Infection Control Assessment and Response: Evaluating High-Risk Hemodialysis Facilities Based on a Scoring Mechanism of Predetermined Infection Control-Related Criteria

BACKGROUND:  The Epidemiology and Laboratory Capacity for Infectious Diseases Competitive Supplement provides additional resources to enhance infection control beyond Ebola preparedness in outpatient settings including hemodialysis facilities, called Infection Control Assessment and Response (ICAR). There are 77 licensed hemodialysis facilities across Colorado. The Colorado Department of Public Health and Environment (CDPHE) identified a set of indicators and a subsequent scoring system in order to prioritize ICAR assessments for facilities at highest risk for infection-control issues.

METHODS:  We gathered available data for each of the 77 hemodialysis facilities from the National Healthcare Safety Network, CDPHE’s Health Facilities and Emergency Medical Services Division (HFEMSD, which licenses and monitors health care facilities), Centers for Medicare & Medicaid Services (CMS), and Medicare’s Dialysis Facility Compare. Data elements included census (patient-months), bloodstream infection rates, access-related bloodstream infection (BSI) rates, central venous catheter (CVC)-associated bloodstream infection rates, CMS infection-related citations by HFEMSD surveys, dates of last CDPHE infection control survey visit, Dialysis Compare five-star rating, and percentage of the facility patient population positive for hepatitis C. We calculated the inter-quartile range for each variable and assigned a point value (1-4 or 5, as applicable) based on the quantitative value of each indicator. For facilities that had missing values, we assigned the midpoint value in that range. Total scores for each facility were summed to calculate a final risk score for each facility. Facilities with the highest scores were assigned a “highest risk” status. 

RESULTS:  Risk scores for each hemodialysis facility ranged from 12-29 points (median 21 points).   The five highest risk facilities had larger patient populations, high BSI, CVC and access-related BSI rates, and had not had a CDPHE infection-control survey within the last year.  Additionally, four of the five highest scoring facilities had infection-related citations from previous HFEMSD surveys.  The five lowest scoring facilities had smaller patient populations, low BSI, access-related BSI and CVC rates, and had a recent CDPHE survey within the last year except for one facility. Moreover, only two of the five lowest scoring facilities had infection-related citations from previous HFEMSD surveys. 

CONCLUSIONS:  Using a set of predetermined infection-related and patient population-based indicators to calculate an aggregate point value was an effective way to prioritize ICAR assessments for hemodialysis facilities most at risk for infection-control issues. Weighting each data element differently may yield further validity to future scoring assessments and could be considered.