Outpatient Hemodialysis Centers Research Articles

Cost-effectiveness of bioimpedance-guided fluid management in patients undergoing haemodialysis: the BISTRO RCT.

The BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial investigated the effect of bioimpedance spectroscopy added to a standardised fluid management protocol on the risk of anuria and preservation of residual kidney function (primary trial outcomes) in incident haemodialysis patients. Despite the economic burden of kidney disease, the cost-effectiveness of using bioimpedance measurements to guide fluid management in haemodialysis is not known. To assess the cost-effectiveness of bioimpedance-guided fluid management against current fluid management without bioimpedance. Within-trial economic evaluation (cost-utility analysis) carried out alongside the open-label, multicentre BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial. Thirty-four United Kingdom outpatient haemodialysis centres, both main and satellite units, and their associated inpatient hospitals. Four hundred and thirty-nine adult haemodialysis patients with > 500 ml urine/day or residual glomerular filtration rate > 3 ml/minute/1.73 m2. The study intervention was the incorporation of bioimpedance technology-derived information about body composition into the clinical assessment of fluid status in patients with residual kidney function undergoing haemodialysis. Bioimpedance measurements were used in conjunction with usual clinical judgement to set a target weight that would avoid excessive fluid depletion at the end of a dialysis session. The primary outcome measure of the BioImpedance Spectroscopy to maintain Renal Output economic evaluation was incremental cost per additional quality-adjusted life-year gained over 24 months following randomisation. In the main (base-case) analysis, this was calculated from the perspective of the National Health Service and Personal Social Services. Sensitivity analyses explored the impact of different scenarios, sources of resource use data and value sets. The bioimpedance-guided fluid management group was associated with £382 lower average cost per patient (95% CI -£3319 to £2556) and 0.043 more quality-adjusted life-years (95% CI -0.019 to 0.105) compared with the current fluid management group, with neither values being statistically significant. The probability of bioimpedance-guided fluid management being cost-effective was 76% and 83% at commonly cited willingness-to-pay threshold of £20,000 and £30,000 per quality-adjusted life-year gained, respectively. The results remained robust to a series of sensitivity analyses. The missing data level was high for some resource use categories collected through case report forms, due to COVID-19 disruptions and a significant dropout rate in the informing BioImpedance Spectroscopy to maintain Renal Output trial. Compared with current fluid management, bioimpedance-guided fluid management produced a marginal reduction in costs and a small improvement in quality-adjusted life-years. Results from both the base-case and sensitivity analyses suggested that use of bioimpedance is likely to be cost-effective. Future work exploring the association between primary outcomes and longer-term survival would be useful. Should an important link be established, and relevant evidence becomes available, it would be informative to determine whether and how this might affect longer-term costs and benefits associated with bioimpedance-guided fluid management. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number HTA 14/216/01 (NIHR136142).

Survey of Hemodialysis Patients’ Knowledge of Their Infection Risk and Acceptability of a Nasal Decolonization Intervention

Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.Disclosure: Marin Schweizer: Speaker- 3M; Contracted research-3M; Anitha Vijayan: Honoraria - Quanta, Baxter, Fresenius Consulting, Astute, NxStage

Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study

Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers. Mixed methods, observational study. Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months. At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics. Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified. This was an exploratory evaluation with a small sample size. This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study.

Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study.

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making. To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection. Qualitative descriptive study. Five outpatient hemodialysis centers in Calgary, Alberta. Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists). We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective. While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers. Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study. Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Renin-Angiotensin-Aldosterone System (RAS) Inhibitors May Suppress the Prevalence of Peripheral Arterial Disease (PAD) in Elderly, Chronic Hemodialysis Patients.

