Outpatient Hemodialysis Facilities Research Articles

Assessments and observations of infection prevention and control practices in US outpatient hemodialysis facilities, 2015-2018: important opportunities for improvement.

Infections cause substantial morbidity and mortality among patients receiving care in outpatient hemodialysis facilities. We describe comprehensive infection prevention assessments by US public health departments using standardized interview and observation tools. Results demonstrated how facility layouts can undermine infection prevention and that clinical practices often fall short of policies.

Integrating Care Coordination and Mental Health Research Into Dialysis Practice: Stakeholder Perspectives, Methods, and Outcomes

Despite many studies suggesting beneficial innovations for patients, few make it into clinical practice. This study aims to enhance patient care by facilitating effective dissemination of patient-centered outcomes research to health care workers in outpatient dialysis facilities, aided by the Patient-Centered Outcomes Research Institute's (PCORI) dissemination and implementation framework. Dissemination and implementation project. Outpatient hemodialysis facilities in the United States. We brought together panels of key stakeholders, which included researchers, patient subject matter experts, and dialysis personnel. Their role was to provide guidance on the content and methods for disseminating research findings. With a focus on 2 critical patient safety areas-care coordination or care transitions and mental or behavioral health-we developed virtual education modules. These modules were then made available to outpatient dialysis facilities by the national 5-Diamond Patient Safety Program. In 2022, the training was used by more than 2,500 dialysis facilities and approximately 40,000 dialysis staff in the care coordination module, and by more than 300 dialysis facilities and 5,000 staff for the mental health module. Cumulatively, the modules affected more than 179,000 patients. Evidence of efficacy was the significant increase in trainee knowledge of research findings and implementation considerations (P≤0.05). Potential selection bias because dialysis facilities that did not participate in the program may differ significantly from those that did, which may affect generalizability. In addition, variable timing in release of the different modules may have influenced uptake by facilities. By using key stakeholder guidance and accessible virtual education modules, the implementation framework shows promise in effectively disseminating research findings within outpatient dialysis settings. This method potentially carries implications for broader health care settings as well. Our study addresses a common health care challenge-many promising ideas for improving patient care never actually reach the patients. We aimed to bridge the dissemination gap by sharing research with health care workers in outpatient dialysis, promoting evidence-based practice. We collaborated with experts, patients, and dialysis personnel to develop easy-to-understand educational materials focused on 2 critical topics: care coordination and mental health. In 2022, our training benefited more than 2,500 facilities and 40,000 staff for care coordination, and 300 facilities with 5,000 staff for mental health, positively affecting more than 179,000 patients. We found that the training significantly increased knowledge among staff. Our approach shows promise for sharing research effectively in dialysis centers and potentially in other health care settings.

Validation of an instrument to assess fluid control in outpatient hemodialysis patients

Purpose: To validate an instrument to assess fluid control in outpatient hemodialysis patients, using the NANDA International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) terminologies.Methods: A methodological study was carried out in two steps: (1) construction of an instrument composed of operational definitions of the defining characteristics of the nursing diagnosis Excess fluid volume, indicators of the NOC outcome Fluid balance, and activities of the NIC intervention Fluid management, from a narrative literature review, and (2) content validation of the instrument by five experts through a focus group.Results: The instrument was composed of operational definitions of 27 defining characteristics of Excess fluid volume, 23 Fluid balance indicators, and 13 Fluid management activities. Twenty-five out of the 27 defining characteristics were considered valid. Two defining characteristics were excluded from the instrument, as they were considered unsuitable for assessing outpatients on hemodialysis. Thirteen out of the 23 indicators of Fluid balance were reformulated, and two were removed. Thirteen activities of Fluid management were reformulated.Conclusions: An instrument was built incorporating components of the nursing diagnosis Excess fluid volume, the nursing outcome Fluid balance, and the nursing intervention Fluid management. The instrument was considered valid in terms of content and can be used to assess outpatients on hemodialysis. Implications for nursing practice: The instrument created may contribute to the standardization, qualification, and improvement of nursing practice in outpatient hemodialysis facilities.

