Infection prevention is now years removed from the old dogma that healthcare infections are the inevitable result of treating patients with high acuity on invasive devices or suffering from underlying conditions.
There may be an irreducible minimum, but the expectation that infections would occur created a complacency and, in some cases, denial. In some quarters, that mindset still holds. This is what an infection preventionist faced when she realized almost half of patients in outpatient dialysis were developing bloodstream infections.
Perhaps given the nature of the findings — particularly the strong backlash from dialysis physicians — the facility where the infections occurred was not identified in a recent podcast on preventing dialysis infections held by the Centers for Disease Control and Prevention.
“Sally Hess, MPH, CIC, has many years of experience as an infection preventionist and most recently was the manager of an infection prevention team at an academic medical center,” said moderator Priti Patel, MD, a medical epidemiologist in the CDC Division of Healthcare Quality Promotion. “She’s been an integral part of our dialysis patient safety efforts since 2009.”
A member of the CDC’s Making Dialysis Safer for Patients Coalition, Hess shared her personal story of trying to reduce dialysis-related infections.
She stressed the importance of physician leadership in dialysis centers and developing a culture of safety as an essential part of any infection prevention initiative.
Hess contrasted the resistance she faced in dialysis with the openness and transparency of a “Getting to Zero” campaign that successfully reduced central line-associated bloodstream infections (CLABSIs) in hospital ICUs.
The CDC estimates some 40,000 central line-associated bloodstream infections occur annually in hemodialysis patients in the U.S.
The ICU “Zero” initiative was marked by transparency and a blame-free process, encouraging full accountability to drive down infections. “We had a great physician-led team that worked on implementing and improving the insertion and removal of central lines, and a team of nurses focused on improving the care and maintenance of the lines,” she said.
An IP attended weekly rounds and if there had been an infection, the case was presented and discussed, Hess said.
“It was refreshing that the culture allowed for open and transparent discussion without blame,” she said. “This led to an honest discussion of the challenges and prompted many improvement opportunities.”
The process was marked by an impressive commitment and zeal for the task at hand that increased as the days out from the last infection grew longer.
“They really wanted to have zero infections,” she said. “When an infection occurred after several months of zero infections there was always alarm, followed by renewed effort to understand what really happened at the bedside.”
The ICUs went on to have stretches of more than a year without a single CLABSI, she said.
Impasse
In contrast, her experience with dialysis infections was marked by resistance and denial by some of the clinicians involved.
“I was the person responsible for surveillance of bloodstream infections throughout our healthcare system,” Hess said. “Even with the drop in our ICU cases, there were still a lot of positive blood culture results being sent to me for review on a daily basis. Where were they coming from? Were they healthcare-associated?”
Noticing they were coming from outpatients, she investigated further and found that the common thread was that many were patients at one of six hospital-owned outpatient dialysis centers.
“In addition, some of the blood cultures were obtained in the emergency room or on admission to the hospital,” she said. “I spoke with the hospital epidemiologist about the trend and we decided it was worth a closer look. For the remainder of the year, I saved all the positive reports from the locations of interest.”
Hess collected information on the cases and entered the events into CDC’s NHSN Dialysis Event Surveillance module.
“At the end of the year, I did a deep dive analysis of the accumulated reports, and my suspicions were correct. The majority of cases were coming from outpatient dialysis,” she said. “There were about 130 positive blood cultures in dialysis outpatients.”
With the total census of the six dialysis centers around 300 patients, “it looked like just shy of half of our dialysis patients had a positive blood culture during the past year. I knew we could do better than that.”
Hess found a concerned ally in the nurse manager of the dialysis centers.
“She shared with me that when she mentioned her concerns to the physicians, she frequently got the feedback that infections were to be expected in this patient population,” Hess said. “From their perspective, it didn’t seem out of the ordinary.”
Hess, the hospital epidemiologist, and the nurse manager presented the surveillance data at a large, multidisciplinary team meeting that included all the facility’s nephrologists, fellows, nurse leaders, and pharmacists.
The data showed that the bloodstream infection rates were high for all six centers, compared to national rates.
After she presented the local data, the physicians in the audience discounted its value. Saying dialysis patients have much higher acuity, they questioned the CDC metric of the number of infections per 100 patient-months.
“One very vocal nephrologist felt the data didn’t reflect a problem,” Hess said. “I was feeling a bit overwhelmed by all this disbelief. Having worked with the ICU physicians, I realized that if they don’t recognize that there’s a problem, then nothing will happen to change the situation.”
Feeling a bit “exasperated,” Hess rallied and told the physicians, “There were about 130 infections in 300 patients during the past year. This impacted almost half of your patients and their loved ones. Many were hospitalized and some died. We can do better than that.”
Despite this powerful conclusion, the meeting ended without action. “I felt personally defeated,” Hess recalled. “The nurse manager, however, did not give up. She arranged for a smaller work group to look further into the problem.”
The Comeback
The group included several medical directors, nurse managers, assistant nurse managers, pharmacists, and the hospital epidemiologist. Most of this team had been at the large meeting, and began to review the data, with the hospital epidemiologist concluding that no matter how one looked at it, having one-third to one-half of dialysis patients infected was “not acceptable.”
The group reviewed the surveillance criteria and rate definitions, with more emphasis on understanding and explaining it in terms the clinicians would find meaningful.
“We discussed the risks of infection for patients, their gut feeling as to what was happening, and the expected standards of practice, especially at the chairside,” Hess said.
Looking at what had been successful in the ICUs, the work group talked about the importance of engaging all team members in the outpatient settings.
“At the end of the meeting, there seemed to be a shared sense of urgency and the nurse manager felt empowered to actively pursue opportunities for reducing risks,” she said. “We had the start of an action plan.”
With the buy-in and support from the physician leaders, Hess and colleagues started working directly with the nurses and patient care technicians in the centers. Process improvements were made and dialysis nurses and technicians were urged to be infection prevention advocates.
“They received enhanced infection prevention education and were encouraged to share their knowledge,” she said. “They developed infection prevention ‘eyes,’ always on the lookout for challenges and improvement opportunities. Following these changes, infections dropped significantly and were sustained with less than 10 infections per year for multiple years.”
Saying she was “floored” by Hess’s description of the initial reaction to the infection data, moderator Patel asked Hess if she had advice for other clinicians in a similar situation.
“Have a vision for where you want to be, such as ‘getting to zero,’” Hess said. “Use local data and recognize that there is always room for improvement. Most of all, remember that you can’t do this on your own. Having a way to measure and compare your progress is essential.”
One key in any setting is to establish a work culture that is transparent about errors without focusing on blame.
“Staff don’t want to be blamed for an infection, especially when their potential role in a patient infection is not always obvious,” Hess said. “A culture that refrains from accusing behavior and supports positive feedback is important.”
The culture of safety should include patients, staff, and leaders. “Each team member must have knowledge, skills, motivation, and support to actively prevent infections,” she said.