According to the hypertension guidelines, calcium antagonists are recommended as antihypertensive drugs for Stage 5 of chronic kidney disease (CKDG5) and late elderly patients, whereas renin-angiotensin-aldosterone system (RAS) inhibitors (RASi) are not recommended. We screened elderly CKDG5D patients at a single outpatient maintenance hemodialysis center for the progression of peripheral arterial disease (PAD) using the ankle-brachial index (ABI) and skin perfusion pressure (SPP) tests, as well as logistic regression analysis, to determine the association between PAD and the treatment with RASi and the association between the treatment with RASi and the need for hospitalization within one year of observation. With the presence of PAD as the explanatory variable and the presence of RASi as the objective variable, the odds ratio was 1.23 (95% confidence interval [CI] 0.37 to 3.82) in univariate analysis. After adjusting for confounding factors (age, gender, and hypertension), the odds ratio in multivariate analysis was 0.83 (95% CI 0.46 to 6.08). The presence or absence of PAD was significantly associated with an odds ratio of 3.24 (p = .04, 95% CI 1.0 to 10.25) and 4.63 (p = .026, 95% CI 1.20 to 17.84) in univariate and multivariate analyses, respectively, when the outcome was hospitalization at one year, regardless of the presence or absence of RASi. However, in univariate analysis, the odds ratio was 1.23 (95% CI 0.37 to 3.82) with RASi status as the explanatory variable and one-year hospitalization as the objective variable. After adjusting for confounders, the odds ratio in multivariate analysis was 0.83 (95% CI 0.46 to 6.08). Although further large-scale, multicenter studies are needed to establish the evidence, our results suggest that RASi treatment may have a suppressive effect on the prevalence of PAD and the need for hospitalization in elderly CKDG5 dialysis (CKDG5D) patients.

Longitudinal analysis of risk factors associated with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among hemodialysis patients and healthcare personnel in outpatient hemodialysis centers.

In this prospective, longitudinal study, we examined the risk factors for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among a cohort of chronic hemodialysis (HD) patients and healthcare personnel (HCPs) over a 6-month period. The risk of SARS-CoV-2 infection among HD patients and HCPs was consistently associated with a household member having SARS-CoV-2 infection.

Knowledge and Perceptions on End-of-life Care among End-stage Renal Disease Patients on Hemodialysis.

The role of end-of-life care is fundamental for end-stage renal disease (ESRD) patients, who are known to have a high morbidity and mortality rate despite being on dialysis. This requires effective communication and shared decision-making. Thus, exploring patients' knowledge and perceptions is essential to improve the gaps in delivering end-of-life care. This study aimed to describe the knowledge and perceptions of end-of-life care among ESRD patients on hemodialysis (HD). This was a cross-sectional study involving 14 outpatient HD centers in Kuantan, Malaysia. Patients were recruited from March to June 2019. A validated questionnaire was delivered via interview-based surveys by the researcher or trained interviewers. The majority of the respondents had poor knowledge of the disease and end-of-life care. However, more than 70% of the respondents felt that it was important for them to be actively involved in medical decision-making, as well as being prepared and planning for death. End-of-life needs, which included management of symptoms and psychological, social, and spiritual support, were important to most respondents. Additionally, patients with higher educational backgrounds were observed to have higher scores for both knowledge and perceptions (P <0.05). The study found poor knowledge but acceptable perceptions among patients. This highlights the gaps in the current local approach in clinical practice to end-of-life care in ESRD.

Online Reviews of Hemodialysis Centers Correlate With Medicare and Medicaid Survey Measures of Patient Experience.

Patient experience in outpatient hemodialysis has been shown to be significantly correlated with health outcomes. The current gold standard for assessing patient experience in outpatient hemodialysis is the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS). Online reviews of outpatient hemodialysis centers could potentially serve as an additional source of information regarding patient experience, but they have not been well validated. This study aims to determine whether overall scores and subscores from patient-authored online reviews of outpatient dialysis centers are correlated with current gold standard survey-based measures of patient experience in outpatient hemodialysis. All reviews of hemodialysis centers posted to the online review site CiteHealth.com between March 2008 and October 2019 were collected (1081 reviews of 762 centers). Publicly-available ICH-CAHPS survey summary data and End Stage Renal Disease Quality Incentive Program (ESRD QIP) summary data from May 2016 to October 2019 were obtained from the Dialysis Facility Compare website. Spearman correlation coefficients were calculated between facilities' mean online review overall scores and subscores within a given year and their ICH-CAHPS ratings from the same year. Statistical significance was assessed with a 2-tailed permutation test. A Bonferroni correction for multiple hypothesis testing was applied. The mean "Overall" score from CiteHealth.com had a significant positive correlation with the "Center Care Quality," "Staff," and "Facility" scores from ICH-CAHPS surveys. No significant correlation could be found between the mean "Overall" CiteHealth.com score and any other ICH-CAHPS patient satisfaction metric. There was a significant positive correlation between the mean CiteHealth.com "Center" score and the ICH-CAHPS "Center Care Quality" score, the mean CiteHealth.com "Facility" score and the ICH-CAHPS "Facility" score, and the mean CiteHealth.com "Staff" score and the ICH-CAHPS "Staff" score. No significant correlation was found between the mean CiteHealth.com "Nephrologist" score and the ICH-CAHPS "Nephrologist" score. No significant correlation was found between online review scores and ESRD QIP health outcome measures. Certain components of online reviews are significantly correlated with ICH-CAHPS measures of patient experience. Additionally, online reviews come with narrative comments that can offer specific insights into positive and negative aspects of patient care that cannot always be elucidated by numeric survey questions. Online reviews may have utility as an adjunctive source of information to patient experience surveys such as the ICH-CAHPS.

