Infections are now neck and neck with cardiovascular complications as a primary reason for hospitalization and mortality among kidney patients receiving dialysis. To help counter this trend, ASN recently partnered with the US Centers for Disease Control and Prevention (CDC) to develop the Nephrologists Transforming Dialysis Safety (NTDS) Project to promote infection prevention in outpatient dialysis facilities.
The project is funded by a 3-year contract with the CDC that began July 15, 2016. ASN convened a town hall to inform and receive feedback about NTDS from the kidney community at Kidney Week in Chicago in November 2016.
“We must aim for reduction and eventually elimination of infections,” said Alan Kliger, MD, NTDS project committee chair. Kliger is affiliated with the Yale New Haven Health System.
Patients undergoing maintenance hemodialysis are at a high risk for infection because their treatment requires frequent use of catheters or insertion of needles to access the bloodstream. Dialysis patients often have changes to their immune systems, making them more prone to infections, and for some, frequent hospitalizations expose them to healthcare-associated infections (HAI).
Key goals of NTDS are to
promote better dissemination and implementation of existing CDC infection control guidelines in dialysis facilities,
provide better education and tools to clinicians and trainees to stop infections from developing,
establish antibiotic stewardship programs for dialysis facilities, and
develop stronger ties between nephrologists and HAI experts at the state and federal levels.
“The CDC has developed tools and special procedures, yet the incidence and mortality from infections has not changed,” Kliger said. “This [effort] needs to be very special work with dialysis centers, with the nephrologist as leader, chair of the team, not just relying on other healthcare workers such as nurses or technicians to report infections.”
Strategies to engage nephrologists in infection control efforts as part of NTDS will include collaboration with dialysis companies, development of continuing medical education (CME) programs that emphasize infection prevention, and work with academic training programs to educate and train nephrology fellows.
The project includes nephrologist representatives from two of the largest dialysis companies (LDOs), as well as adult and pediatric nephrologists from small dialysis companies (SDOs), and academia, infectious disease specialists, hepatologists, state HAI program representatives, dialysis nurses, dialysis technicians, CDC, and ASN Council.
Kliger noted that Methicillin-resistant Staphylococcus aureus (MRSA) infections are 100 times more likely, and hepatitis C infections, 5 times more likely, in maintenance dialysis patients than in the general US population. Also common in dialysis units are infections from vancomycin-resistant enterococci and other multidrug-resistant organisms.
Four workgroups will provide clinical expertise and direction to the NTDS Project: Quality Assessment, Improvement, and Education (QAIE); Training Programs; State and Federal Health-Acquired Infections Programs; and Current and Emerging Threats.
QAIE chair Leslie Wong, MD, MBA, FASN, said the current state of infection control in dialysis facilities is untenable. Wong is Vice Chairman of Nephrology and Director of the End-Stage Renal Disease Program at the Cleveland Clinic.
“Infections consume our energy, resources, and most importantly the lives of our patients,” Wong said. “We know how to prevent infections, but we won’t, can’t, or don’t do it. It’s just not acceptable. I do not want to practice in this environment for the rest of my career.”
Wong noted that many facilities in the US are cited repeatedly for infection-related events. “When you mention compliance in the dialysis facility, it immediately evinces negative remarks,” he said. To change this culture, “we need to start with a needs analysis, root causes, leadership, organizational behavior, and patient engagement.”
The QAIE Workgroup is planning a series of infection prevention webinars as well as infection prevention symposia at ASN Kidney Week meetings in 2017 and 2018. The workgroup also hopes to develop educational tools and to dialogue with national dialysis organizations about medical director leadership training and preparedness, the Virtual Mentor Dialysis Curriculum, and support from CDC’s National Healthcare Safety Network.
Training Program Workgroup chair Sharon Adler, MD, said one goal of the Training Program Workgroup is to develop educational tools with similar content for use by both fellows and practicing nephrologists. Adler is chair of the education committee at the Harbor-UCLA Medical Center Division of Nephrology.
The workgroup also aims to secure accreditation for infection control training and to provide an update to the American Board of Internal Medicine nephrology blueprint regarding inclusion of knowledge about infection prevention in dialysis units on the Nephrology initial certification and maintenance of certification exams. Also under consideration is a proposed emphasis on education to reduce the use of catheters, called “Target Zero Catheters.”
“We would like to examine the barriers in going from catheters to fistulas,” Adler said.
Kidney care professionals need to familiarize themselves with state and federal programs for healthcare-associated infections (HAI), said Anitha Vijayan, MD, FASN, of the Division of Nephrology at Washington University in St. Louis. Vijayan co-chairs the NTDS Workgroup on State and Federal HAI Programs with Eugene Livar, MD, Healthcare-Associated Infections Program Manager, Arizona Department of Health Services.
“We must engage nephrologists, not just dialysis nurses, to report infections,” Vijayan said. “Not a lot of state HAI programs include dialysis units.”
Vijayan said the workgroup hopes to develop a directory of state-level HAI program contacts and educate state and federal HAI programs about NTDS.
T. Alp Ikizler, MD, of the Vanderbilt University School of Medicine Division of Nephrology and Hypertension, co-chairs the NTDS Current and Emerging Threats Workgroup with John Boyce, MD, infectious disease specialist, Middletown, CT. One of the workgroup’s first tasks will be to perform a “gap analysis” of dialysis units’ response to Ebola as a case study for emerging threats.
“We will communicate with SDOs and LDOs to know what they are doing [regarding emerging threats],” Ikizler said.
Other areas of focus include an increased emphasis on basic infection control protocols such as hand hygiene, dissemination of existing guidelines for hepatitis B and C, and identification of infection control issues that lack clear guidance.
“What about isolating patients with infections?” Kliger asked. “The Centers for Medicare & Medicaid Services is clear on hepatitis B isolation, but not for other multidrug-resistant organisms that are transmissible.”
“We definitely need more input and research on these areas to determine what is effective and feasible,” said the CDC’s Priti Patel, MD, MPH, of the CDC’s Division of Healthcare Quality Promotion, and CDC liaison for the NTDS project.
Dialysis units’ response to multidrug-resistant organisms and level of antibiotic stewardship will also be under the purview of the Current and Emerging Threats Workgroup.“We have programs [for antimicrobial stewardship] in hospitals but not in [freestanding] dialysis units,” said Kliger. “We must think globally to prevent multidrug-resistant organisms from spreading. We also need to think about the effects of antibiotics on the patient’s gut microbiome.”
NTDS will engage nephrologists, ancillary healthcare providers, health departments, and other stakeholders to implement best practices that will safeguard dialysis patients against infections. “We need to look at what we know is best and change the culture to use these practices,” Kliger said.
“It’s not an issue of having the right tools out there,” said QAIE Workgroup chair Wong. “It’s about the transformation of health care in general. We grew up in medicine thinking that we just gave orders to others to get the best outcomes for our patients. We have to realize that health care is a system and that we have to work within that system. Do we inspire or do we deter these practices from happening?”
