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.

Increasing the use of arteriovenous fistulas (AVF): a network QI project.

In 2002, the Intermountain End-Stage Renal Disease Network Inc., Network 15, initiated a quality improvement project, "Increasing Arteriovenous Fistulas Within Network 15." The primary objective of this project was to maximize the placement of arteriovenous fistulas (AVF) within the adult in-center hemodialysis population in Network 15. A closely related objective was to ensure policies and procedures were in place at each facility to encourage placement and maintenance of fistulae after they had been placed. Based on the facility-specific percentage of adult patients reported to have a fistula in January 2001, eight facilities were selected to participate in the project. Approximately 100 project partners (facility staff, nephrologists, and surgeons) collaborated to improve AVF rates for incident and prevalent patients. The interventions for this project were multifaceted and included face-to-face meetings with project partners, dissemination of a National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) summary paper on vascular access, video materials and written information for patient and staff, post-operative "Fistula Care Packages" educational meetings, and data feedback to facility staff nephrologists and surgeons. Of the seven indicators selected for this project, the predicted improvement was met in four. Overall improvement was noted in six of the seven process/outcome measures. A statistically significant (p=0.05) improvement was noted in the rate of fistulas used for treatment for prevalent (all) hemodialysis patients. This rate increased by about one-third from baseline to remeasurement.