COVID-19 Outbreak in a Hemodialysis Center Using Universal Masking and Eye Protection

Background: Up to half of all new SARS-CoV-2 infections are acquired from presymptomatic or asymptomatic individuals. Hemodialysis patients and healthcare providers (HCPs) may be at increased risk for COVID-19 due to the need for extended close contact. Universal masking and eye protection are strategies used to reduce SARS-CoV-2 exposure, particularly from presymptomatic or asymptomatic individuals. We describe an outbreak of COVID-19 in an outpatient hemodialysis center despite universal masking and universal HCP eye protection. Methods: An COVID-19 outbreak investigation was performed in a hemodialysis center where universal masking was in use by all HCPs and patients and universal eye protection (goggles, safety glasses) was in use by all HCPs when directly encountering patients. After a cluster of cases was identified in early November 2020, all patients and HCPs were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) when symptomatic and weekly until the conclusion of the outbreak. Results: From November 12, 2020, through December 7, 2020, 14 (23.3%) of 60 patients and 9 (28.1%) of 32 HCPs tested positive for SARS-CoV-2 by RT-PCR (Figure 1). The median ages of the patients and HCPs were 64 years (range, 42–87) and 42 years (range, 29–68), respectively. Also, 5 (5.4%) individuals (3 patients and 2 HCPs) were asymptomatic at the time of testing. Furthermore, 7 (7.6%) individuals (5 patients and 2 HPCs) were hospitalized; 2 patients and no HCPs died. No lapses in universal masking or, for HCPs, eye protection prior to or during the outbreak were identified during the investigation. All HCPs and patients wore medical-grade face masks that were discarded at the end of the day; HCPs wore safety glasses or goggles during patient interactions. Although audits of face mask and eye protection compliance were not performed, independent interviews supported high HCP and patient adherence prior to the outbreak. Neither the staff nor patients shared meals at or outside the hemodialysis center. Most patients and HCPs shared the same hemodialysis shift, suggesting the presence of an index case; however, a source case could not be identified despite an extensive investigation. Conclusions: Universal masking and eye protection have been shown to reduce transmission of SARS-CoV-2 from presymptomatic or asymptomatic individuals in the healthcare setting. This report suggests that such measures cannot prevent all outbreaks. We speculate that certain factors associated with hemodialysis care, such as prolonged close patient–HCP contact, may have facilitated this outbreak. Whether nonadherence to universal masking and eye protection or failure of empiric droplet precautions contributed to this outbreak remains unknown.Funding: NoDisclosures: None

SARS-CoV-2 Infection Risk Factors among Maintenance Hemodialysis Patients and Health Care Personnel In Outpatient Hemodialysis Centers.

Increased risk of SARS-CoV-2 infection was associated with community prevalence.Increased risk of SARS-CoV-2 infection was associated with exposure to infected family members and personal infection prevention measures.

