Reducing infection in the outpatient dialysis facility

Reducing infection in the outpatient dialysis facility


[ Music ]>>Hello and welcome to today’s webinar, Tune
in to Safe Healthcare: Reducing Infection in the outpatient dialysis facility – Results
of the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal
Disease or SCOPE Collaborative. Hosted by the Centers for
Disease Control and Prevention and the Making Dialysis Safer
for Patients Coalition. CDC’s mission is to save lives and protect
the health and safety of Americans. My name is Priti Patel and I
am a medical officer who serves as the Dialysis Activity Leader within the
Division of Healthcare Quality Promotion at the Centers for Disease
Control and Prevention. I am also the Medical Director of the Making
Dialysis Safer for Patients Coalition. This webinar is part of a series of infection
control related webinars the CDC hosts along with a variety of external partners and experts. The Making Dialysis Safer for Patients Coalition
is a collaboration of diverse organizations who have joined forces with the
common goal of promoting the use of CDC’s recommended interventions and resources to prevent bloodstream infections
in dialysis patients. I am pleased to introduce the featured
speakers for our webinar today. Dr. Bradley Warady is a Professor
of Pediatrics at the University of Missouri, Kansas City School of Medicine. He is the Director of the Division of
Nephrology and the Director of Dialysis and Transplantation at Children’s
Mercy Hospital. Dr. Alicia Neu is a Professor of Pediatrics and
the Division Director for Pediatric Nephrology at the Johns Hopkins University
School of Medicine. She is also the Director of Pediatric
Dialysis and Kidney Transplantation at the Bloomberg Children’s
Center at Johns Hopkins Hospital. Both Doctors Warady and Neu are members of
the project committee for the American Society of Nephrology or ASN, Nephrologist
Transforming Dialysis Safety Initiative. I’ve had the pleasure of interacting
with them on that committee and experiencing first hand their
passion for preventing infections. Doctors Neu and Warady helped to spearhead
the development of the SCOPE collaborative, the topic of today’s presentation. And it remains the faculty leads of the
collaborative since its launch in 2011. Before we get started there are a
few housekeeping items to cover, we welcome your questions,
please submit any questions or comments you have via your chat window
located on the lower left hand side of the webinar screen any
time during the presentation. Questions will be addressed after
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speakers are turned on with the volume up, the audio for today’s conference should
be coming through your computer speakers. In addition, the speaker’s slides from
today’s presentation will be provided to participants in a follow up email. Without further ado I’d like to turn it
over to our first presenter, Dr. Warady.>>Well, thank you Priti very much for that
introduction and I just want to begin by saying that Dr. Neu and I are very honored
to be able to provide this webinar to give folks some insight into the
activities of the SCOPE collaborative. Knowing how many people that have signed up for
this webinar, it’s great to hear that there’s so many of us around the nation that have
the goal of decreasing the rate of infection in patients on dialysis, both
pediatric and adult patients. I suspect that many of you
are not pediatric providers and so I thought I’d give you two
background slides to give you a little bit of insight into pediatric dialysis. This slide is from the 2011
annual report of the NAPRTCS, or the North American Pediatric Renal
Trials and Collaborative Studies. An organization that has had a registry of
pediatric kidney disease for more than 25 years. And here we’re looking at the primary
diagnoses associated with the development of end stage kidney disease in
children based on some 7,000 children. You note that the most common diagnosis
is focal segmental glomerulus sclerosis or steroid resistant nephrotic syndrome. Followed by aplastic, hypoplastic,
dysplastic kidneys and obstructive uropathy. The latter generally being posterior urethral
valves and then a host of other disorders. Again, for the adult practitioners you’ll
note the absence of systemic hypertension or diabetes mellitus as a cause of end stage
kidney disease in the pediatric population. This next slide also from the
2011 report of NAPRTCS looks at the dialysis modality by age group. You’ll note that PD is in yellow and
hemodialysis is in blue and we divided it into four different age groups
at dialysis initiation. So you’ll see that in those children who
initiate dialysis at less than 2 years of age the vast majority are
prescribed peritoneal dialysis. Some 95% largely because hemodialysis
is very complex in these young infants and there’s a lack of adequate vascular access. Both increasing age of the children when they’re
cared for in a pediatric dialysis program. You’ll note a progressive increase
in the percent of the children who received hemodialysis such
as in the adolescent population. There’s near equal distribution of children
on peritoneal dialysis and hemodialysis. Now if we were just going to look at
adolescent individuals who are cared for in adult programs the vast majority of
those children do in fact receive hemodialysis. But you might ask why did we
focus on reducing peritonitis in the SCOPE collaborative
as our initial project. And really three major reasons for that,
number one peritonitis is the leading cause for hospitalization in the pediatric PD
patient, not only in the U.S. but globally. Recurrent peritonitis is a leading
cause for PD failure and the need to transfer the children to hemodialysis. And then finally maybe most importantly,
infection is a leading cause of mortality in children who receive chronic
peritoneal dialysis. [ Pause ] This slide reviews the variability
in peritonitis rates that we see in the pediatric population, we’re looking at
peritonitis rate in months between infection. So we look at the mean data from the
NAPRTCS you can see that the mean rate is about 1 infection every 28 patient months. This data here is from the international
pediatric peritoneal dialysis network where the mean infection rate is approximately
one infection every 20 patient months. But each of these dots represent the peritonitis
rates at different centers across the U.S., different pediatric dialysis centers. So you can see the great variability with
these centers having very frequent episodes of peritonitis and this center here