Absence of SARS-CoV-2 infections among patients with end-stage renal disease following facility-wide testing in four outpatient hemodialysis facilities

Facility-wide testing performed at 4 outpatient hemodialysis facilities in the absence of an outbreak or escalating community incidence did not identify new SARS-CoV-2 infections and illustrated key logistical considerations essential to successful implementation of SARS-CoV-2 screening. Facilities could consider prioritizing facility-wide SARS-CoV-2 testing during suspicion of an outbreak in the facility or escalating community spread without robust infection control strategies in place. Being prepared to address operational considerations will enhance implementation of facility-wide testing in the outpatient dialysis setting.

Kidney Recovery in Patients With Acute Kidney Injury Treated in Outpatient Hemodialysis or Rehabilitation Facilities

Rationale & ObjectiveSince January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.Study DesignSingle-center prospective cohort study.Setting & Participants111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.ExposureHospitalization-related clinical parameters were evaluated.OutcomeKidney recovery as a composite of being alive and no longer requiring HD or other form of kidney replacement therapy.Analytical ApproachDiscrete-time survival analysis and logistic regression were used to determine adjusted probabilities of kidney recovery at prespecified time points and to evaluate clinical parameters associated with recovery.Results45 (41%) patients recovered kidney function, 25 (55.5%) within the first 30 days following discharge, 16 (35.5%) within 30 to 60 days, and 4 (9%) within 60 to 90 days. Adjusted probabilities of recovery were 36.7%, 27.4%, and 6.3%, respectively. Of the remaining patients, 49 (44%) developed kidney failure requiring chronic kidney replacement therapy and 17 (15%) died or went to hospice. Patients who did not recover kidney function were older, had more comorbid conditions, had lower estimated glomerular filtration rates at baseline, and received more blood transfusions during hospitalization when compared with those who recovered kidney function.LimitationsSelection bias given that patients included in the study were all eligible for AKI management with outpatient HD as part of Medicare/Medicaid services.ConclusionsAt least one-third of AKI-D survivors discharged from an acute care hospital dependent on HD recovered kidney function within the first 90 days of discharge, more commonly in the first 30 days postdischarge. Future studies should elucidate clinical parameters that can inform risk classification and interventions to promote kidney recovery in this vulnerable and growing population.

Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project.

Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities. The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool. The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff. Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities

Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.

A small cluster of COVID‒19 in an outpatient hemodialysis facility

A small cluster of COVID‒19 in an outpatient hemodialysis facility

Opportunities to Improve Antibiotic Prescribing in Outpatient Hemodialysis Facilities: A Report From the American Society of Nephrology and Centers for Disease Control and Prevention Antibiotic Stewardship White Paper Writing Group

Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis.

Progress in Preventing Bloodstream Infections in Hemodialysis: Data From the National Healthcare Safety Network, 2014–2018

Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.Funding: NoneDisclosures: None

Delivering Safe and Effective Hemodialysis in Patients with Suspected or Confirmed COVID-19 Infection: A Single-Center Perspective from Italy.

New “Severe Acute Respiratory Syndrome Coronavirus 2” (SARS-CoV-2) is responsible for a clinical entity named Coronavirus Disease 2109 (COVID-19) by the World Health Orgazination, which is now a pandemic (1). In Europe, Italy was the first, and so far the largest, epicenter of the epidemic. It is now clear that many asymptomatic and paucisymptomatic patients went undetected, causing significant diffusion of the disease. Asymptomatic infections are common: among 634 confirmed patients on board the “Diamond Princess” cruise ship, 306 were symptomatic and 328 asymptomatic at the time of testing (2). It is now clear that when a patient with atypical severe pneumonia was diagnosed as COVID-19 in a small city, Codogno, in a previously healthy 38-year-old man, on February 20, 2020, more patients with undetected COVID-19 were present in Northern Italy. In addition to the cluster around Codogno, about 50 km south of Milan, which was promptly put under strict lockdown, two additional relevant clusters emerged near the cities of Bergamo and Brescia. The delay in enforcing a lockdown in the latter areas is probably one of the leading causes of the more severe outbreak now affecting these provinces. Extensive testing in the initial phase of disease diffusion was adopted in the Italian Veneto area, resulting in better containment of new cases. A nationwide lockdown measure was passed by the Italian government when Northern Italy, which has the highest concentration of well organized hospitals in the country, started showing signs of difficulty handling the rapid increase of patients in need of treatment in intensive care units (ICUs). A comparison of Chinese and Italian data on COVID-19 may be of interest to other countries where the disease is now spreading. The Chinese Center for Disease Control and Prevention described the characteristics of a large cohort of COVID-19 patients (3), showing that …