FC 075POST-MORTEM HEPATIC AND BONE MARROW IRON CONTENT IN HEMODIALYSIS PATIENTS: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Studies using T2 MRI liver scans among Hemodialysis (HD) patients raised concern about the presence of iron overload in this population, regularly treated with intravenous (IV) iron. Histological evidence of tissue iron overload is scarce, since the majority of studies were performed in pre-erythropoiesis- stimulating agents (ESA’s) era, when blood transfusions were common. Primary objective: to quantify iron in the liver and bone marrow by biochemical and histological analysis, in adult CKD stage 5-HD. Secondary objectives: To explore association of clinical, laboratorial parameters, IV iron therapy and iron stores. Method After approval of local Ethical committee and informed consent from families, liver biopsy and bone marrow aspirate were obtained in the first 24h post-mortem from 21 chronic HD patients with anemia or under anemia treatment who died in Hospital Fernando Fonseca. Exclusion criteria: blood transfusion in the previous 2 weeks, acute or chronic liver disease, HIV infection, known hematologic or oncologic disease. Clinical, laboratorial and anemia therapy data were retrieved from hospital registry and outpatient HD centers. Biochemical liver iron content (LIC) was quantified by atomic absorption spectrophotometry. Histological semi-quantitative grading of iron storage was made in the liver and bone marrow using Scheuer’s and Gale’s criteria of grading Perls’ stain, respectively. Results Of 21 patients included, 10 (47,6%) were male, median (IQR) age 76.0 (67.5-85.5) years old, 18 (85.7%) white, 3 (14.3%) black, dialysis vintage was 47.0 (12.5-104.0) months. Charlson Comorbidity index was 10.0 (7.5-11.0), 7 (33%) patients had diabetes, and 11 (52.4%) used an arteriovenous fistula as vascular access. The cause of death was infection (n=9, 42.9%), cardiovascular (N=6, 28.6%), HD withdrawal (n=2, 9.5%) and unknown =3 (14.3%). Median (IQR) hemoglobin was 9.8 (8.5-11.4) g/dl and 11 (52.3%) patients had hemoglobin &amp;lt;10 g/dl. Ferritin was 494.0 (136.0-850.5) ng/ml and TSAT 19.9 % (13.3-26.0). 19 (90.5%) patients were receiving IV iron therapy. Median (IQR) IV iron administered in the previous 6 and 12 months before death was 800 (300-1250) mg and 1500 (650-2175) mg, respectively. All patients were on ESA therapy, median (IQR) dose 5000 (3000-9000) UI/week and erythropoietin resistance index was 9.6 (4.2-16.6). Median (IQR) liver iron content determined by atomic absorption was 42.5 (22.9-69.7) µmol/g. 9 patients (42.9%) had normal LIC (&amp;lt;36 μmol/g), while the remainder had mild to moderate overload. Median (IQR) Scheuer grade was 2 (1-3) and 13 (62%) of liver biopsies had increased (Scheuer grade &amp;gt; 1) iron deposition at histology. Median (IQR) grade of Perls staining in the bone marrow was 3 (3-4) and 9 (45%) had increased (Gale’s grade &amp;gt;3) iron content in the bone marrow. Iron semi-quantitative scores in liver and bone marrow had strong positive correlation (r=0.71, p&amp;lt;0.001). There was a strong positive correlation between LIC and ferritin (r=0.86, p &amp;lt; 0.001) and also TSAT (r=0.56, n=16, p=0.02). Hemoglobin was negatively associated with LIC (r= -0.46, p=0.04), and with iron content in the bone marrow (p=0.04). LIC did not associate with ESA dose, C-reactive protein, dialysis vintage or other clinical parameters. There was no statistically significant association between the dose of IV iron administered in the previous 6 and 12 months with LIC, ferritin,TSAT or iron scores in bone marrow and liver. Conclusion In these HD patients, there was biochemical and histological evidence of iron accumulation in liver and bone marrow. Ferritin and TSAT showed strong correlation with iron deposits, but none was found with the dose of IV iron administered. In this study, anemia severity was associated with higher degree of iron storage both in the liver and bone marrow, suggesting a multilevel blocking mechanism of iron’s utilization.

14. Feasibility of A Digital Video Health Education Program at an Outpatient Hemodialysis Center During A Pandemic

14. Feasibility of A Digital Video Health Education Program at an Outpatient Hemodialysis Center During A Pandemic

An integrative approach to detect protein–energy wasting among chronic kidney disease maintenance hemodialysis patients

<br><b>Background:</b> Malnutrition is a major predictor of overall outcome in patients on hemodialysis. Regular and frequent evaluation of the nutritional status of these patients is advisable. <b>Aims and Objectives:</b> This study aimed to look at nutritional status of a hemodialysis cohort and to evaluate whether multiple assessment tools improve the detection of malnutrition in this cohort. <b>Materials and Methods:</b> A prospective study in two outpatient hemodialysis centers was conducted over 6 months. Stable patients without any irreversible organ damage and preserved cognitive function were included in the study. Data collected included demographics, comorbid conditions, and baseline laboratory investigations. The nutritional assessment tools included body mass index (BMI), 7-point Subjective Global Assessment, Global Leadership In Malnutrition (GLIM), handgrip strength, and body composition analysis. <b>Results:</b> A total of 121 subjects (77 males, 44 females) participated in the study. Based on BMI, only 14% were underweight. 7-point SGA detected 77 malnourished subjects, whereas according to GLIM criteria, all patients had some degree of malnutrition. Body composition analysis showed depleted total body protein mass in majority of patients. There was a correlation between total body protein mass and handgrip strength. The assessment tools showed some degree of correlation in patients who were malnourished. <b>Conclusions:</b> Use of a single assessment tool often underdiagnoses malnutrition in hemodialysis patients. An integrative approach using multiple evaluation tools may be beneficial in these groups of patients.<br>

