NTDS: Educational Initiatives in Pursuit of Transformational Change

  • 1 Alan S. Kliger, MD, Chair of Nephrologists Transforming Dialysis Safety (NTDS), and Bonnie Freshly, MEd, CMP, ASN Excellence in Patient Care Project Specialist on behalf of the NTDS Project Committee, report no conflicts of interest..
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Since its creation in 2016, Nephrologists Transforming Dialysis Safety (NTDS) has worked with the Centers for Disease Control and Prevention (CDC) in its mission to “enhance the quality of life for people with kidney failure by engaging nephrologists as team leaders in transformational change that continuously improves the safety of life-sustaining dialysis.” The first goal of NTDS was to target zero infections in dialysis patients. NTDS created a series of Targeting Zero infection-prevention webinars and online educational resources for the kidney community, which provide practical, evidence-based guidance for providers and can be accessed on demand at viewers' convenience. Since 2017, NTDS has produced 7 webinars with over 12,000 views. NTDS continued this series on September 28, 2021, with “Management of [Clostridioides difficile] C. diff[infection] (CDI) in Outpatient Hemodialysis Settings.” This webinar describes risk factors for CDI and transmission dynamics of C. diff and utilizes case scenarios to show common pitfalls and best practices to stop C. diff transmission. The webinar will soon be available on demand on the ASN Learning Center.

Fall 2021 brought the release of two online, case-based learning modules: one on Antibiotic Prescribing and the other on Optimizing Hemodialysis Vascular Access Planning. These resources, which offer continuing education (CE) for both physicians and nurses, incorporate case scenarios, video instruction, and links to community resources. They also feature knowledge checks that allow the learner to consider treatment decisions based on key points in the case scenarios.

  • The “Antibiotic Prescribing” case-based module demonstrates key concepts in antibiotic treatment, including a standard process for blood culture collection, the use of the SBAR (situation, background, assessment, and recommendation/request) for improving communication, application of antibiotic stewardship principles to treat methicillin-susceptible Staphylococcus aureus (MSSA) infections, infection source determination, the importance of repeat blood cultures, and optimization of care transitions from the hospital back to an outpatient dialysis facility.

  • “Optimizing Hemodialysis Vascular Access Planning” similarly uses a case-based format to present core concepts to improve safety and mitigate infections by reducing catheters. Chapters address central venous catheter (CVC) reduction strategies, planning for hemodialysis (HD) access, patient-centered selection of the “right” vascular access, arteriovenous (AV) fistula cannulation using the buttonhole technique, the role of endovascular AV fistulas, and future innovations in HD vascular access.

Coming soon to the ASN Learning Center is “The Patient Voice,” a case-based infection-prevention and patient safety training tool, designed by dialysis patients for patients. In this moving session, patient advocates describe their experience with multiple treatment modalities to feature key recommendations in improving patient and provider communication. Understanding these experiences is key to creating an environment in which patients feel safe to ask questions and raise concerns with their providers. The patient advocates strongly underline that patients are the experts on how chronic kidney disease (CKD) affects them and remind us that there is more to their lives than dialysis or transplantation. These patient-teachers underscore that when the patient and provider each acknowledge one another as human beings, richer and deeper communication improves care.

In 2020, NTDS examined the feasibility of using an electronic catheter care audit tool to reduce catheter-related infections. A pilot study conducted in seven outpatient HD facilities adapted CDC's catheter care audit tools (catheter connection, catheter disconnection, and exit-site care) in an interactive electronic audit tool. Feedback from participating staff was favorable, and many felt the use of the electronic audit tools facilitated patient and staff engagement. In the next phase, the Vascular Access Workgroup will modify the electronic audit tools to engage patients to act as observers of catheter care and hand hygiene. The electronic tool will include educational materials to teach patients about the procedure before they act as observers. The updated audit tools will be trialed in several pilot facilities in the spring of 2022.

Finally, NTDS partnered with CDC to examine the hypothesis that principles of human factors engineering can be used to improve processes of care in dialysis facilities. Experts in human factors engineering from Carilion Clinic at Virginia Tech worked with NTDS and CDC to observe how staffs work in complex outpatient dialysis environments to identify barriers and facilitators to infection prevention and to propose solutions that make infection prevention easier and more intuitive. After completing human factors assessments at six dialysis facilities around the country, the engineers described their findings related to infection prevention in a final report. The human factors team agreed, “The current process of dialysis is complex, sometimes surpassing human capabilities and augmenting human limitations.” Details of the findings from the first six human factors assessments will be submitted for publication later in 2021. In 2020, the COVID-19 pandemic caused postponement of additional site visits. The workgroup is eager to restart this work when it is safe, with two additional in-center assessments and four assessments of home dialysis facilities, including assessments of 12 patients in their home.

With these and future initiatives, NTDS will continue its pursuit of transformative care that improves the lives of patients living with kidney diseases. Additional information about all NTDS projects can be found on the ASN website (https://www.asn-online.org/ntds/).