Infections in Non-Acute Care Settings:  End Stage Renal Disease ESRD

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Infections in Non-Acute Care Settings: End Stage Renal Disease ESRD

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1. Priti Patel, MD, MPH AHFSA Annual Conference September 20, 2010 Infections in Non-Acute Care Settings: End Stage Renal Disease (ESRD) Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases

2. Important Trends Growing dialysis population: 2007: ~367,000 has tripled since 1988 2020 projection: ~530,000 Infections in hemodialysis 2nd leading cause of death Most common: vascular access In 10 years (2020), number is projected to be ~530,000 In 10 years (2020), number is projected to be ~530,000

3. Hospitalization Rates Cause-specific hospitalization rates among hemodialysis patients, 2006: Vascular access infection = ~125 admissions / 1000 pt-yrs Bloodstream infection = 103 admissions / 1000 pt-yrs Pneumonia = 76 admissions / 1000 pt-yrs Since 1993, rates* have increased for: All infections (+34%) Bloodstream infection (+31%) Cellulitis (+20%) Pneumonia (+7%) Cellulitis (+20%) Pneumonia (+7%) Cellulitis (+20%) Pneumonia (+7%)

4. Delivery of Dialysis Care 5,062 dialysis facilities nationwide ~850 are hospital-based Increasingly consolidated ownership 2 for-profit chains treat ~60% of all patients Economic incentives Limited infection control resources or training Typical hemodialysis treatments: ~4 hours x 3 times per week Vascular access to facilitate hemodialysis Less than 20% are hospital-basedLess than 20% are hospital-based

5. Regulatory Changes April 2008 – The Centers for Medicare and Medicaid Services (CMS) released new conditions for coverage for End Stage Renal Disease (ESRD) facilities First comprehensive revision since 1976 Incorporates CDC / HICPAC* infection control recommendations First time infection control is a separate condition Explain ESRD Since rules were first adopted in 1976 What is a condition Infection control used to only be citable under “environmental conditions” whereas now, it is it’s own separate condition that involves everything from HH to hep B isolationExplain ESRD Since rules were first adopted in 1976 What is a condition Infection control used to only be citable under “environmental conditions” whereas now, it is it’s own separate condition that involves everything from HH to hep B isolation

6. CMS Conditions for Coverage Includes by reference: Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients, 2001 Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002

8. Early Impact & Perspective New Conditions went into effect October 2008 Has helped to highlight the importance of infection control in dialysis settings Infection control has been the most common category of citation during the new survey process Demonstrated gaps: In adherence to recommendations prior to the new conditions In the recommendations and conditions

9. CMS Conditions for Coverage: New Opportunities Improving infection control Reduce infections and improve patient outcomes Infection prevention & the Conditions Conditions are a floor, not a ceiling Need to go beyond requirements to truly prevent infections Is a starting point for many other opportunitiesIs a starting point for many other opportunities

10. Number and Type of Healthcare Adverse Event (HAE) Investigations in Dialysis, 1999-2009

11. HAE Investigations in Dialysis, 1999-2009 A variety of events were investigated; many resulted in severe adverse patient outcomes One-third of investigations involved hepatitis C virus (HCV) transmission Infection control lapses were implicated in 11 investigations: 7 HCV, 3 bacteremia, 1 fungemia Lapses in proper dialysis equipment use and maintenance were implicated in 4 investigations: 2 chemical intoxication, 1 bacteremia, 1 fungemia

12. Initial cases were identified through routine screening in 6 investigations: 5 HCV, 1 chemical intoxication Delays in reporting HAEs to public health officials occurred in at least 5 investigations Includes 2 investigations of HAEs resulting in patient deaths and other severe health outcomes Identification & Reporting

13. What Can Be Said About Outbreaks Breaches in infection control Basic practices – hand hygiene, aseptic technique, e.g. Sharing medication and supplies Poor injection safety practices Lack of proper surface cleaning & disinfection Other common themes Delays in identification & reporting Limited resources / expertise to handle locally Failure of equipment or equipment maintenance Manufacturing error Failures with reuse: not filling dialyzers with correct concentration of germicide not mixing or diluting germicide to proper concentrations, etc

14. High Impact Areas for Surveyors

15. Handling of injectable medications Vascular access site care Environmental cleaning + disinfection practices Infection control training Monitoring & acting upon facility data High Impact Areas for Surveyors

16. Medication Handling

17. Vascular Access Site Care

18. Environmental Cleaning & Disinfection

19. Infection Control Training & Education Have an initial and ongoing training program Frequency: upon employment and at least annually thereafter Required content areas are specified Gaps: Standards for depth & adequacy of training Availability of quality training programs & materials Role of periodic practice audits

20. Quality Improvement: Monitoring Facility Data Conduct surveillance to determine infection rates, monitor trends in those rates, and assist in identifying lapses in infection control practices A log or other tracking mechanism, such as the Dialysis Module of the National Healthcare Safety Network (NHSN) should be used Surveillance data Bloodstream infection rates Culture and susceptibility Hepatitis B & C testing Water testing Immunization rates Gaps: Standards for surveillance methods Pyrogenic reactions Allergic reactions Pyrogenic reactions Allergic reactions

21. Summary & Future Directions Surveyor process Observe & assess key procedures Includes patient care processes CDC, CMS & others HCV screening Defining surveillance requirements Addressing gaps in infection control training & education Defining and promoting best practices for infection prevention

22. Thank you! National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

23. Invasive Methicillin-Resistant S. aureus (MRSA) Infections, 2005 Incidence of invasive MRSA infections 45.2 cases per 1,000 dialysis population = 100 X rate in general population (0.2 – 0.4 per 1000) Dialysis patients ~0.1% of the U.S. population 15% of all invasive MRSA infections Invasive MRSA in dialysis 86% were bloodstream infections (BSIs) 90% required hospitalization, mortality = 17% The incidence of invasive MRSA infections is approximately 45.2 cases per 1000 dialysis popn, a rate that is 100 times greater than in the general population. Dialysis patients make up approximately 0.1% of the US population but accounted for 15% of all invasive MRSA infections reported to CDC’s Active Bacterial Core surveillance system in 2005. Of these invasive MRSA infections in dialysis patients, 86% were bloodstream infections, 90% required hospitalization and the in-hospital mortality was 17% (Of 5287 cases of invasive MRSA reported to CDC in 2005, 813 (15%) occurred in dialysis patients) Most invasive MRSA infections are healthcare-associated community onset. Dialysis is a major component of that. And whereas there has evidence of reductions in BSIThe incidence of invasive MRSA infections is approximately 45.2 cases per 1000 dialysis popn, a rate that is 100 times greater than in the general population. Dialysis patients make up approximately 0.1% of the US population but accounted for 15% of all invasive MRSA infections reported to CDC’s Active Bacterial Core surveillance system in 2005. Of these invasive MRSA infections in dialysis patients, 86% were bloodstream infections, 90% required hospitalization and the in-hospital mortality was 17% (Of 5287 cases of invasive MRSA reported to CDC in 2005, 813 (15%) occurred in dialysis patients) Most invasive MRSA infections are healthcare-associated community onset. Dialysis is a major component of that. And whereas there has evidence of reductions in BSI

24. Quality Improvement: Acting Upon Data The facility must-- Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence Take actions to prevent future incidents Notify appropriate State and local public health officials of viral hepatitis seroconversions and other infectious diseases, and clusters of adverse events that occur among patients in the facility Pyrogenic reactions Allergic reactions Pyrogenic reactions Allergic reactions

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