Management of Hemodialysis Patients with Suspected or Confirmed COVID-19 Infection: Perspective of Two Nephrologists in the United States.

The coronavirus disease 2019 (COVID-19) pandemic is unprecedented and information about the severe acute respiratory syndrome coronavirus 2 is evolving rapidly. New York is one of the epicenters of the COVID-19 outbreak in the United States, reporting >1000 confirmed cases as of March 17, 2020, and cases are escalating exponentially. The majority of cases are in Westchester County ( n =220) and New York City (NYC; n =463), which includes Bronx (1). The local index patient case was a Westchester man who became ill on February 22, was not associated with a recent travel exposure to a country on the watch list (China, Iran, South Korea, and Italy), or known to have had direct contact with a COVID-19–confirmed patient. At the present time it is estimated that community-wide transmission accounts for 87% of confirmed cases. Nephrologists in the Bronx have been handicapped in managing patients with ESKD during the early weeks of the COVID-19 pandemic due to the limitations of available rapid testing for severe acute respiratory syndrome coronavirus 2. Montefiore Medical Center, located in the north Bronx in close proximity to Westchester, has been one of the main tertiary care hospitals in NYC caring for persons under investigation (PUIs) and for COVID-19–confirmed patients. Our nephrology division’s clinical faculty care for approximately 850 patients with ESKD (approximately 800 on hemodialysis and approximately 50 on peritoneal dialysis) in 12 outpatient hemodialysis facilities (two Fresenius and 10 DaVita facilities) in the Bronx. We report our experience with caring for the ESKD population and patients who are hospitalized with AKI in the Bronx during the first 3 weeks of the local NYC COVID-19 pandemic. Strategies proposed for the prevention and management of COVID-19 transmission for patients with ESKD in the outpatient dialysis facilities have been dynamic. The American Society of Nephrology’s (ASN’s) Nephrologists Transforming …

Multicenter Outbreak of Gram-Negative Bloodstream Infections in Hemodialysis Patients

Contaminated water and other fluids are increasingly recognized to be associated with health care-associated infections. Weinvestigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. Matched case-control investigations. Patients who received hemodialysis at Facility A, B, or C from July 2015 to November2016. Infection control practices, sources ofwater, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. Exposures in cases and controls were compared using matched univariate conditional logistic regression. 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wallboxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers' hands to contaminate central venous catheters with contaminated fluid from the wall boxes. Limited patient isolates for testing, on-site investigation occurred after peak of infections. This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.

Materiality in information environments: Objects, spaces, and bodies in three outpatient hemodialysis facilities

The materiality of information environments, and its role in information behavior, has received little attention. We present an ethnographic study involving 156 hours of observation and 28 patient interviews in outpatient hemodialysis facilities. Using an extended “Semiotic Framework for Information Systems Research,” the findings show that objects, spaces, and bodies were integral to 6 sociomaterial layers of facility information environments: the physical, empiric, syntactic, semantic, pragmatic, and social world. Objects of importance in the information environments included dialysis machines, instruments, records, paper documents, televisions, furniture, thermostats, lighting, and personal possessions. Spatial features, including compartmentalization, displays, distance, proximity, and spatially‐grounded routines, also constituted information environments. The information environments were also shaped by patient immobility, bodily discomforts, and orientation to bodily states. Each sociomaterial layer introduced enablers and constraints to information access, flow, and acceptance; these combined to construct patients primarily as passive recipients of information rather than active seekers and producers of information. A sociomaterial perspective and related focus on objects, spaces, and bodies offers a lens for professional information practice. We contribute information environment design guidance to facilitate such practice and stress that the value of certain sources and types of information can be materially encoded in an environment.

