‘Target zero’: Expert discusses how to reduce dialysis-related infections
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At the virtual Innovations in Dialysis: Expediting Advances Symposium, the chair of the Nephrologists Transforming Dialysis Safety program discussed measures the group has taken to reduce infections for patients on dialysis.
Alan Kliger, MD, clinical professor of medicine at Yale University, told the audience that the ultimate goal of the program is to eliminate infections in the dialysis unit or, as he termed the goal, “target zero.”
“The genesis of this idea came 4 years ago after the CDC recognized that 10% of all dialysis patients die as a result of infections, most of which are treatable,” he said.
According to Kliger, the CDC subsequently published data with the intention of reducing the number of dialysis-related infections. However, no significant reductions were observed. This led the CDC to give the American Society of Nephrology a contract to develop “a robust program” that might have a more substantial impact.
Kliger said the program has three main components, broadly categorized as education, human factors assessment and leadership.
One part of the education component, Kliger said, is collecting available evidence and sharing that information with nephrologists, nephrology nurses and dialysis technicians. The group has created a blood culture standard model and a hepatitis C monitoring and treatment algorithm. Dialysis staff members are trained on obtaining blood cultures and given specific evidence-based advice on when to test for hepatitis C, as well as how to think about managing patients who become infected. In addition, a set of recommendations has been developed for preventing the transmission of C. difficile infections.
“Hemodialysis patients are two to two and a half times more likely to develop C difficile infections, with a mortality rate that is twice as high as the general population,” Kliger said, emphasizing the need for such recommendations. “So our recommendations included infection prevention, hand hygiene, the appropriate personal protective equipment, preferred treatment placement of patients, bathroom facility precautions and how long patients need to stay on these isolating measures after they no longer are positive for the infection.”
Kliger also posited that checklists have been shown to be effective tools to ensure tasks are done correctly, which is especially important in a busy dialysis unit. To determine if a checklist developed by the CDC was feasible for use, as well as to see if it could lead to meaningful change, the group launched a pilot at six dialysis facilities across the United States. Kliger noted that COVID-19 has halted progress on the trial, but the group will resume study once dialysis facilities can again be visited safely.
Lastly in education, the group has hosted webinars and constructed an online learning module to provide an interactive format for learning the best ways to manage infections in the outpatient dialysis facility.
The second component Kliger addressed was human factors assessment, which he defined as a “scientific discipline that examines how capabilities and limitations of humans occur and then applies the knowledge of those abilities and limitations to the design of tools, technologies and processes.” In the last 18 months, he said the group has visited eight dialysis facilities, during which a team of human factors engineers joined nephrologists, nephrology nurses and CDC infection specialists to observe operations at the clinics. Specific suggestions were then given for improving operations in the areas of central venous catheters, hand hygiene, medication preparation and disinfection of the dialysis station.
Regarding the third component, leadership, Kliger said, “We know that without effective leadership, at the level of both the nephrologist and the nephrology nurse, that we cannot ever get to goal of zero infections.”
To this end, the group has started a “kidney leadership academy” that is being piloted at Northwest Kidney Centers. Engaging both medical directors and head nurses in each dialysis unit, Kliger and colleagues have been examining individual leadership styles to develop strategies that improve how staff members work together in teams and provide advice on conflict management.
“We do have traction,” Kliger concluded. “We can target zero infections with this multidimensional approach.”
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Kliger A. Nephrologists transforming dialysis safety: Target zero infections in dialysis patients. Presented at: Innovations in Dialysis: Expediting Advances Symposium; Aug. 31-Sept. 1, 2020 (virtual meeting).
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