Three years ago, the Chief Medical Officers from 13 dialysis providers met to share common issues about patient outcomes: successes and area for improvement. A commitment to share clinical and facility level approaches to issues, protocols, and policies, even data, grew out of this initial meeting. Since that time there have been two national meetings attended by the CMOs and their operational teams and enormous collaboration has taken place to improve patient satisfaction and quality of dialysis. We have had monthly calls, including separate calls by operations teams, to enhance the experience of the patient undergoing dialytic therapy. This is not about the business of the dialysis provider. It is about the quality of patient care.
There is a commitment to address issues such as the catheter rate, hospitalizations and rehospitalizations, the quality of the intradialytic experience, infection prevention, morbidity and mortality, and which quality measures and processes really make a difference in the welfare of patients.
Additionally, the CMO group has had several meetings with various agencies within the Centers for Medicare & Medicaid Services, and has acted as a resource to the advocacy groups Kidney Care Council and Kidney Care Partners. But the primary purpose has been to have an informal discussion and sharing of ideas among colleagues who have agreed that acting together can have a unique impact on patient outcomes through collaboration.
The three documents published in the January, February and March issues of Nephrology News & Issues represent agreements by the undersigned CMOs and their providers to address change that will impact key clinical conditions of patients within their respective dialysis facilities. We believe that we cannot necessarily always await to act for an evidence-based process. When the preponderance of evidence suggests that action must be taken, then we are prepared to respond. The optimal use of antibiotics, this month’s topic, follows our first paper published in January on the risks of the buttonhole access technique.
Working together, we believe that we can make a change in our patients’ dialysis experience and, most importantly, their survival.
Tom Parker III, MD
Requirement for blood cultures for suspected infection prior to initiation of antibiotic therapy
T. Alp Ikizler, MD
Rationale and background
Bloodstream infections (BSIs) are a prominent clinical problem in patients undergoing maintenance hemodialysis (MHD). 1Outpatient dialysis facility BSI rates are becoming a quality measure for which dialysis facilities might be held accountable in the payment year 2016 end-stage renal disease (ESRD) quality incentive program (QIP) and future payment years. The goal of this document is to adopt industry accepted algorithms for identifying and reporting contaminated blood culture results. We anticipate that this approach will reduce under-reporting of blood culture results by supporting electronic medical record integration with external labs as an industry standard. This will result in reliable tracking and reporting internal blood culture proportion rates.
Figure 1 outlines the basic components of the proposed algorithm for obtaining blood cultures (any blood test drawn to ascertain the presence of an infectious agent) and subsequent practice in maintenance dialysis patients. Continuous clinical surveillance is key to diagnosis and prevention of BSI. The current National Healthcare Safety Network (NHSN) definition of signs of suspected infection includes redness, pus, or swelling for local infection and fever, rigors, or hypotension for systemic infection. It is expected that the physicians and advanced practitioners will be required to order a blood culture before each antibiotic therapy when signs of systemic infection are present. Blood cultures are the gold standard for diagnosing BSIs. Cultures can provide information on the presence of organisms in the blood, the species of infecting organism, and the organism’s antimicrobial susceptibilities as well as guide the appropriate management. To increase yield and to assist with interpretation, multiple culture sets should generally be obtained. While it is recommended that blood cultures be drawn before initiating antimicrobials, blood cultures are still indicated if clinically appropriate in patients on antimicrobials with the caveat that sensitivity might be less in these situations.
In order to increase sensitivity and minimize the risk of contamination, it is recommended that a minimum of two sets of blood cultures be collected. Whereas it has been recommended that, optimally, percutaneous cultures should be obtained in addition to those from the access lines, it is recognized that this may be difficult and therefore is not a recommendation. 2 Drawing two sets (one set is two bottles; aerobic and anaerobic) of blood cultures from the access lines or HD catheters is a practical alternative if spaced at least five minutes apart. It is not recommended to routinely perform surveillance cultures through central lines to identify patients at risk for future CRBSIs.
Choice of antibiotic therapy should depend on the cause and suspected infectious agent. Results of the blood cultures should be tracked and antibiotic choice should be adjusted based on the culture and sensitivity results. Repeat blood cultures should be obtained if clinically indicated.
1. Kallen AJ. Identifying and classifying bloodstream infections among hemodialysis patients. Semin Dial 2013;26:407-15.
2. Allon M. Treatment guidelines for dialysis catheter-related bacteremia: an update. Am J Kidney Dis 2009;54:13-7.
3. Clincal Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Scoiety of America. Clinical Infectious Disease 2009; 49:1-45