The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities.

Antimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%-35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed. To quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.Study design and settingAn interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period. Implementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met. Within 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.

Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model.

Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits. We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources. On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs. The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.

Potentially Avoidable Readmissions in United States Hemodialysis Patients

IntroductionPatients with end-stage kidney disease have a high risk of 30-day readmission to hospital. These readmissions are financially costly to health care systems and are associated with poor health-related quality of life. The objective of this study was to describe and analyze the frequency, causes, and predictors of 30-day potentially avoidable readmission to hospital in patients on hemodialysis.MethodsWe conducted a retrospective cohort study using the US Renal Data System data from January 1, 2008, to December 31, 2008. A total of 107,940 prevalent United States hemodialysis patients with 248,680 index hospital discharges were assessed for the main outcome of 30-day potentially avoidable readmission, as identified by a computerized algorithm.ResultsOf 83,209 30-day readmissions, 59,045 (70.1%) resulted in a 30-day potentially avoidable readmission. The geographic distribution of 30-day potentially avoidable readmission in the United States varied by state. Characteristics associated with 30-day potentially avoidable readmission included the following: younger age, shorter time on hemodialysis, at least 3 or more hospitalizations in preceding 12 months, black race, unemployed status, treatment at a for-profit facility, longer length of index hospital stay, and index hospitalizations that involved a surgical procedure. The 5-, 15-, and 30-day potentially avoidable readmission cumulative incidences were 6.0%, 15.1%, and 25.8%, respectively.ConclusionPatients with end-stage kidney disease on maintenance hemodialysis are at high risk for 30-day readmission to hospital, with nearly three-quarters (70.1%) of all 30-day readmissions being potentially avoidable. Research is warranted to develop cost-effective and transferrable interventions that improve care transitions from hospital to outpatient hemodialysis facility and reduce readmission risk for this vulnerable population.

Impact of a Regional Collaborative to Reduce Bloodstream Infections in Outpatient Hemodialysis Facilities

Impact of a Regional Collaborative to Reduce Bloodstream Infections in Outpatient Hemodialysis Facilities

Patient safety culture and nurse-reported adverse events in outpatient hemodialysis units.

Patient safety culture is an important quality indicator in health care facilities and has been associated with key patient outcomes in hospitals. The purpose of this analysis was to examine relationships between patient safety culture and nurse-reported adverse patient events in outpatient hemodialysis facilities. A cross-sectional correlational, mailed survey design was used. The analytic sample consisted of 422 registered nurses who worked in outpatient dialysis facilities in the United States. The Handoff and Transitions and the Overall Patient Safety Grade scales of the Agency for Healthcare Research and Quality's (AHRQ) Hospital Patient on Safety Survey were modified and used to measure patient safety culture in outpatient dialysis facilities. Nurse-reported adverse patient events was measured as a series of questions designed to capture the frequency with which nurses report that 13 adverse events occur in the outpatient dialysis facility setting. Handoff and transitions safety during patient shift change in dialysis centers was perceived negatively by a majority of nurses. On the other hand, a majority of nurses rated the overall patient safety culture in their dialysis facility as good to excellent. All relationships between patient safety culture items and adverse patient events were in the expected direction. Negative ratings of handoffs and transitions safety were independently associated with increased odds of frequent occurrences of vascular access thrombosis and patient complaints. Negative ratings of overall patient safety culture in dialysis units were independently associated with increased odds of frequent occurrences of medication errors by nurses, patient hospitalization, vascular access infection, and patient complaints. Findings from this analysis indicate that a positive patient safety culture is an important antecedent for optimal patient outcomes in ambulatory care settings.

887Opportunities to Improve Completeness of MRSA Bloodstream Infection Reporting From Outpatient Hemodialysis Facilities to the National Healthcare Safety Network

887Opportunities to Improve Completeness of MRSA Bloodstream Infection Reporting From Outpatient Hemodialysis Facilities to the National Healthcare Safety Network