Фибрилляция предсердий у диализных пациентов (опыт одного центра)

The aim of the research is to determine frequency of atrial fi brillation; factors that lead to the formation of atrial fi brillation and the development of cardiovascular complications in dialysis patients. Material and methods. Analysis of current clinical practice in one out-patient hemodialysis center. Results. The incidence of atrial fi brillation in dialysis patients is 10.5 %. Most patients (72.4 %) had a paroxysmal form of atrial fi brillation. Th ere is clinical and laboratory characteristics of patients with atrial fi brillation. Atrial fi brillation occurred in 58.6 % of dialysis patients in average in 45 [15.4; 70.5] months after the beginning of regular hemodialysis, the rest got it in pre-dialysis period. Th e main factor associated with the development of atrial fi brillation on dialysis is the duration of dialysis therapy. Dialysis patients with atrial fi brillation are characterized by more pronounced systemic infl ammation and a higher incidence of hyperparathyroidism compared with patients without atrial fi brillation. Cardiovascular complications developed in 41.4 % dialysis patients with atrial fibrillation. Anuria is a factor associated with the development of myocardial infarction and stroke. Conclusion. Atrial fibrillation is found in every tenth dialysis patient. An increase in atrial fi brillation was noted along with an increase in hemodialysis duration. To optimize dialysis treatment of patients with atrial fibrillation further research is needed

Working on Wellness: Impact of a Pilot Workplace Wellness Program in a Hemodialysis Center

This article describes the impact of a 12-week workplace wellness program on staff (n = 14) of an outpatient hemodialysis center. The program focused on decreasing dietary sodium and increasing habitual physical activity. The average systolic and diastolic blood pressure of participants decreased by 16.9±21.6 mmHg (p < 0.05) and 4.1±14.0 mmHg (p < 0.05), and body weight decreased by 2.7±1.9kg (p < 0.05). The mean step count at baseline was 7,052±3,278 but increased to 10,388±2,882 (p < 0.05) during a walking challenge. There was a reduction in self-reported barriers to making healthy nutritional changes (p < 0.05) and engaging in habitual physical activity (p < 0.05). Our pilot findings suggest that workplace wellness programs in hemodialysis centers are feasible and effective.

What’s New? Improving Home Medication Lists for Patients on Outpatient Dialysis

Nursing working in outpatient hemodialysis centers face a unique set of challenges working with patients with end stage kidney disease who carry a high medication burden for their multiple chronic conditions. Patient medication lists may not always accurately reflect the entirety of medications prescribed or taken; therefore, nurses are not aware of medication changes that occur in between dialysis treatments. This places patients at risk for medication-related problems or adverse events during treatment. A quality improvement project was developed that included an addition to the daily weight sheet related to any medication changes prior to each patient treatment. Survey results found that assessing for medication changes prior to each treatment improved the accuracy of patient medication lists, which ultimately decreased complications for patients and also improved nurse satisfaction.

Use of a gentamicin-citrate lock leads to lower catheter-related bloodstream infection rates and reduced cost of care in hemodialysis patients.

Central venous catheters (CVC) are a major contributor to infections in hemodialysis (HD) patients, leading to high morbidity and mortality. Gentamicin-citrate (GC) lock is used as standard of care at centers belonging to a mid-size dialysis organization. Four outpatient HD centers acquired by the organization continued to use heparin for catheter locks for a period of time before converting to the provider's standard of using GC lock. In this retrospective observational study, we included patients receiving HD by CVC at these four centers. We report rates of CVC-related bloodstream infections (CVC-BSI) during the heparin lock and the GC lock periods; crude rate ratios and adjusted rate ratios using Cox survival analyses adjusting for potential confounders; microbiology patterns; safety signals (gentamicin resistance, hospitalizations and deaths); and financial impact on payer. A total of 220 and 281 patients used tunneled CVCs, accounting for 25,245 and 44,550 catheter days in the heparin and the GC lock periods, respectively. CVC-BSI event rates were 66% lower in the GC lock period (CVC-BSI event rate: 0.20 per 1000 catheter-days) than the heparin lock period (rate: 0.59 per 1000 catheter days); rate ratio 0.34 (95% confidence interval (CI) 0.15-0.78, P = 0.01). In the fully adjusted multivariable Cox model, use of GC lock was associated with 70% reduction in CVC-BSI events (HR 0.30, 95% CI 0.12-0.72, P = 0.01). No increased risk of gentamicin resistance, hospitalizations, or death associated with use of GC lock were observed. Use of GC lock was associated with an estimated saving of $1533 (95% CI: $259-$4882) per patient per year. Use of GC lock led to significant reductions in CVC-BSIs with no signal for harm, and is associated with significant cost savings in dialysis care.

