Bloodstream infections and preventable dialysis deaths

On June 28, Fresenius Medical Care prepared to reopen its Bessemer Kidney Center, a 36-station clinic located outside of Birmingham that had been the site of two patient deaths and the hospitalization of three patients in early May. After an extended review by the state Department of Health and the Centers for Disease Control, investigators said they were unable to find a common thread to link the cases, other than all the incidences were infection-related.

Fresenius spokesman Kent Jarrell said the company planned to disinfect the entire clinic before reopening. “He also said Fresenius has "conducted a retraining of staff on best practices in infection control." He said Fresenius "will correct the issues at the clinic raised by state and federal health authorities and will continue to work with them to assure operations at the clinic meet all regulations and requirements."

Infection kills

Bloodstream infections are the second highest cause of death among dialysis patients in the United States, behind sudden death (usually related to cardiovascular disease). But in many cases the root cause of infections is “man made.” The risk escalates when staff do not follow basic universal precautions: washing their hands, changing gloves, and wiping down and disinfecting chairs and dialysis equipment properly.

Using infection prevention guidelines from the CDC can lead to a 32% decrease in overall bloodstream infections, according to the results from the CDC's Dialysis Bloodstream Infection Prevention Collaborative. The interventions were simple: using chlorhexidine (an antiseptic for the skin) for catheter exit-site care; staff training and competency assessments focused on catheter care and aseptic technique; hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. "Dialysis patients often have multiple health concerns, and the last thing they need is a bloodstream infection from dialysis,” said CDC Director Tom Frieden, MD, MPH. “These infections are preventable.”

Deeper problems in Alabama

Fresenius’ plan to disinfect the clinic and do training is a good step. But the dialysis provider needs to look at the history at its clinics in the Birmingham area and consider bigger steps if it wants to correct deficiencies cited by the state. A 55-page report completed by a Medicare surveyor, based on a May 28 visit to the Bessemer clinic during the investigation into the patient incidences, suggests deep operational issues, including understaffing, inexperienced trainers, poor record keeping — and a medical director who said he knew nothing about it. Some examples include:

The clinic staff did a poor job of recording vital signs, machine settings, and clinical measurements during treatments.
Patients assigned to four-hour treatments were let off early on different sessions—some getting as little as 2 hours and 17 minutes for the treatment. “There was no documentation by the RN of the rationale for early termination and the consequences of not receiving the entire prescribed treatment as directed per the facility policy,” the report said.
Preceptors at the clinic, which must have at least one year of experience, including six months with Fresenius, were conducting training with as little as five months on the job. And although preceptors are supposed to be screened and selected by management, fellow staffers were making such decisions.

“Based on interviews and review of staffing schedules, it was determined the governing body failed to assure that the dialysis clinic was properly staffed with a sufficient number of staff with dialysis experience to provide safe patient care,” the report concluded. When a staff RN was asked if she ever had to work a shift short-staffed, she said. "Yes. Consistently short since I've been here. New staff and inexperienced.” The clinic’s education coordinator for the Birmingham area was asked how many dialysis patients a patient care technician provides care for and responded. "I would say 4 to 1 (4 patients to one PCT). I've heard of 5 to 1 or 6 to 1 and that hurts my heart to hear. Even with 13 years of ESRD experience if I were told I had 6 patients to care for I would cringe inside."

The best dialysis…

We know that there are many clinics across the country that provide good dialysis care, including Fresenius units. But the best course on infection control is useless in an environment where staff may be forced to cut corners because of thin ranks and leadership that is in the dark. Fixing the bigger problem will restore patient confidence. -by Mark Neumann