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    Absence of readily available hand sanitizer and remote location of sink could be a barrier to infection control in this dialysis unit

Human Factors Engineering Helps Identify Threats to Infection Control in Dialysis

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Central venous catheter care takes a great deal of dexterity, so much so that some clinicians at Westchester Medical Center’s dialysis clinic say it “takes three hands,” said Renee Garrick, MD, a nephrologist and executive medical director at the center. Yet interruptions during this critical procedure are common—raising the risk of an infection control breach.

Garrick spoke during a webinar hosted by Nephrologists Transforming Dialysis Safety (NTDS), ASN’s partnership with the Centers for Disease Control and Prevention (CDC).

Understanding how such disruptions in critical procedures affect infection control in dialysis settings is one important part of NTDS, which is working with the CDC to target a goal of zero dialysis-related infections. To help achieve this goal, NTDS engaged human factors engineering researchers to assess infection control practices at six outpatient dialysis facilities across the United States to find ways to improve them.

“We can’t necessarily change the human condition, but what we can do is change the conditions in which humans work,” said Sarah Henrickson Parker, PhD, senior director of the Center for Simulation, Research, and Patient Safety at the Carilion Clinic in Roanoke, Virginia, which is conducting the research. The clinic is part of the Virginia Tech Carilion School of Medicine.

“Human factors and system safety [engineering] is really focused on trying to understand all those aspects of the system that are influencing how people do their job and take that human capability and limitation into account to actually redesign work so that it is safer,” Parker said.

Systems design

Parker and her team were tasked with assessing four key infection control practices at the dialysis facilities, including hand hygiene, injection safety, environmental disinfection, and central venous catheter care. To do this, they observed nearly 8000 infection control tasks during 484 patient encounters over 157.5 hours at the facilities. They also discussed the procedures and systems involved with both frontline staff and leadership from each facility.

In the process, they identified several key challenges including patient factors like access and clotting delays; environmental factors like noise, lighting, machine design, and access to hand hygiene; the complexity of center policies and procedures; and things like interruptions during care, alarms, multitasking, and difficulties delineating clean versus dirty. The researchers’ sketches of staff movements during workflows often looked like a “bowl of spaghetti,” revealing the importance of facility layout, noted Garrick, who chairs the NTDS Human Factors Workgroup.

“It’s easy to see that the environment in which our staff work influences the care that we provide,” Garrick said. “All of these environmental interactions can affect how easily our staff can follow infection control steps no matter how good our policy and no matter how well trained and well intentioned our staff might be.”

Interruptions during care were also identified as a major concern. About 1 in 5 patient encounters were interrupted, noted Garrick. Only 18% of these interruptions were clinically relevant, and many occurred during critical procedures. For example, 62% of interruptions occurred during fistula or graft care and 18% occurred during central venous catheter care.

One common type of interruption was alarms. Alarms went off during about half of the patient encounters even though 70% of them were not clinically actionable. Garrick noted that staff often have to stop what they are doing and touch the machines to turn off the alarms, which “dramatically” increased the need for hand hygiene and introduced opportunities for breaches in hand hygiene. The noise from alarms and other sounds in the unit can also affect both patients and staff.

“Noise levels can influence the perception of the staff and the perception of our patients regarding the kind of care that they’re receiving and the quality of that care,” Garrick said.

Task-stacking or multi-tasking was another concern identified by the researchers. Garrick noted that such multitasking may feel essential in a busy dialysis center, but it may increase the likelihood of interruptions and errors.

“We’re switching back and forth quickly from one task to another and when we do it, we’re actually using the same cognitive function [to accomplish multiple tasks],” Garrick said. “The reality is that that can actually kind of overwhelm human capabilities.”

Other challenges identified were complex procedures and policies regarding items designated as “clean” or “dirty.” Often, items may switch from clean to dirty during the course of a patient’s care, Parker noted.


Absence of readily available hand sanitizer and remote location of sink could be a barrier to infection control in this dialysis unit

Citation: Kidney News 11, 10/11

Facilitating better care

The researchers also identified factors that can support infection control practices, including interoperability of machines and computer systems, teamwork and staffing support, and leadership.

“The facilities that worked well together tended to support each other in times of stress where patients needed extra help,” Garrick said.

The NTDS program doesn’t yet have any new recommendations on how to improve infection control in dialysis units based on the human factors data, said Alan Kliger, MD, nephrologist and clinical professor at Yale School of Medicine in New Haven, Connecticut. But the preliminary insights shared during the webinar, which will be freely available on the NTDS website, may help dialysis centers better implement existing CDC infection control guidelines.

“We hope that by presenting these initial findings we’ve provoked some thoughts about what we can do in our clinical practice to alleviate some of the problems that we’ve addressed,” he said. For example, he suggested that dialysis centers may want to implement a policy that bars nonessential interruptions during critical procedures, an approach similar to what airlines use to prevent nonessential pilot interruptions during takeoff.

Kliger also emphasized the importance of engaging staff and soliciting their ideas about configuring workflows and tasks to improve the efficiency and safety of care. He highlighted strategies such as creating a staff input bulletin board or encouraging group staff interactions.

Often, small changes in workflows and practices can make a big difference in how well highly trained staff are able to do their jobs, Parker said. Human systems engineering analyses can help identify those changes.

“By identifying these systems issues or these systems contributors, we can improve care for patients as well as make life easier for providers, let them do what they are good at, what they are trained to do.”