A Needs-Assessment Survey of Healthcare Professionals Accountable for Infection Prevention and Control in Hemodialysis Setting

<h3>Background</h3> Little is known about the challenges of infection prevention and control (IPC) program implementation in hemodialysis settings. A survey was conducted to study these challenges and the resources needed to overcome them. <h3>Methods</h3> Outpatient hemodialysis centers (OHC) and hospitals with hemodialysis units were invited to send healthcare professionals (HCPs) accountable for IPC to attend an IPC training program. All attendees were asked to complete an anonymous 11-question IPC program needs-assessment survey during the training. Qualitative and descriptive analyses were used to study the results. <h3>Results</h3> Out of 32 HCPs who responded to the survey, a majority (n=24, 75%) reported working in OHC. Half of the respondents (50%) identified their primary job roles as RN/LPN involved in patient care, 10 (31.3%) as nurse managers/other leadership positions and only 7 (21.9%) as infection preventionists. Many (68.8%) reported >10-year experience. They identified issues related to hand hygiene (66.7%), bloodstream infection (BSI) prevention (38.9%), and cleaning and disinfection (38.9%) as top 3 IPC concerns at their facilities. The top 3 barriers to implementing IPC practices were: high volume of patients/ time constraints (72.4%), lack of staff understanding/motivation/compliance (69%); and lack of patient engagement (34.5%). Educational webinars (68.8%), conferences (68.8%), and having IPC experts available via phone or video-conferencing (53.1%) were reported as potentially helpful in developing and improving IPC programs. Top educational needs identified were hand hygiene (40.6%), preventing BSI (25%), and cleaning and disinfection (21.9%). The preferred methods for receiving educational updates on IPC-related topics were e-mails (87.5%), conferences (78.1%), and webinars (43.8%). <h3>Conclusions</h3> HCPs accountable for IPC in hemodialysis settings usually have other primary job roles. Several barriers were reported in program implementation, which will require significant time commitment to mitigate. Professional organizations and other stakeholders should advocate for protected IPC time for these HCPs, and support IPC program improvement efforts.

Developing an Infection Prevention Position for a Multi-Center Hospital-based Dialysis System

<h3>Background</h3> There exists in most dialysis centers opportunities for improvement, including infection control practices, work practice safety, medication safety, regulatory compliance, training, and cost reduction. Although IP's are experts in HAI prevention, implementation science and problem-solving, it is typical for dialysis centers to have only limited access to an infection preventionist (IP). This hospital-based dialysis system created a .8 FTE IP dialysis staff position to support existing quality improvement efforts and address compliance and infection control issues. <h3>Methods</h3> 2 IPs are responsible for this health system's infection prevention program, including 4 outpatient hemodialysis centers, 1 inpatient hemodialysis center and a home peritoneal dialysis program. Prior to September 2018, the dialysis centers' monthly audits, compliance and quality improvement issues were the responsibility of the centers' supervisors and manager. Based on an increase in NHSN positive blood culture events and observed infection control and compliance issues, the health system identified the need for additional IP support for dialysis. A .8 FTE IP position was created within dialysis with job responsibilities in the area of both infection control and compliance. <h3>Results</h3> Positive blood culture events dropped 42%, from 12 in 2018 to 7 (as of December 2019). Compliance with the contact time during dialysis catheter hub disinfection improved from 8% to a sustained 100%. Likewise, compliance with skin antisepsis contact time improved from 40% to a sustained 100%. The IP was a major contributor to over 25 successful quality improvement projects which focused on safety, infection prevention, regulatory compliance and cost reduction. <h3>Conclusions</h3> The addition of an IP to the dialysis staff can contribute to best practices, safety, infection prevention, regulatory compliance, and reduced costs. Collaboration with the health system's IP's, dialysis staff and leadership is essential for success.