having very infrequent peritonitis. And this variability in the peritonitis
rate suggested there is variability in the care provided these children. And our hypothesis has been that if we can
develop more uniform approaches to care that we would indeed seek
improvement in the rates, a decrease of infections in
these children on chronic PD. [ Pause ] So the SCOPE collaborative is part of the Children’s Hospital Association’s
quality transformation network which utilizes a quality improvement process
to increase implementation of standardized care of practices, or as we call them care bundles. This system is such that we’re utilizing again
the SCOPE collaborative which has experience with CHA, the Children’s Hospital Association, in the experience facilitating
national collaboratives. CHA has established collaboratives not only
with end stage kidney disease but a number of other disorders affecting children. Their model also includes multidisciplinary, multi-institutional faculty
which we’ll get to in a moment. As I mentioned to you already the NAPRTCS
that’s our data coordinating center, so all the data is located centrally of
the NAPRTCS and the NAPRTCS has 25 years of experience with data collection in
pediatric CKD, dialysis and transplantation. With data from over 140 pediatric
nephrology centers across North America. Now most important to this collaborative
structure are the site teams, as I said before there are
multidisciplinary teams that are testing and implementing the care of bundles. Now in each team there must be
pediatric nephrology representation and pediatric dialysis nurse representation. But there also may be individuals from the QI
department, infectious disease, even surgeons. And so the makeup of the team
in individual sites does vary but there’s always pediatric nephrology
and pediatric dialysis nurses. These teams report process and outcome data on a
monthly basis and they participate in workshops and webinars and ListServ’s and we’ll
come back to that in a few moments. [ Pause ] This is a map that just gives you visualization
of where these sites are that are participating in the SCOPE collaborative
some 40 sites as you can see. Each represented by a star and the names of the individual sites are
located here around the map. And virtually all of the largest pediatric
dialysis programs in the country are part of this truly national collaborative
to decrease peritonitis and exit site infection in
these children on chronic PD. [ Pause ] Now once again, the SCOPE collaborative is
part of this quality transformation network that utilizes quality improvement to increase
implementation of standardized care practices. This system also requires a
process to ensure ongoing, reliable performance of standardized care. And the education elements of corporate
teams so if need be they can change behavior to increase the implementation
of these standard practices. I want to emphasize from the start that
while I’m sharing with you our experiences with the processes in the
pediatric dialysis program, these same processes can most
definitely be incorporated into adult dialysis programs as well. So, we’re going to go over each of
these processes in the next few slides. We need to standardize care as
part of the SCOPE collaborative if we hope to decrease peritonitis rates. And so to do that we’ve established three sets
of care bundles, a PD catheter insertion bundle which addresses both the intraoperative and the
immediate post-operative care of that catheter. The training bundle which focuses on the
training of the patient and family prior to going home on peritoneal dialysis. And the follow up care bundle which addresses
the content of the monthly clinic visits and the evaluation, the education that
takes place during those periods of time. This slide reviews the content of
the PD catheter insertion bundle. So the catheter exit-site orientation
is in the lateral or downward position since those positions seem to be associated
with the lowest rate of peritonitis in children. A first generation cephalosporin is provided
intravenously within 60 minutes prior to the incision for the PD catheter placement. No sutures are utilized at the
exit-sites to decrease the likelihood of catheter exit-site infections. And postoperatively the catheter
is immobilized once again to decrease the likelihood
of exit-site infection. There are no dressing changes within the
first 7 days and then only in a sterile manner until that exit-site is well-healed and then
no catheter utilization for the first 14 days. [ Pause ] This slide reviews the patient and caregiver
training bundle, the training is performed by a qualified nurse on a 1 to 1
ratio with that patient and family. Ideally there’s a primary provider
and an alternate for each patient. There’s appropriate teaching age
and there’s unit training protocols that are based upon the content
of the pediatric guidelines from the International Society
for Peritoneal Dialysis. There are specific protocols that are utilized
in teaching that address aseptic techniques, exit-site care and we utilize
the recommendations of the World Health Organization
for hand hygiene. Post training there’s a concept test and
a demonstration test and a home visit to occur again with each training. Finally, our third bundle is the PD
catheter and exit-site follow up care bundle. And this is the content of those monthly
visits, so at each visit the exit-site is scored by the nurse utilizing a
scoring system that was developed by the International Pediatric
Peritoneal Dialysis Network. And during each visit there are key
aspects reviewed of hand hygiene, exit-site care and aseptic techniques. Now one component of this bundle that very few
sites utilized before the SCOPE collaborative is the utilization of a six month
demo test and concept test and that is every six months while
that patient is receiving PD. And this is a means to review the retention
of the information that has been shared with the patient and the family
as part of the training process. There is focused retraining
after each peritonitis episode and then prophylactic antibiotics are
used following touch contamination or any of the breaks in technique
according to the guidelines of the International Society
for Peritoneal Dialysis. And this is particularly important because
we see that coag negative staph is one of the most common organisms that gives rise
to peritonitis in our patient population. Now, the next important issue to
address is auditing and it’s important that we audit our performance so that
we can insure reliable performance of the standardized care and if indeed
