AHRQ kit to prevent dialysis infections
Infection prevention in end stage renal diseases
About one in six U.S. dialysis patients die annually from an infection and 12% of dialysis patients are hospitalized due to septicemia, according to the Agency for Healthcare Research and Quality (AHRQ).
While those estimates are based on 2007 data, the statistics served as a call to action for AHRQ, which is funding a major new infection prevention project for end-stage renal disease (ESRD) facilities. Called the National Opportunity To Improve Infection Control in ESRD (NOTICE), the project seeks to reduce vascular access infections, enhance infection control best practices, and improve the safety culture in dialysis facilities.
"We funded this project to develop practical, research-based tools that end-stage renal disease facilities can use to make care safer for patients who get dialysis," says Darryl T. Gray, MD, ScD, medical officer for the Center for Quality Improvement and Patient Safety at AHRQ.
The primary pathogens infecting dialysis patients include susceptible and drug resistant strains of Staph aureus, E. coli, Pseudomonas and Klebsiella.
"Dialysis patients are exposed to these pathogens more frequently than other patients because the hemodialysis process requires accessing a patient’s bloodstream, and these patients are often hospitalized for various illnesses," he says. "These factors, along with the fact that dialysis patients’ immune systems don’t work as well as they should, make it easier for common pathogens to make dialysis patients sick."
There also have been outbreaks of hepatitis C virus in dialysis facilities, but HCV is not a major emphasis of the project.
"Screening patients for hepatitis C and tracking the transmission [of HCV] are not routinely done in dialysis facilities, and they are not part of the AHRQ-funded project," Gray says. "However, many of the infection prevention techniques used in the AHRQ project, such as proper disinfecting of equipment between patient treatments, will help prevent transmission of hepatitis C."
The project’s recently completed first phase included baseline analysis and development of a 24-page toolkit, which includes infection control worksheets and checklist designed for dialysis facilities. (Available at: http://1.usa.gov/TmUt85) The second phase will includes testing the tools in end-stage renal disease facilities and performing additional analyses, Gray says.
"We expect the second phase to be complete by the end of this year," he adds.
Primary tool: Checklists
Each checklist or infection control worksheet describes methods to prevent infections associated with vascular access. They identify 73 distinct items of appropriate practice. For example, the 9-step checklist for access of AV fistula sites goes from hand hygiene (HH), supply assembly, all the way to inserting cannulation needles, removing gloves and HH again.
"The checklists cover steps to prevent infection during initiation of dialysis, medication preparation, and during the administration and termination of dialysis," Gray explains. "They also cover disinfecting the treatment station and making sure that supplies are not contaminated."
AHRQ also offers a change package to help facilities implement and sustain these infection prevention methods.
The project’s analysis is underway and near completion, Gray notes.
"The primary infection measure is vascular access-related infections (VAIs) per 100 hemodialysis patient months," he says.
The project includes collecting primary source data on local access site infections, bloodstream-associated infections, and positive blood cultures from the subset of study facilities that report infection data to the National Health Safety Network. Medicare claims also are included in the source data.
ESRD facilities are performing their own audits of adherence to the checklist items. They were evaluated during a post-orientation period from October 2011 to January 2012.
"Infection control evaluators monitored adherence to infection control procedures described in the checklists among staff from 34 ESRD facilities," Gray says.
Project participants are using a toolkit that contains educational materials, including modules on improving safety culture that adapt AHRQ’s Comprehensive Unit-based Safety Program framework for use in ESRD facilities. They also are using a modified version of the AHRQ Hospital Survey on Patient Safety Culture to measure safety culture changes that are occurring due to the use of the toolkit, he adds.
The five-page survey asks about staff support and workload issues, patient safety, supervisors, communications, frequency of events, and the facility’s work climate. It also asks for a letter grade for how well the work area is doing on patient safety.
Most materials are available online at the AHRQ website. The project is expected to end in the fall of 2014.