A group-randomized evaluation of a quality improvement intervention to improve influenza vaccination rates in dialysis centers.

BACKGROUND: Patients with end-stage renal disease (ESRD) are at high risk of complications from influenza, but many dialysis centers report <50% influenza immunization coverage. STUDY DESIGN: A group-randomized evaluation of a multicomponent intervention to increase influenza vaccination rates in poorly performing dialysis centers in ESRD Networks 6, 11, and 15. SETTING & PARTICIPANTS: Facilities with the lowest immunization percentages in 2006-2007 were selected from each network and randomly assigned to a standard (n = 39) or intensive intervention (n = 38). INTERVENTION: Standard intervention included a feedback report with comparison to other centers in their network and educational materials for staff and patients. Intensive-intervention centers also received 3 educational seminars, assistance with and review of center-specific action plans, and monthly monitoring of vaccination plan and rates. OUTCOMES: Change in vaccination rate in following year. MEASUREMENTS: Dialysis center records of patient vaccination status. RESULTS: There was an 8.9% (P = 0.04) adjusted mean absolute difference in improvement between intensive- and standard-intervention centers. LIMITATIONS: Some vaccinations were self-reported by patients. The vaccination data form does not have an option for patient data unavailable, which may have caused patients without data to be coded as unvaccinated. CONCLUSIONS: Multicomponent interventions may serve as a successful strategy to increase influenza vaccination rates at poorly performing centers, with a benefit beyond that provided by usual oversight and support.

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study.

BACKGROUND: Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease. STUDY DESIGN: A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15. SETTING & PARTICIPANTS: Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients. PREDICTOR OR FACTOR: Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders. OUTCOMES: Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine. MEASUREMENTS: Patient vaccination, given at or outside the center. RESULTS: Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively). LIMITATIONS: Data are cross-sectional, and vaccinations outside the center were self-reported. CONCLUSIONS: Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.

Variation in infection prevention practices in dialysis facilities: results from the national opportunity to improve infection control in ESRD (End-Stage Renal Disease) project.

OBJECTIVE To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection. SETTING AND PARTICIPANTS Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status. MEASUREMENTS Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012. RESULTS There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%-92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%-100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation. CONCLUSIONS Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.

Analysis of renal bone disease treatment in dialysis patients.

End-Stage Renal Disease Network 11 initiated a renal osteodystrophy quality improvement activity in 1999. One component was the collection and assessment of dialysis facility renal osteodystrophy protocols, whereas another component was the analysis of bone disease-related medication use. Two hundred eighty-eight facilities were invited to submit protocols. A model bone disease and mineral metabolism protocol was developed as the standard for comparison. From the model protocol, an instrument was created to evaluate eight key areas (baseline screening of key laboratory data, dietary intervention, phosphate-binder use, vitamin D use, monitoring of key laboratory indicators, management of hypercalcemia, oversuppression of parathyroid hormone [PTH], and guidelines for both hemodialysis and peritoneal dialysis patients). A bone disease-related prescription survey was completed for 749 randomly selected patients. Survey information included vitamin D and phosphate-binder use and related laboratory values (calcium, phosphorus, intact PTH [iPTH], and calcium x phosphorus product). Although 45% of facilities had six or more points on the evaluation tool, protocols were still incomplete compared with the model. Mean facility-specific scores among the five states in the Network ranged from 1.0 to 5.9 (possible scores, 0 to 8). Most patients were prescribed a phosphate binder; however, 31.8% had average phosphorus levels greater than 6.0 mg/dL during the 3-month period. Only 58% of patients with average iPTH concentrations greater than 260 pg/mL were prescribed vitamin D. Of patients treated with vitamin D, 39% had iPTH concentrations less than 130 pg/mL. There is opportunity to improve renal osteodystrophy protocols in Network 11 and reinforce potential hazards of sustained hyperphosphatemia and hyperparathyroidism.