Infection Rejection: Bringing Infection Control Programs to Outpatient Dialysis Centers in New Jersey

BACKGROUND:   Hemodialysis is a necessary treatment for most patients with end stage renal disease. Although it presents increased risks for transmitting potentially deadly infections, hemodialysis is typically delivered in outpatient centers that lack traditional infection control programs.  To help protect this vulnerable patient population, New Jersey passed a law in 2001 with regulations mandating outpatient dialysis centers to contract with a Certified Infection Preventionist  (IP). The purpose of this study was to evaluate the positive and negative effects of this legislation and its enforcement on the New Jersey Department of Health (NJDOH), outpatient dialysis facilities, and the IPs who consult with them.

METHODS:   In partnership with colleagues at the state HAI program as well as the State Survey Agency responsible for licensing, inspection, and certification of dialysis centers we examined the growth of dialysis delivery in New Jersey. Deaths among dialysis patients due to sepsis were derived from the United States Renal Data System (USRDS) annual report. A survey was developed for distribution  to NJDOH surveyors, dialysis facilities, and IPs, to examine the nature of the arrangement between the IP and facility, the percentage of time the IP dedicates to each facility, the IPs responsibilities, challenges of hiring qualified IPs, benefits and adverse effects of the arrangement, and state level impacts.

RESULTS:   In 1990 there were only 38 licensed outpatient dialysis centers in New Jersey. As of 2011, New Jersey had 133 outpatient dialysis centers serving 12,208 patients. Over the last 10 years, the number of individuals with end stage renal disease in New Jersey has increased by over 30%. The percentage of deaths due to sepsis in patients undergoing hemodialysis has decreased from 29.6% in 1999-2002, to 20.6% from 2008-2011. Preliminary survey results suggest this decrease has been coincident with increased interactions and formal relationships between dialysis clinics and IPs; however, interpretation of the requirements for IP engagement varies widely. Final results will be available in May 2013.

CONCLUSIONS:   New Jersey has established progressive mandates for infection control in ambulatory care settings and specifically hemodialysis centers that may be reducing deaths due to infections. However, current legislation is open to varied interpretation by the dialysis center and is difficult to enforce. Additional, more tailored measures are needed to increase infection prevention and control in hemodialysis centers to protect this growing and fragile population.