sites. In other words, to confirm that CRB rates in patients using STP are not greater than the CRB rates in patients using the gold standard of CVC care. It is unknown whether using the STP improves patient satisfaction with their CVC care.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
SINGLE
Enrollment
78
Video and educational pamphlets of the STP will be used to assist in training participants randomized to this intervention. The participant must successfully demonstrate the STP on a training mannequin and be deemed by the study coordinator as ready to independently and correctly perform it before proceeding.
Nuanced differences may be present at participating units; however, the key components of the intervention are 1) HD nurse delivery of CVC care 2) chlorhexidine or povidone cleansing 3) dry gauze dressing 4) standardized frequency. For both STP and control arms, participants whose HD centre uses polysporin triple ointment as part of standard CVC care will continue to have it applied as per program policy.
Toronto General Hospital
Toronto, Ontario, Canada
RECRUITINGPrimary Feasibility Measure of the HIPPO SAT trial: Defined by 5 outcomes
Outcome Measures of Feasibility 1. The level of agreement between the date the nurse contacts the coordinator to inform them of a suspected infection and the date the culture was sent to the lab from the HD unit 2. The percentage of eligible patients who consent to participate in each participating satellite unit 3. The percentage of satellite HD patients with CVCs who are screened for eligibility 4. The percentage of patients in the Shower Technique arm passing the shower technique test at 3 and 6 months 5. The percentage of patients in the control arm who are contaminated i.e. using aspects of the STP such as chlorhexidine swabs at home at the exit site which they were not using at baseline
Time frame: 6 months
Secondary Feasibility Outcome: The change in Vascular Access Questionnaire (VAQ) score over time using the Shower Technique protocol compared to standard care.
The VAQ is a measure of patient satisfaction with their vascular access that is previously un validated in this population
Time frame: 6 months
Secondary Feasibility Outcome: The level agreement between the Deep Breath and CVC Seal tests and the blinded photo test
Once written consent is obtained, the participant will undergo formal testing for CVC exit site healing. The tests of CVC exit site healing are as follows: 1) Deep Breath Stability Test measures the migration of the CVC as marked by a 2 cm indicator on the CVC from the skin at CVC exit. There should be \< 3 mm movement between complete exhalation and inhalation; 2) CVC Seal Test is a visual inspection against an objective checklist to determine healing; and 3) Blinded Photo Test where two photos are taken of the CVC exit site to be evaluated for healing by independent blinded trained assessors. Both assessors must agree that the exit site is healed to pass the test.
Time frame: After consent and prior to randomization
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.