we see that we are not achieving that reliable performance, it
allows us to modify behavior to again hopefully improve the implementation
of these standardized care practices. Now, in most quality processes, one looks
at a subset of data and then analyzes that as part of quality improvements. We do something different in SCOPE, we gather
compliance data on every catheter insertion, on every initial training session
and on every single follow up visit. So we have a robust data set of compliance that helps us again achieve the best
possible outcome in these children. When we look at compliance in the SCOPE
collaborative, we look at it as an all of none phenomena, so for instance this
are the components of the training bundle. If we’re looking at compliance
and training we have to be compliant in all aspects of the bundles. So for a nurse to say that
she has been compliant in conducting the training bundle
she has to be compliant in all of these different elements
of that training bundle. It’s truly an all or none phenomena and
thus we have a very high bar to achieve in the SCOPE collaborative but we
think that is the best approach to achieving the optimal
standardized care practices. [ Pause ] Now the next important process in this overall
initiative is to teach the clinical teams to change their behaviors and to
teach them how to engage patients and families to implement the best practices. I think this is one of the most important
components of this entire initiative. This engagement of patients and families,
clearly when you’re conducting a procedure like peritoneal dialysis that occurs in the
home, we have to have a seamless partnership between the clinical team and the patients and
families if we hope to achieve the best success. And so I think this has been
an integral component of SCOPE that is now being shared
across our collaborative. We teach the clinical teams to use
quality improvement methodology to increase implementation of
these standardized care practices. And the model employed by SCOPE
is the model for improvement. This includes the use of plan, do,
study, act cycles or PDSA cycles, small tests of change that drive improvement. Also crucial in this entire process
is developing a culture of safety. Patient safety, especially infection prevention,
must be a priority in the dialysis unit of every member of the health care team
including the patient and their families. And all of these stakeholders must
be empowered to implement that change if we hope to achieve the best outcomes. This is an example of the
PDSA cycle and the improvement that was experienced at one of our centers. This is data from Nationwide
Children’s Hospital. Here we’re looking at monthly
compliance rates as well as rolling 12 month cumulative compliance
rates for insertion compliance reflected by the redline, training compliance
reflected by the blue line and a follow up compliance by the green line. But the focus here on the 12 month rolling data
on the insertion compliance you can see early on there was zero compliance in
terms of the insertion processes. But over time there were marked
improvements again following the introduction of these three different products
following their previous day cycles, most recently the catheter insertion check list. [ Pause ] This is the checklist that has been used by
Nationwide Children’s Hospital and I’m not going into great depth about the checklist. Other than to say that the checklist
includes information on the proper antibiotic to use prior to catheter insertion. The dose of the antibiotic, what to do
postoperatively, how to address the exit-site and a host of factors all that
addressed optimal catheter care. Now what’s important is not only
did this product assist the folks at Nationwide Children’s Hospital
in improving their outcome. But this product was shared amongst all
the collaborative sites and incorporated into other sites as well
to improve their outcome. So the sharing of resources among collaborative
sites within SCOPE have been another key product and something that has lent
itself to improved outcomes across all 40 centers participating
in the collaborative. [ Pause ] Next we need to support the teams with monthly
transparent data and networking sessions. Another key aspect of the SCOPE collaborative
and this slide is from the homepage of the NAPRTC, just to highlight the fact
that there’s real time data that is available to be shared among all the sites in a transparent manner that
are participating in SCOPE. These data like I said are real time
and anyone can see anybody else’s data. This is very, very important for
the quality improvement process. Centers need to be able to track their own
data so they can see how they are doing and they can identify areas
where they’re struggling and where some change in
behavior may be helpful. They can also view other center’s data to allow
them to identify centers who are doing well, so that they can reach out to those
centers and learn from their experience. Something else that again is
incorporated into our DNA in pediatrics, it could also be utilized by adult providers. I’m going to quote Jane Steward, Jane works
with us at CHA and she stated that the model for this philosophy of transparency is to
steal shamelessly and share seamlessly. And that’s something that all of us
practice in the SCOPE collaborative. Now we also share information
on the volume of data that we’re receiving with
all of our participants. So this is an example of data
that we share with our team, data collected between October
2011 and October 2016. So you can see we had over 1,200
enrollments and information on more than 1,000 catheter insertions. We have information on almost 1,100
training sessions and 15,000 follow up forms. And information on 833 infections, nearly
600 episodes of peritonitis and 237 episodes of exit-site peritoneal infections. So this robust data base
allows us to analyze these data and hopefully generate important information
that may ultimately be incorporated into bundles and help us decrease the rate of peritonitis. We also shared information with our teams on the
rate of infection, here we’re looking at data on the aggregate monthly
exit-site infection rate. So here we’re looking at months between
infections, this is all exit-site infections and this is the same data but
characterized by infections per patient year. Now here we’re looking at the months over time. And I think what should be evident to you is
the great variability that occurs on a month to month basis in the number of infections
that are seen across the collaborative. But if you look at it as a 12
