Each year in the United States, more than 8000 hemodialysis patients die after experiencing sepsis or other serious infectious complications. Of those patients, the highest percentage have infections related to a central venous catheter. Other vascular access sites can also become infected and cause sepsis.
Infections caused by multidrug-resistant organisms are far more common in the dialysis population than in the general population and have a high rate of mortality. Influenza is common and can be deadly in patients receiving dialysis. It has recently been estimated that more than 1000 dialysis patients in the United States die annually of influenza-like illnesses. Healthcare transmission of hepatitis C has occurred frequently among dialysis patients, and Clostridium difficile infections have increased in this population. Hospitalizations for infectious diseases now exceed hospitalization for cardiovascular disease in dialysis patients.
The Centers for Disease Control and Prevention (CDC) has recommended practices to prevent and monitor serious infectious disease in dialysis patients, using interventions that have been demonstrated to reduce infections and infectious complications. Despite these recommendations, sepsis and other complications of infection remain leading causes of morbidity and mortality in the dialysis population.
In response to this challenge, the CDC embarked on two major initiatives to raise awareness of the problem and the proven measures to reduce infection. The first initiative established The Making Dialysis Safer for Patients Coalition to bring organizations and individuals together and facilitate the implementation and adoption of tools to reduce infections. For the second initiative, the CDC provided 3 years of funding to the Americn Society of Nephrology (ASN) to establish Nephrologists Transforming Dialysis Safety (NTDS), a project with a goal to “Target Zero Infections” in dialysis patients. NTDS has reached more than half a million professionals through peer-reviewed and other publications, lectures, seminars, focus groups, and social media to get the word out: infections are the second leading cause of death and the leading cause of hospitalization—and most of these incidents are preventable.
To truly understand how work at the front lines of care is influencing patient safety, the CDC and the NTDS have integrated expertise from the field of human factors engineering. Human factors is a scientific discipline that examines human capabilities and limitations and applies that knowledge to the design of tools, technology, and processes to facilitate safe, efficient, and effective work. The focus of human factors is to integrate the scientific findings from psychology and engineering on human performance and to apply those findings to the design of daily work.
In the dialysis unit, staff members with diverse skill sets interact with one another and with complex patients with multiple comorbidities and with very complicated dialysis machines and other devices, ultimately to safely and efficiently deliver dialysis care. These complex interactions often present both barriers and facilitators to excellent team performance. System issues, such as time pressures, dialysis facility layout and space constraints, and dialysis policies and procedures, alongside variability in individual skill sets and cognition, result in a complex, challenging, and dynamic environment in which long-term care is provided. It can be challenging to bring these components together for best care. A hands-on assessment of how these elements—policies, procedures, machines, caregivers, and the patient—come together can enable an understanding of how and why best practice is sometimes not carried out despite best intentions. Human factors engineers, specialists in assessing these complex environments, can help use evidence about human performance to redesign dialysis facility procedures to make them more intuitive and easier to accomplish.
Over a 6-month interval, NTDS is visiting six diverse dialysis facilities with respect to geography, ownership, and adult and pediatric patient populations. At each site, a team consisting of human factors engineers from Virginia Tech and Carilion Clinic in Roanoke, VA; physicians and nurses from the NTDS; and physicians and infection preventionists from the CDC spends two and a half days observing daily operations. The team interviews leadership and staff at each unit, conducts staff focus groups, and uses human factors assessment tools to understand the culture of each facility and the opportunities to improve operations. In each facility, this team specifically examines four domains: techniques of central venous catheter procedures at the onset and completion of dialysis, hand hygiene, medication preparation and administration, and disinfection of the dialysis station after dialysis procedures.
The team collects information on the movement patterns of staff as they go about their routine and urgent care duties, and they speak with staff about the challenges of their work and the need to multitask. They collect approximately 1000 pieces of information at each facility, detailing staff movement, medication administration procedures, catheter accessing, chair and machine cleaning between shifts, and other staff and patient activities. The engineers will often consider questions like these: If everyone understands the need for hand hygiene before and after touching the access site, why is this policy breached in some instances? What factors, such as space restraints, location of sinks and hand gel dispensers, competing priorities, drying effects of the alcohol-based gel on the skin, local practice culture, or other factors, may contribute to observed breaches in best practice? What unique aspects of each dialysis unit facilitate their staff “doing the right thing” every time?
NTDS, CDC, and the human factors engineers are compiling an overview report for each of these dialysis facilities. These reports outline the “facilitators” and “barriers” to delivering best-practice care in each of the four domains examined. After all six visits are completed, the team will then compile a detailed analysis of all data, allowing additional analysis of practices, facilitators, and barriers, and identify ways to improve or redesign processes to reduce infections and other unintended complications.
The NTDS project, now in its third year, has taught us that three essential components can make care safer in dialysis facilities:
Knowledge of best practice. Every dialysis facility and all staff members need to understand what evidence-based best practice is, how to deliver it to their patients, and how to provide ongoing monitoring of these practices to sustain best care.
Effective and inspiring leadership. Nursing and medical leaders who can inspire their staff to better serve patients are the glue that holds a staff together and the vision of where a facility needs to go. By the example of their own practice, these leaders show how good communication, receptivity to feedback, examination of data from the patient cohort, and ability to respond effectively to clinical challenges all lead to happier staff and healthier patients.
Analysis of how facility policies and procedures translate to direct care. Human factors engineering provides the tools and the analytic techniques to understand the reality of a unit as it operates and to identify what potential system redesigns might provide improved outcomes for staff and patients alike. We might find some procedures that are most successful and can be shared among all dialysis units. We may find barriers that many facilities have in common, and potential solutions with widespread opportunity for improvement.
Our team is working together to target zero infections in dialysis units. These efforts may help change the current reality, whereby more hospital days are caused by infection than cardiovascular disease, or when one in ten dialysis patients dies of complications of infectious disease. We can get to zero preventable infections for our dialysis patients.