CMS and CDC target infections in dialysis

Reimbursements linked to surveillance

In the latest in a remarkable surge of infection prevention initiatives, the Centers for Medicare and Medicaid Services (CMS) is partnering with the Centers for Disease Control and Prevention to prevent healthcare associated infections in dialysis facilities.

The initiative includes a new CMS requirement for dialysis facilities to submit three months of 2012 infection and antibiotic use data to CDC's National Healthcare Safety Network (NHSN) in order to receive full Medicare payment. This is the first CMS/CDC data collaboration related to dialysis settings. However, the two agencies have been aligning patient safety efforts on multiple hospital quality measures.

In 2008 data, hemodialysis patients acquired some 37,000 central-line associated bloodstream infections (CLABSIs), the CDC reports. In addition, within the last decade there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings that include dialysis centers. The CDC is providing several new resources to dialysis facilities and patients to ensure smooth NHSN enrollment and improved quality care. These include a new dialysis safety web site including infection prevention recommendations, as well as step-by-step NHSN enrollment and training materials. (See editor's note, below.)

There are thousands of free standing dialysis centers in the U.S., owned primarily by the major corporate chains in the field. To a lesser degree, dialysis services are offered by or affiliated with hospitals. Hospital based IPs that fall in this category should prepare to begin reporting data, while the regulation for freestanding clinics would seem to provide a new opportunity for IP consultants.

"We have a dedicated dialysis unit so we are already looking at this new pay for reporting initiative as something we are clearly planning to comply with," says Russ Olmsted, MPH, CIC, an infection preventionist at St. Joseph Mercy Health System in Ann Arbor, MI. "We actually already have our dialysis unit enrolled in NHSN and they are reporting."

The substantial number of CLABSIs among hemodialysis patients is also a problem for hospitals, as the infections are a major cause of admissions and readmissions. A primary prevention measure is the avoidance of central lines in favor of arteriovenous fistulas for dialysis patients.

"If a [dialysis] patient develops a bloodstream infection, inevitably they are going to be admitted to a nearby hospital," Olmsted says. "The way I interpret this updated pay for reporting rule, if you didn't have a dedicated dialysis unit in your hospital it should have minimal impact in terms of needing to report this. But certainly if you have a dialysis facility within your scope of service then there is a pretty significant incentive to go ahead and begin reporting this data if you are not already."

Infection prevention measures

CDC recommendations to prevent infections in hemodialysis include the following:

Surveillance and feedback using NHSN: Conduct monthly surveillance for BSIs and other dialysis events and enter events into CDC's NHSN. Calculate facility rates and compare to rates in other facilities using NHSN. Actively share results with front-line clinical staff.

Hand hygiene surveillance: Perform monthly hand hygiene audits with feedback of results to clinical staff.

Catheter care/ vascular access observations: Perform quarterly audits of vascular access care and catheter accessing to ensure adherence to recommended procedures. This includes aseptic technique while connecting and disconnecting catheters and during dressing changes. Share results with front-line clinical staff.

Patient education/engagement: Provide standardized education to all patients on infection prevention topics including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit.

Staff education and competency: Provide regular training of staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing at least every 6-12 months and upon hire.

Catheter reduction: Incorporate efforts (e.g., through patient education, vascular access coordinator) to reduce catheters by identifying barriers to permanent vascular access placement and catheter removal.

Chlorhexidine for skin antisepsis: Use an alcohol-based chlorhexidine (>0.5%) solution as the first line agent for skin antisepsis, particularly for central line insertion and during dressing changes. Povidone-iodine, preferably with alcohol, or 70% alcohol are alternatives.

Catheter hub cleansing: Cleanse catheter hubs with an appropriate antiseptic after the cap is removed and before accessing.

Antimicrobial ointment or chlorhexidine-impregnated sponge dressing: Apply bacitracin/gramicidin/polymixin B ointment or povidone-iodine ointment to catheter exit sites during dressing change OR use a chlorhexidine-impregnated sponge dressing.

[Editor's note: The CMS rule is available at http://bit.ly/sdENgT

To enroll a dialysis facility in NHSN, visit http://1.usa.gov/s4rRBX

To view new CDC dialysis safety website, visit http://1.usa.gov/rCyyXe]