month rolling average you can see that there has indeed been a gradual
improvement in the exit site infection rate. Once again here’s a month between infection,
the rolling 12 month cumulative data and here’s the infections per patient year. And so you note that early on October
2011, the annualized rate was somewhere around 0.38 infections per patient year and we
progressively improve to somewhere around 0.15, 0.14 infections per patient year. Other data that we share with our team
related to exit-site is data like this. A control chart, so here we’re looking at
once again the annualized infection rate. And we’re looking here at data
just on 22 centers who provided us with historical data before the initiation
of the collaborative and then looking at the experience of those same centers
following the initiation of the collaborative. So here’s the historical data
and the mean pre-study right here and here’s the post collaborative
data over 57 months. These are the monthly collaborative
rates of exit-site infection. And you can see that we’ve seen a progressive
improvement, still more work to be done, but a progressive improvement about a 25%
decrease in the rate of exit-site infections. But I show you this as just another
example of the kind of data that we share with all the sites within our collaborative
on a regular basis to point out our success and to point out the challenges
that are still in front of us. Now, while looking at infection
rate is critically important we look at another outcome metric and that is the
fiscal impact of infection prevention. And we do that by combining the data
from SCOPE with data from the PHIS, a data base that is the Pediatric
Health Information System. That’s a data base that includes information
from more than 45 children’s hospitals across the nation, including fiscal data. And by combining these data we find to
date that the median cost of a treatment of peritonitis was about $14 thousand
per episode with higher costs associated with patients who experience an ICU stay,
who experience septic shock in association with their hospitalization or who
have developed fungal peritonitis. Well, you might ask well where
does all this networking occur? And I think this is again critically
important to the success of SCOPE. So we have monthly webinars and in those
webinars we have the participation of one or more representatives from virtually all
40 centers that are participating in SCOPE. The webinars may be educational sessions,
we may be sharing challenging cases. We may be discussing potential
new initiatives but it’s a way to truly hear from one another’s experience. Maybe the most important networking
opportunity is the twice yearly, face to face learning sessions that we have. This gives us an opportunity to sit
at the same table with individuals, learn from their expertise and their insights
that we can incorporate into our own sites. We hear failures, we hear success stories
and I think all that has allowed us to then generate more PDSA
cycles, more improvement, that has been shared across the collaboratives. So this is a kind of interaction, again
it’s occurring here in pediatrics. It certainly can occur in adult
programs as well and is key to the improvement practices
that we’re experiencing. There’s an eGroup list serve,
there’s a practice inventory where the nurses are collecting information on
pediatric practices, not only those that are within the bundle but even
outside the bundle and the again, review of that information lends
itself to more information in terms of how we might decrease
infection risk in our patients. And then there’s regular online sharing of resources amongst all the
participants from the collaborative. Finally we need to scientifically
assess the impact of our effort, we need to take all the data
that we’ve collected. We need to analyze the data and
we need to publish that data so that it can be shared amongst the
dialysis community both peritoneal dialysis and hemodialysis, both pediatric and adults,
and so now I’m going to hand over the microphone if you will to Alicia Neu, she’s going to review
the analysis of the data that we’ve collected on PD and she’ll also introduce the new
initiative in SCOPE that of the assessment of hemodialysis patients,
so Alicia it’s all yours.>>Great, thanks Brad, so again
as Dr. Warady said the final step in the QI process is the scientific
assessments of the impact of the effort. And he’s already shown you how we continuously
assess that impact using control charts. And as he mentioned we intermittently perform
rigorous statistical analyses on all of the data that we collect on all these patients. And we recently published the results of an
analysis of the first three years of SCOPE. These were published in KI and the title page
from that manuscript is shown on this slide. Excuse me. I’ll briefly review the results
of that analysis which focused on the improvement in follow
up bundle compliance. And the change in peritonitis rates over
those first three years of the collaborative. As Dr. Warady mentioned there are currently 40
pediatric dialysis units participating in SCOPE but in order to be included in the analysis
that I’m presenting, a center had to be in the collaborative at the
time of launch in October 2011 and there were 29 centers at that time. The analysis was further limited to
those centers which had provided patient and infection counts for the
13 months prior to launch. Or historic data to which the post-launch
infection rates could be compared, 24 centers met these criteria. From which there were 644 patients enrollments,
751 catheter insertions, 319 training sessions and 7,977 follow up forms submitted in
the first 36 months of the collaborative. As mentioned by Dr. Warady, compliance for
all three bundles is assessed as all or none. Meaning that every patient’s catheter insertion
training session or follow up event had to comply with all of the elements of the
respective bundle to be considered compliant. Infection rates for each center were calculated as an annualized rate using
the formula shown on this line. And then the collaborative rates were
calculated as the mean of the center rates. So, I should emphasize that although more than
640 patients were enrolled in the collaborative, because the central hypothesis of SCOPE is that
more uniform practices across centers will lead to a reduction in infection
rates at those centers. For statistical purposes the unit of interest
is the dialysis facility and not the patients. So the effective sample size for
these — this analysis is 24. This slide shows the monthly compliance
