Improving infection control in a dialysis setting

One of the most critical issues challenging providers of dialysis care is that of preventing infections. Because hemodialysis requires repeated exposure of the bloodstream for venous access, clinicians must be diligent in keeping bacteria at bay. This is particularly important given that patients with kidney disease have lowered immune responses and are therefore more susceptible to infections.

Bloodstream infections (BSIs) are a leading cause of hospitalization in dialysis patients and one of the leading causes of death. According to the Centers for Disease Control and Prevention (CDC), an estimated 37,000 BSIs occur each year among dialysis patients with central lines, and as many as one in four of these patients may die as a result of their infection.¹ In addition, the estimated cost per hospitalization from a bloodstream infection among this population is $23,000.² Thus, preventing BSIs fulfills the triple aim, which is to improve population health, enhance patient experience of care, and reduce health care costs.

DaVita Kidney Care has responded to this challenge with ongoing application of CDC recommendations, including core interventions, protocols, audit tools, checklists, and ongoing clinician education.³ In addition, the company has invested in building a sustainable infrastructure to give support to infection prevention and control. This infrastructure, part of the company’s WipeOut Infection program, includes employing two full-time epidemiologists and a dedicated team of infection preventionists.

WipeOut also addresses vaccination for pneumococcal pneumonia and influenza; surveillance and vaccination for Hepatitis B; and surveillance for Hepatitis C.

The program has helped physicians to lower central venous catheter-related BSI rates by nearly 30% in three years, and consistently vaccinating more than 90% of patients for both pneumococcal pneumonia and seasonal influenza. That success is linked to DaVita’s CathAway program, which has achieved a 45% reduction in the number of patients who have been dialyzing at DaVita for 90 days or more with a catheter in place.

Surveillance, prevention, response

The success of an infection control program, as with any patient safety activity, depends on having access to robust and trustworthy data. Surveillance in real time is the first step, and the cornerstone of our infection prevention and control program. The objective of data surveillance is to understand the scope of the problem, identify emerging patterns, assist teams in crafting an appropriate response, and to apply the first principles of antibiotic stewardship.

The key to a good surveillance system for BSI is completeness of data capture. Our goal is to identify all IV antibiotic starts and to obtain blood culture results for > 90% of those IV antibiotic starts that are associated with signs of potential systemic infection (e.g. fever, rigors, or hypotension). Whenever a positive blood culture is identified, the results are appropriately reported to the CDC’s National Healthcare Safety Network. Facility performance on completeness of blood culture capture in suspected BSI is measured and reported as part of DaVita’s clinical quality index.

Evaluating BSI rate in the context of the completeness of blood culture results for episodes of suspected BSI is an important contribution to infection surveillance and is worthy of consideration for broader implementation in the clinical dialysis community.

Prevention

Another aspect of WipeOut is prevention. The etiology of most BSI episodes in patients with CVCs is thought to involve hub contamination, followed by hub colonization, which is followed in turn by intraluminal colonization and manifested ultimately as bacteremia. Thus, efforts to prevent CVC-related BSI focus necessarily on reducing the risk of contamination or colonization of the catheter hub. In DaVita facilities, all supplies needed for putting patients on, caring for dialysis exit sites, and taking patients off dialysis are bundled in respective packages to maximize process control, minimize user interruption that may lead to accidental contamination, and provide technology that physicians can order, including needle-free connectors and alcohol-impregnated caps, to lower the risk of hub contamination or colonization.

The company also views proper immunization as an essential part of kidney care. Last year, patients and staff received training on best practices with a focus on awareness and attention to detail. For example, staff members are taught to be mindful of the seasonality of infections and work preventatively to protect patients from the increased threat of BSIs in the summer and respiratory infections in the winter.

Response

The final cornerstone of the program is response. The tools, reporting resources, and support expertise built to provide surveillance and prevention also allow timely and informed response to each serious infection event. Encouraging that antibiotic starts for suspected BSI be accompanied by a blood culture has major benefits for assessing the appropriateness of the antibiotic choice for ongoing therapy if an organism has been identified and sensitivities determined (looking for the so-called bug-drug mismatch), or, alternatively, for considering discontinuation of antibiotics if no organism has been identified.

Summary

Infection control is a responsibility that belongs to everyone, from the technicians and nurses and physicians who interact most closely with patients to facility administrators and to state and federal partners. We all have a role in infection detection, prevention and response—a role that requires consistency and dedication. - by Levi Njord and David Van Wyck, MD

References

Tracking infections in outpatient dialysis facilities. Centers for Disease Control and Prevention. Accessed Feb. 20, 2017. https://www.cdc.gov/nhsn/dialysis/.

Following CDC protocols cuts dialysis bloodstream infections in half. Centers for Disease Control and Prevention. May 13, 2013. Accessed Feb. 17, 2017. https://www.cdc.gov/media/releases/2013/p0513-dialysis-infections.html.

Dialysis safety. Centers for Disease Control and Prevention. Sept. 21, 2016. Accessed Feb. 28, 2017. https://www.cdc.gov/dialysis/index.html.