OBJECTIVES: The study aims to assess the effectiveness of a quality improvement intervention in reducing hospital referrals due to tunneled hemodialysis catheter (THC) dysfunction by empowering community dialysis nurses to administer lytic dwell. This procedure is conventionally performed in acute hospitals.

METHODS: Multifaceted quality improvement interventions consisting of education, audit, feedback, and peer support were implemented in 40 community dialysis centres in Singapore since 1 Dec 2022. The interventions involved empowering community dialysis nurses to perform: 1. Catheter flow restoration with Lytic dwEll at community diAlysis centRe (CLEAR); 2. Optimizing Blood flow, locking solution, Anticoagulant and Standardising Technique (BLAST). The impact on hospital admission rates, infection rates, and patient feedback was studied. A decision tree was constructed to compare the treatment of malfunction THC in community and acute hospitals.

RESULTS: As of 31 March 2024, 100 community dialysis nurses had been trained. During the study period, 219 cases of THC dysfunction were reported in participating community dialysis centres. Community dialysis nurses performed a lytic dwell in 143 cases that fulfilled the inclusion and exclusion criteria while the remaining patients were referred to the hospital for treatment. THC flow restoration was successfully performed in 125 (87.5%) cases. There were no reported catheter-related infections in patients who underwent treatment, and the treatment was well received by patients. The median number of patients referred to hospitals for THC dysfunction reduced from 48 cases per month at baseline to 31.5 cases per month. Decision tree analysis demonstrated estimated that total cost for treatment of THC dysfunction was S$ 75,252 in the community, and S$ 318,587 in hospital.

CONCLUSIONS: A qualitive improvement collaborative approach to transit away from predominant inpatient care is effective in reducing hospital admissions due THC dysfunction and is essential to reduce the burden on healthcare system.