with each of the care bundles over time with PD catheter insertion bundle in
blue, the training bundle in orange and follow up care bundle in green. Note the significant month to month
variability in both the training and catheter insertion compliance. This is in large part due to the low number of
these events, we would typically get between 2 and 25 catheter insertion or
training events reported every month. In addition, it’s related against an all or
none compliance scoring, so if you completed 90% of the insertion bundle you don’t get
a score of 90 you get a score of 0. Conversely, the average number of follow up
events is about 250 per month and as you can see across the collaborative the follow up care
compliance slowly but steadily increased over the first three years of the collaborative. It increased so that by just over two years
after the collaborative launch we hit a level of 80% compliance with follow up care. Changes in bundle compliance over time
were assessed using generalized linear mix model techniques. Which confirmed that the probability
of compliance with the follow up care bundle increased significantly over
the first 36 months of the collaborative. That’s highlighted here in the red box. Not surprisingly given the variability
in compliance and the small number of events every month, these models could not
detect a significant increase in compliance with either the insertion
or the training bundle. Although it’s impressive that we were
able to ultimately achieve 80% compliance with the follow up bundle there may be some in
the audience who are wondering why it took us over two years to reach this
level of compliance. As a reminder the PD catheter follow up bundle
requires that hand hygiene, exit-site care and aseptic technique be
reviewed with the patient and the care giver at every
single follow up visit. The bundle also requires that the
patient and family demonstrate competence with these procedures using both the concept
of demonstration tests every six months. Again, compliance is scored as all or none, so
if you review exit-site care and hand hygiene but not aseptic technique, you get scored
as a zero for that follow up event. The PD providers in the audience will
immediately recognize the difficulty in getting all of these bundle elements
into an already busy PD clinic visit. That requires review not only of infection
prevention but also the many other aspects of the care of these complex patients. Thus, it’s not surprising that centers
may be able to implement some but not all of the bundle elements consistently
at every single visit. In fact, this figure shows both the
monthly overall compliance with a follow up bundle here in this solid line. Along with the compliance with each of the
subcomponents in the various dotted lines. Note that compliance with nearly all of
the elements individually achieved a 70 to 80% compliance level within
a few months of the launch. But overall compliance which again requires
that we do every single one of these things in every single visit did not
reach 80% until the fall of 2013. Again, if you were previously surprised
that it took us over two years to get 80%, you may now be surprised
that we got there at all. And achieving this level of compliance was
only possible because the entire care team at each center participated in
the quality improvement process. Each center as Dr. Warady mentioned is charged
with developing ideas to increase compliance. They are to test them in a few patients, they
get feedback from the entire healthcare team and from the patients and then they either
spread it to other patients if it was successful or if it wasn’t successful they
go back to the drawing board. They modify it and try again. These small test of change, the development
in testing of ideas does not stop at the individual dialysis unit
and as Dr. Warady said the strength of the SCOPE collaborative
is the sharing of resources. Ideas, processes, tools,
experiences and resources are shared and stolen freely across
the SCOPE collaborative. This slide shows examples of the some of the
resources that have been developed and shared across the collaborative to
increase follow up compliance. Some centers, some fortunate centers have a
dedicated nurse educator whose sole job during the PD visit is to make sure the
topics of exit-site care, hand hygiene and aseptic technique are reviewed. Many centers have developed visual aids such as
posters or flip charts to help in the review. And then one of the most popular
methods is to have the patient or the family actually perform
the exit-site care in the clinic. This not only allows you to review hand
hygiene and exit-site care but also allows you to have a demonstration of the
competence during that visit. Not only is it difficult to include all
of the reviews in each and every visit but review fatigue is a significant problem. It doesn’t matter how fancy your flip chart
is, if it’s the only resource you have to review exit-site care it doesn’t take long
before it’s no longer an effective review. Again, the sharing of resources is incredibly
important and this slide shows examples of some of the techniques to minimize review fatigue
that have been shared across the collaborative. This includes having the patient or their
family monitor the hand hygiene practices of the providers in clinics. That includes everyone, the doctor, the
nurse, the dietician, the social worker. Another very popular technique
is to use Glo Germ. For those of you who are not familiar with Glo Germ it’s a substance
that’s visible under black light. And so the patient or their family
puts the Glo Germ on their hands, they then perform hand hygiene and then they
put their hand under a black light and any areas where the hand hygiene wasn’t
effective will glow. It’s very popular particularly
among adolescent boys. Many centers have developed video games and
the picture here in the bottom left hand corner of the slide is a video game that
we developed here at Hopkins. And our dialysis nurse, Barbara
Case, intentionally makes mistakes at several steps of the aseptic technique. And the patient is instructed to click
the mouse whenever they see a mistake and the video game immediately tells them
whether they’ve correctly identified a mistake. And then finally some centers
will have the patient or family record themselves performing
the dialysis procedure in the home. Every patient and caregiver has to
demonstrate competence with this procedure. But there’s a difference between performing
the procedure in a clinic and performing it in the home on a day in and day out basis. So they record themselves performing
