Starting a Surveillance Program in the Dialysis Clinic
There are more than 300,000 hemodialyis patients in the United States, and mortality is high: each year about 21 percent die due to complications of treatment or of an underlying illness.1
Infections are the second leading cause of mortality. Each year, about 10 percent of dialysis patients are hospitalized due to infections,1 which are frequently severe and require the use of strong antibiotics. This frequent antibiotic exposure makes hemodialysis patients especially vulnerable to resistant bacterial infections. These factors make it essential for a dialysis clinic to monitor infectious diseases among patients in order to improve their care.
Why Conduct Surveillance?
Surveillance is the first step of any prevention program. Surveillance data can help identify clusters of illness so that appropriate prevention activities can be developed and implemented based on local needs. Surveillance data are also used to evaluate the effectiveness of prevention activities. For example, a campaign to improve the hand hygiene practices of healthcare workers is expected to result in a reduction of infections. Surveillance data can help determine whether the resulting decline is mostly because of an overall improvement or if only a few facilities are responsible for the change.
Monitoring antimicrobial resistance should be part of dialysis surveillance because dialysis patients are at a greater risk of acquiring infections with organisms that are resistant to antimicrobials. Surveillance allows for analysis of the most frequent organisms, their antimicrobial susceptibility patterns and trends in resistance over time. Antimicrobial use—especially the use of vancomycin—should be monitored, and should be reported back to healthcare providers. There are alternatives to vancomycin, such as cefazolin, that might be appropriate to treat infections in this population.2 Surveillance data could help providers evaluate antimicrobial use and begin special studies to assess whether certain antimicrobial use is inappropriate.
Good records on hepatitis B and C testing as well as the hepatitis B vaccination status for healthcare workers and patients are important to prevent transmission of these bloodborne pathogens. A survey conducted annually by the Center for Medicare & Medicaid Services and the Centers for Disease Control and Prevention found that, through 2002, vaccination for hepatitis B increased among healthcare workers to 90 percent.3 Vaccination coverage among dialysis patients, however, peaked at 55 percent to 60 percent. Surveillance records allow facilities to compare their vaccination coverage with other facilities and provide motivation for improvement.
The Most Frequent Infections
Chronic hemodialysis patients are especially vulnerable to infections because they are immunosuppressed and have frequent punctures to their vascular access site. Dialysis patients face the potential for infections on a daily basis.
The sources of bacterial infections can be exogenous, that is, from dialysis fluids or equipment, or endogenous, that is, by invasion of organisms that are normal residents of the patient’s skin.2 Water from municipal sources is not sterile, and after disinfection with chlorine and chloramines, low levels of bacteria remain. Outbreaks of infections where water has been the source are most frequently gram-negative bacteria (e.g., Acinetobacter, Pseudomonas, Serratia); however, gram-positive organisms that contaminate water can also cause infection (e.g., Mycobacteria).
Organisms residing on the patients’ skin can cause infections of the vascular access site, which provides physical entry to the blood system. Vascular access infections are among the most serious complications of chronic hemodialysis. Staphylococcus aureus and S. epidermidis are the most frequent organisms associated with vascular access infections. Both of these are normal residents of the skin, and approximately 31 percent of the healthy U.S. population carry S. aureus in their nose without causing any signs of infection.4
Because the type of vascular access is the most important risk factor for bloodstream infections, monitoring access type in surveillance is critical. Two aspects of this method data collection are helpful. First, a census of all patients by type of vascular access (e.g., what percentage of patients have fistulas, grafts, temporary, or permanent catheters) and second a notation of the type of vascular access used at the time a patient develops infection.
Antimicrobial resistance is an important problem among hemodialysis patients because they are frequently treated with antibiotics and have multiple hospitalizations and procedures. In addition, organisms such as S. aureus easily develop or acquire resistance and methicillin-resistant S. aureus (MRSA) has become a clinically important pathogen among hemodialysis patients.
Hepatitis B is a relatively stable pathogen that can contaminate the environment, most notably on dialysis equipment, multi-dose medication vials, and medications that are not prepared aseptically. Personnel can also cross-contaminate patients by caring for infected and uninfected patients without using appropriate infection control precautions.2
Patients or healthcare workers can develop chronic infection without symptoms, and potentially transmit it to others. Because vaccination is effective in preventing infection with hepatitis B, vaccination of patients and healthcare workers, as well as a testing program are important components of infection control programs in dialysis. Other bloodborne pathogens that can cause infections among hemodialysis patients include hepatitis C and HIV, but are effective in preventing other bloodborne pathogens.
CDC and Dialysis Surveillance
Between 1999 through 2004, the Dialysis Surveillance Network was an Internet-based system provided by CDC for volunteer outpatient dialysis centers to monitor dialysis events using a standard protocol. In 2004, about 137 facilities were enrolled. In 2005, CDC integrated its healthcare-associated surveillance systems into the National Healthcare Safety Network. In 2006, already more than 40 dialysis facilities have enrolled in NHSN.
Participants enter data online and generate analyses of their data with comparisons to other participants. Three events trigger a report: an overnight hospital stay, an outpatient start of an IV antimicrobial andor a positive blood culture. Data on the infection or event, type of vascular access, use of vancomycin, and other information are collected on the report form. These events become the numerator for event rates.
Once a month, the frequency of the types of vascular accesses is measured (fistula, graft, cuffed catheter, non-cuffed catheter, port) and the results are used for the denominator of event rates.
At enrollment and once a year thereafter, facilities complete a practice survey with general characteristics of the facility and routine infection control practices. All information is confidential and identifying information is optional; identifying information on patients or dialysis centers is ever published.
How to Get Started
A recently published study (see p. 26) used participation in dialysis surveillance activities as a measure of success towards improving quality of care.5 Researchers used the CDC dialysis surveillance protocols and software. They estimated that, after set up of the system, an average of two hours per month of personnel time were needed to conduct surveillance in a hemodialysis facility serving about 112 patients per month.
Facilities interested in conducting surveillance activities should start by exploring resources provided by CDC by visiting www.cdc.gov/ncidod/dhqp/dpac_dialysis_data.html
If the facility would like to formally join the dialysis facilities already conducting surveillance within the National Healthcare Safety Network at CDC, enrollment will be open in late 2006. CDC conducts training in dialysis event surveillance during professional conferences and periodic webcasts.
Recommendations for conducting surveillance are also central to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative, which is available at: www.kidney.org/professionals/KDOQI/index.cfm Local End-Stage Renal Disease Networks also may have organized efforts to support surveillance in outpatient facilities, see www.esrdnetworks.org
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