Application of Nursing Quality Index Management in Reducing the Infection of Tunnel-Cuffed Hemodialysis Catheter

Objective: To explore how the nursing quality management reduces the infection of tunneled-cuffed hemodialysis catheter (TCC). Methods: The TCC infection rate from January 1 st to December 31 th was used as the baseline data, and the TCC infection rate from January 2014 to December 2017 was used for annual comparison. Through the nursing quality index management mode, the TCC infection rate was compared quarterly, annually and year by year by taking the measures of joint ward checking, optimizing nursing process, ana-lyzing the root cause of infection cases and formulating countermeasures. Results: The Centre has been implementing the management of nursing quality indicators since 2014. TCC infection rate is an important part of Quality of Nursing Index Management. The comparison between 2013 and 2014 (X 2 = 4.20, P = 0.04) was P < 0.05, which was statistically significant. TCC infection rate dropped from 1.19‰ in 2013 to 0.51‰ in 2017. The number of TCC patients and indwelling catheter days increased year by year from 2013 to 2017, but the rate of TCC infection decreased year by year. Conclusion: The nursing quality index management can effectively reduce the incidence of TCC infection.


Introduction
In China, the number of maintenance hemodialysis (MHD) patients has increased dramatically. According to the statistics of the National Blood Purifica-tion Case Information Registration System, the growth rate of MHD patients in China from 2011 to 2014 was as high as 44.9%, ranking the second in the world and the fastest in the world [1]. Vascular access is the lifeline of MHD patients.
Central venous catheter as a vascular access is widely used in clinical dialysis, but catheter related infection (CRI) is one of the main complications and the main causes of the catheter dysfunction [2]. It has serious influence to patients with hemodialysis, resulting in patients extending the hospitalization. Severe cases can cause deaths [3]. In order to reduce the occurrence of CRI and reduce the pain and economic burden of patients, the center applied the nursing quality index management to the management of CRI and achieved better results. The nursing quality index is the quantitative measurement of nursing quality, the tool for evaluating clinical care quality and care activities. Being quantitative, effective and objective is the basic characteristic of the nursing quality Index [4]. A domestic study has shown that the management of nursing quality index can improve the quality of hemodialysis. But on the CRI, only two quarters of data were compared. It was not statistically significant, however, the indicators fell significantly. The research time is short and there are some limitations [5].

General Information
All the cases were selected from hemodialysis patients using TCC in our center from 2013 to 2017. There were a total of 434 cases, aged from 6 to 93 years old.
The primary diseases were hypertensive nephropathy, diabetic nephropathy, chronic glomerulonephritis, cystic nephropathy, obstructive nephropathy and so on. The TCC detention period was from 2 months to 7 years. Catheterization was performed in 426 cases of the right internal jugular vein, 7 cases of the left internal jugular vein and 1 case of the right femoral vein. Hemodialysis was performed three times a week for 4 hours each time.

General Information of the 434 Patients
The basic information of the 434 patients was as follows: 217 males and 217 fe-     shower, and then re-fix the exposed part of the catheter in front of the chest wall.

Application of Quality of Nursing
Lectures on catheter maintenance were given to patients no less than twice a year, and special guidance was given by the nurse in charge of each dialysis.

Statistical Methods
SPSS 23.0 Software was used for statistical analysis of the data, and the counting data were expressed as rate. X 2 test was used, and P < 0.05 was considered as statistically significant.

Statistical Results
The number of TCC patients and indwelling catheter days increased year by year from 2013 to 2017, while the total infection rate decreased, as shown in Table 2.
As shown in Table 2

Discussion
TCC infection rate is one of the important indicators to measure the quality of hemodialysis, and the incidence of CRBSI has been reported to be on the rise, which is one of the common complications of maintenance hemodialysis patients [13]. There have been many clinical reports on the use of antimicrobial agents to seal tubes to prevent catheter-related infections, but it is easy to cause bacterial resistance, increase the risk of fungal infection, and increase the economic burden of patients [14] [15]. Non-antimicrobial agents have also been  used to seal catheters to control catheter-related bacteremia [16]. Since the implementation of quality index management of hemodialysis nursing in our dialysis center, root cause analysis has been conducted for TCC infection cases.
Sensitive antibiotics have been selected for sealing for more than 3 weeks for CRBSI patients according to etiological data, and the compatibility of antibiotics and heparin has been noted. It has been reported in the literature that the extending for the prophylaxis of antibiotic sealing tube to 1 -2 weeks can consolidate the curative effect, and prophylactic antibiotic sealing tube is not recommended [17].
Hypertensive nephropathy has occupied the first place in the primary disease in our center. Foreign studies have shown that hypertension is an independent risk factor for catheter infection, and the related reasons are as follows: hypertension is often associated with diabetes or atherosclerosis, increasing the risk of infection [18]; some antihypertensive drugs may help to increase the risk of infection [19]; hypertension affects capillaries in the skin and increases bacterial colonization of catheters [20]. Therefore, the joint management of hypertension and its complications has become a top priority. For patients with hypertension, the focus of nursing in dialysis is to monitor the changes of blood pressure on time and focus on the changes of patients' mental state; strengthen home blood pressure health education for patients; distribute home blood pressure monitoring record books; teach patients to measure blood pressure correctly, record accurately, take medicine on time, control blood pressure within the ideal range; delay the occurrence or development of complications, in order to reduce the incidence of catheterization infection. The patient was taught to observe the dressing in the catheterization place and the surrounding skin condition correctly at home, find the abnormal situation in time, and seek medical advice in time.
The prevention of catheter-related infections is not only a nursing problem, but also a joint effort of three parties. Studies have shown that in Nursing Quality Index Management, certain effects have been achieved in reducing the rate of catheter infection [21]. CRBSI is closely related to aseptic technique operation, disinfection isolation and hand hygiene of medical staff in hemodialysis room  [23]. Therefore, the center does not leave accompanying people on, off, and when opening or sealing the tube, and patients with catheters must wear disposable masks. Clearing the field between the two classes of patients, opening the window for ventilation and reducing the number and activity of indoor staff, reduces the concentration of pathogens in the air, and thus reduces the infection rate. The most difficult factor to control in these three aspects is the patient side, so we value proper in-home catheter nursing for patients. If patients do not know self-protection and self-management, catheter infection will be difficult to effectively control.
This study has some limitations. The number of single center cases is less.
Target management of indicators lacking universally accepted regional standards. This study shows that, TCC infection is difficult to avoid, implement quality index management, find out the root cause of infection, constantly optimize the catheter nursing process, train nurses and patients, the infection rate of TCC can be controlled. In this study, the types of pathogenic bacteria are similar to the results of domestic and foreign studies, but the detection rate of pathogenic bacteria is not high, this part needs to be further studied.