the procedure using a phone or a tablet, they then bring the recording into the
clinic where it’s reviewed with a nurse or a nurse educator and then opened
in a non-accusatory environment. The patient and the family are reminded that
the goal of the review is not to place blame but to identify ways to improve their technique. These are just a few of the examples of
the many resources that have been developed across the collaborative,
as Dr. Warady mentioned. They’re shared by centers on the eGroup or
may be presented on the monthly webinars or at our face to face learning sessions. And then they’re made available
on the online at the CHA or the Children’s Hospital Association website. Moving from compliance to infection
rates because again the goal of the collaborative is not just to get people
to do all these things during clinic but rather to see whether or not all these things
actually can reduce infection rate. Among the 24 centers included in this analysis
there were 206 peritonitis episodes reported over 3,778 patient months in the 13
months prior to the collaborative launch. These same centers reported 320
infections over 8,853 patient months in the 36 month post launch period. While it is tempting to compare these
two crude rates, we need to remember that the post launch rate here includes the
entire 36 months following collaborative launch including that two year period
when the implementation of the follow up care bundle was low. Thus a comparison of these rates would not
test the hypothesis that more uniform delivery of care will reduce infection rates. Because it includes in the postop period a time,
or a post launch, not postop, post launch period when a time when care was not uniform. In order to test that hypothesis you have
to look at average monthly peritonitis rates which allows you to detect
trends and rates over time. To do this a model was fit using
average monthly peritonitis rates and this analysis revealed a
statistically significant reduction in monthly peritonitis rates. From a rate of 0.63 episodes
per patient year to a rate of 0.42 episodes per patient
year at 36 months post launch. This slide shows the average monthly
peritonitis rate in the prelaunch period to the left of this red vertical line. And the 36 month postlaunch
period to the right of this line. Also displayed is the monthly follow up
compliance here in the green dotted line, these data graphically suggest that as follow up bundle compliance increased the
variability in peritonitis rates decreased. In order to determine the level
of follow up compliance required to achieve a significant decrease in infection
rates, we performed a sensitivity analysis in which we compared the peritonitis
rate in the prelaunch period, I’m sorry, I’m going to go back one slide. In the prelaunch period here
with rates following achievements of various levels of follow up compliance. So the rates in this time period were
compared to this, this time period to this. The results of that analysis
are shown on this slide. The mean compliance threshold is here in the
first column and the ratio of peritonitis rates in the prelaunch period over the rate in
the time period after achievement of each of the compliant thresholds are
shown in this fourth column. Since it is a ratio of prelaunch rates
over postlaunch rates the lower the rate after the compliance threshold
isn’t reached the larger the ratio. This analysis confirmed that as mean compliance
increased the peritonitis rates decreased so the ratio increased. Reaching statistical significance
at a mean compliance of 80%. At which the prelaunch peritonitis
rate was 42% higher than the rate in the month following achievement
of this level of compliance. Although, I hope you’ll agree with me that
this is impressive, our work is not done and the SCOPE center continues to work to
maintain compliance with the follow up bundle and to increase compliance with
the insertion and training bundle. We’ve also developed research groups which
have within the collaborative which have tried to identify whether there are clinical or
demographic factors or even other care practices that may influence infection rates. We’ve also developed innovation groups that
have thought to optimize care practices, not specifically included in the bundles. Including improving identification
and treatment of touch contamination, developing health literacy sensitive
education and review materials. And increasing patient and family engagement
in the quality improvement process. We now move to the hemodialysis project and as Dr. Warady mentioned it is our more
recent project and it launched in 2013. Like the PD project the HD project seeks
to reduce HD access related infections by increasing implementation
of standardized care practices. While it is well recognized that
the single most effective way to minimize HD access related infections
is to reduce the use of catheters. It’s also well known that catheter use
remains common in pediatric patients. This slide is taken from the U.S.R.D.S. And it shows hemodialysis access type
among prevalent pediatric patients, hemodialysis patients in the United States. As you can see a majority of children
and particularly young children, continue to have a catheter
as their hemodialysis access. There are many reasons for this including
the fact that the majority of children on dialysis actually receive a kidney
transplant within two years of reaching ESRD. Until a more permanent access
is not always warranted, in addition it may not be technically feasible, as Dr. Warady mentioned to
create a vascular access. Specifically, an AV fistula
in a very small child. Thus any effort to minimize HD access
related blood stream infections in children must include efforts aimed at
reducing catheter associated infections. Therefore the HD project includes standardized
practices for accessing tunneled catheters as well as AV fistulas and AV grafts. The specific practices including the HD catheter
connection procedure is shown on this slide. And includes the requirement for
hand hygiene using the WHO protocol and appropriate personal protective equipment
for the provider and a mask for the patient. The protocol does require
scrubbing of the catheter hub with an appropriate antiseptic solution. While the SCOPE bundle was largely based on
the recommendations from the CDC it does differ from the CDC recommendations in that it allows
sodium hypochlorite to be used to scrub the hub. In addition, the procedure for povodine
iodine does not specifically include a scrub but rather applying and allowing the agent to
dry according to manufacture recommendations. SCOPE is planning to work with the CDC to
