Validation of National Healthcare Safety Network Dialysis Event Data — Georgia 2015

BACKGROUND:  370,000 people in the United States rely on hemodialysis care to manage renal failure and are at risk for developing serious infections due to repeated bloodstream access. Outpatient hemodialysis facilities in Georgia are required to report three types of dialysis events (DE) monthly to the National Healthcare Safety Network (NHSN): intravenous antimicrobial starts (AMX), positive blood cultures (PBC), and pus, redness, or increased swelling at the vascular access site (PRS). Facilities must also report denominator data monthly, which categorizes patients by vascular access type. We validated reporting of DE data and identified barriers to reporting.

METHODS: We reviewed patient records from the period January 1–June 30, 2015 from 30 facilities in the Atlanta metropolitan area; 16 facilities were randomly selected, and 14 facilities were selected due to potential under-reporting, which included high catheter utilization rates and few PBCs, or no reported DEs. Up to 30 patient records were reviewed to identify DEs, using the Centers for Disease Control and Prevention’s (CDC) Dialysis Event Protocol event definitions. A concordance check was performed to classify each event as either correctly, under-, or over-reported. The 21-day rule, an event reporting rule which states 21 or more days must exist between two DEs of the same type for the second occurrence to be reported as a separate DE, was applied to all events. We surveyed staff members responsible for NHSN DE data collection and reporting to evaluate surveillance knowledge and practices.

RESULTS: We reviewed 876 patient records and identified 332 DEs, including 178 (54%) AMX, 64 (19%) PBC, and 90 (27%) PRS events. Twenty percent (36) of AMX events were under-reported and 11% (20) were over-reported; 44% (28) of PBC events were under-reported and 9% (6) were over-reported; and 71% (64) of PRS events were under-reported and 15% (14) were over-reported. Among 28 staff members, common reporting issues identified through the survey included: incorrect reporting of patient vascular access type for monthly denominator (15, 54%); being unable to identify at least one NHSN-defined DE (11, 39%); being unaware of the 21-day rule (9, 32%).

CONCLUSIONS:  We identified the need for improved reporting for all types of DEs. All hemodialysis facilities should have a strong working knowledge of CDC's Dialysis Event Protocol. Consistent and accurate documentation of DEs is an important part of prevention, and can help facilities detect problems, identify trends, evaluate infection prevention activities, and engage staff in quality improvement.