BACKGROUND: The hemodialysis process requires frequent bloodstream access, which increases risk for healthcare-acquired infections (HAI) among hemodialysis patients. Outpatient hemodialysis facilities are a common setting for hepatitis C outbreaks reported to the Centers for Disease Control and Prevention (CDC). The Infection Control Assessment and Response (ICAR) Program provides funding for state and local health departments under CDC’s Epidemiology and Laboratory Capacity Program. ICAR complements existing public health HAI programs by facilitating direct assessment of infection prevention practices and identification of gaps in outpatient dialysis facilities. Objective, non-regulatory ICAR assessments aim to build trust and partnerships between dialysis facility staff and public health departments.
METHODS: Outpatient dialysis facilities are recruited via health department outreach to receive ICAR assessments. Facilities are interviewed using a standardized, hemodialysis-specific assessment tool regarding infection prevention practices in eleven domains and direct observations of practice are completed for seven activities using CDC audit tools. Awardees are encouraged to provide immediate feedback and additional resources to assist facilities to address gaps and make improvements. Assessment forms are de-identified and submitted quarterly to CDC for aggregate data analysis. We examined responses to interview questions and percent adherence from audits performed to identify common gaps.
RESULTS: Between October 2015 and October 2016, 20 health departments completed 168 dialysis facility assessments. Eighteen facilities (11%) were selected because of a current or past outbreak, 11 (7%) based on input from a quality improvement organization or survey agency, and 3 (2%) based on data reported to the National Healthcare Safety Network (NHSN). Most (112 [67%]) facilities were owned by large dialysis organizations; 26 (15%) were hospital-affiliated. Half of assessed facilities (51%, n=85) were not participating in HAI prevention programs. Common infection control challenges identified included suboptimal distance separating adjacent treatment stations (156 [96%]) and absence of a separate room for storage and preparation of injectable medications (60 [79%]). Complete adherence to CDC-recommended practices for central venous catheter exit site care was reported in only 21 (13%) facilities. Observed infection control practices with the lowest pooled percent adherence to CDC-recommended steps included routine surface disinfection of the dialysis station (19%), catheter exit site care (28%), and hand hygiene (46%).
CONCLUSIONS: Outpatient dialysis facility ICAR visits identified multiple infection prevention gaps and opportunities for improvement. The ICAR program can help build relationships between public health and dialysis facilities that can then be leveraged to address infection prevention challenges in this setting.