evaluate these practices and the bundle elements to more closely align with CDC recommendations. After the hub is prepped the catheter is
connected to the lines using aseptic technique, the provider then removes gloves
and performs hand hygiene. The hemodialysis disconnection cap
change procedure is shown on this slide. Again it largely follows the CDC guidelines, except some additional agents
are allowed for the hub scrub. The agents that are included in the SCOPE
bundle are shown here and the agents that are consistent or included in the
CDC recommendations are shown bolded. This slide shows the protocol for dialysis
catheter exit-site care and dressing change. And as with all the protocols
require proper hand hygiene and PPE. The agents for prepping the catheter
exit-site and the allowable antibiotic ointment or creams applied to exit-sites differ
slightly from the CDC recommendations. And again with the agents including the CDC
recommendations being bolded on this slide. Again after the dressing change — well, the frequency of dressing
change is shown here on the slide. And it depends on the type
of the dressing change used. After the dressing is changed the
provider should remove their gloves and perform hand hygiene. The procedure or the protocol for accessing an
AV fistula or graft is shown here and includes that the patient should wash
the site with soap and water. Proper hand hygiene and appropriate PPE are used by the provider unless self-cannulation
is performed. The site is prepped with an
acceptable antiseptic solution and again the acceptable solutions
in the SCOPE bundle are shown. With the CDC recommended solutions bolded. After inserting the needles with
aseptic technic, the gloves are removed and appropriate hand hygiene is performed. Finally the decannulation
procedure is shown here and includes the appropriate
hand hygiene both prior to and after the procedure and appropriate PPE. As with the PD project the HD project
requires that all patients cared for in the unit be enrolled in the project. Obtaining data at the patient
level is included in order to identify clinical and
demographic characteristics. That may increase risk for infection,
especially in high risk populations. This slide details the data collection process for individual patients enrolled
in the collaborative. Unlike the PD project it is not
required that every single procedure in the hemodialysis unit be audited. It would obviously be too labor intensive to audit every single time a patient’s access
was connected and disconnected from the tubing. Therefore centers are advised to audit a
random sample of those procedures every month, they’re encouraged to rotate
the audit so that every shift and as many providers are audited as possible. As noted in the top half of the slide the
targeted number of audits is twice the number of patients cared for in a unit with
a maximum of 30 audits per month. Obviously this means that not every
patient enrolled will have a connection or disconnection audited. In order to ensure that patient level practices
are captured on every enrolled patient. Centers are also asked to provide a follow
up form which includes care practices for every patient at least annually. Just as for PD the data are
submitted online and are available for centers to review in real time. And we obviously also review the data
on our webinars and at our workshop. And the data shown on this slide
represented at the workshop last fall at which time there were
25 centers entering data. From these sites nearly 500 patients have
been enrolled and nearly 5,000 audits or observations have been submitted. This includes more than 3,000 audits
procedures involving catheters and more than 1,300 involving AV fistulas or grafts. The breakdown of those audits
are shown on the slide. 77 infections reported during the over
4,300 catheter months of follow up and 2 infections reported in nearly
1,800 fistula graft months of follow up. Note that centers are asked to
report any positive blood cultures or other infection events and then each
of these events is centrally adjudicated by an infectious disease specialist
to determine if the event qualifies as an access associated infection. So these numbers represent
the adjudicated infections. This slide shows the monthly compliance with
the care bundles across the collaborative with catheter care compliance in red and AV
fistula, AV graft care compliance in blue. Each point shows the compliance
for that care bundle in that month. In general compliance with AV
fistula and graft care is quite high. Compliance with a catheter bundle is more
variable and hovers between 60 and 80%. Although it has increased
slightly over the last few months. A compliance deep dive at our last learning
session in the fall revealed that failure to apply an antibiotic ointment or
cream at the exit-site at the time of a dressing change was the
single most important contributor. To non-compliance with the catheter bundle. This slide shows the monthly rate of catheter
associated infections across the collaborative, following collaborative launch in June 2013. The rates are presented as the number
of infections for 100 patient month. Unlike the PD project which had a uniform
launch date for the initial 29 sites, meaning all centers began
implementing the bundles and collecting and submitting data in October 2011. The HD project has allowed a rolling launch,
that is centers can begin implementation and enrollment any time after June 2013. The number of patient months
and events is along the X axis. And as you can see for the first year and a half
or so there were very few centers entering data which was related to delays in obtaining
IRB approval, consent and ensuring that all of the providers were trained
according to the bundles. Prior to the center’s launch, as
such the number of patient months and the number events was relatively low. As the number of centers and therefore
patients increased the rates actually increased to more accurately reflect the rates across
multiple centers rather than just a few. As you can see as time has gone
on, although there continues to be some variability, the
rates have begun to drop. And since November 2015, the monthly bloodstream
infection rate catheter associated bloodstream infection rate, has been less than
two infections per 100 patient months. Again, these data suggest that the rates are
decreasing but this chart doesn’t allow us to compare the rates prior to and after
implementation of the care bundles at any center or across the collaborative. Conversely, this chart which is a
