Tracking Infections in Outpatient Dialysis Facilities

A leading cause of death among hemodialysis patients, second only to vascular disease, bloodstream and other types of infections are a significant threat to patient safety. CDC helps the dialysis community prevent infections by providing evidence-based guidelines and access to the National Healthcare Safety Network (NHSN), a surveillance system that allows facilities to track infections. These resources are critical for tracking and preventing infections and for evaluating the effectiveness of a specific infection prevention effort.

In 2008, CDC estimated that 37,000 bloodstream infections occurred among hemodialysis patients with central lines. One in four of these infected patients may have died as a result of the infection. Since 1993, hospitalization rates among hemodialysis patients have increased 47% for bloodstream infection and 87% for vascular access infection.

The Burden and Risk

Healthcare providers including doctors, nurses, and technicians can prevent many of these infections by following basic infection prevention recommendations and tracking rates.

A patient’s risk of infection is related to their vascular access type (how a patient’s veins are accessed so they can receive hemodialysis).  Common types include: central lines, arteriovenous (AV) fistulas created from the patient’s own blood vessels, and AV grafts constructed from synthetic materials.

Whenever possible, AV fistulas are the preferred way to receive dialysis because they have the lowest risk of infection. Central lines have the highest infection risk.

NHSN Surveillance Informs Prevention

Tracking infections can identify which patients are at risk or which part of a facility needs improvement.  In addition, surveillance allows CDC to see national trends and direct prevention efforts for the country.

Information collected includes process measures, such as the number of catheters and fistulas used, and outcomes such as infections. This information can be used to evaluate and improve performance locally, statewide, and nationally.

In addition to allowing facilities to categorize hemodialysis patients by type of vascular access used, NHSN provides a variety of analysis options including line listings, rate tables, and control charts, which can be used to better inform quality improvement decisions.

Recently, the Centers for Medicare and Medicaid Services (CMS) published a final rule encouraging all end stage renal disease (ESRD) facilities to track quality indicators through NHSN by following the Dialysis Event Protocol.  Facilities must comply with the rule to receive full payment through the CMS Prospective Payment System (PPS) ESRD Quality Incentive Program (QIP).