U chart allows us to do just that. And these are data taken from 15 centers that
provided historic data that is infection counts and patient counts for the 12 months prior to
the implementation of the bundles in their unit. As well as the rates following
implementation of those bundles. And this chart represents
or provides the results that show a 32.5% decrease in infection rate. From a rate of four episodes or bloodstream
infections per 100 patient months, prior to launch to 2.7 catheter related
bloodstream infections per 100 patient months after launch. As the number of centers and patients
enrolled increases and in particular as we obtain historic data from
additional centers we will be able to perform statistical analyses. As we have for the PD project. I’d like to close very quickly by
acknowledging all of the SCOPE team members and especially our patients and
their families whose hard work Brad and I have had the great
privilege to present today. And who continue to work tirelessly
to improve the care and the lives of children with end stage renal disease. We recognize that we’ve covered
a tremendous amount of information in a very short period of time. But our hope is that we’ve conveyed to you that quality improvement can successfully reduce
access related infections in dialysis patients. Although SCOPE is focused on children
with ESRD, as Dr. Warady said. The basic tenants of the project can be applied
to even the largest adult dialysis facility. The key to the success include
creating a culture of safety in which every healthcare provider
and every patient is engaged in the power to minimize infection. And again using small steps of change to bring
about improvement and spreading those changes to other patients, other shifts
and potentially even other units. We have just a few minutes here, 7 minutes
or so to be able to take a few questions but we have provided our contact information on
this slide, please feel free to reach out to me or Dr. Warady or Jane Stewart at the Children’s
Hospital Association if you have any questions or want to learn more about SCOPE. [ Background noise ]>>Thank you Dr. Neu and Dr. Warady
for your time and expertise today and for sharing with us your experiences. We have a few questions that have come in. Just a reminder to please submit
your questions via the chat window if you have additional questions. Located on the lower half,
left-hand side of the webinar screen. So the first question for our presenters
that has come in via the chat window is, what tools do you have to help
get family members engaged? [ Background noise ]>>Well, you know I’ll respond
to that first, I don’t — I think the first thing is to incorporate the
family members into discussion of patient care. And one of the things that we’ve done in our
own centers to begin to get them engaged is to actually have them participate
in the root cause analyses that take place following the
development of the infection. And one of our own patients who developed
peritonitis having the families sitting at the table and providing their
perspective on infection risk. Was extraordinarily valuable to our healthcare
providers and was truly a great example of engagement of the patient and the family
into improving outcomes of the patient. So, I think that is one way we get them engaged. One other way that we get them engaged is
that we have a regular meetings if you will, with the dialysis families with no agenda
other than things that they want to address to improve the care of their children. And I think that’s very different than
a clinic atmosphere where everyone is on a tight timeline to get the work done. But having a session where there’s
just an agenda really generated by the family’s themselves. I think allows us to really build on that
partnership between the health care providers and the family and I think it really
lends itself to engagement, Alicia.>>I agree Brad and I think again
engaging them in the process, the QI process is very important. You know, we’re implementing some of these
things, the educational and the review materials and so we seek their feedback and
we ask them for ideas, you know. We’re reviewing this with you every month, do
you have ideas of how we can make this better. And they like getting involved in that way. I think most centers also have their data
posted in the clinic and you know it’s pointed out to the patients and the families. So they can share in the improvements and share in the results every time
they come in into the clinic.>>I do want to point out
one other thing that we do on a regular basis is that
we look at our results. And we have, thankfully experienced
great success as part of our involvement in the collaborative in terms
of decreasing infection rates. And we regularly thank the
families, thank the patients for their contribution to those great results. Because again if we are focused
on a home therapy, we recognize that while we provide the
education and the oversight, it’s the families and the patients that are conducting
the therapy on a nightly basis. And so it is that partnership and I think we
have to recognize their significant contribution to the great outcomes we’re experiencing.>>Right and I think that can
translate to the hemo-unit as well, I mean we’re part of the auditing of the
connection and disconnection that many, many centers have someone
auditing the procedure. And so the patients or the family
knows that that’s what’s going on and they can take part in that process. They know that preventing infection is
important and that the unit takes it seriously. And they can share in that.>>We have a couple of other attendees who
are asking similar questions about what kinds of materials are available on the SCOPE website. I believe that most of what
you showed when it comes to facility specific information
would be presumably available just to those facilities that
are participating in SCOPE. But are there other materials
that are available more broadly?>>There are some materials that are
available more broadly, you’re exactly right, the center specific data
are on a separate website. There’s also some material that
is on a SCOPE specific site, the Children’s Hospital Association and so
you actually have to register to get on it. But most of it is publicly available, I think
we have some people from the association, they could correct me if I’m wrong on the call. Alicia just to clarify — so go ahead.>>I just want to emphasize if there are any
pediatric dialysis programs that are listening to the webinar that are not
participants in SCOPE to date. They certainly have the opportunity to
join the SCOPE collaborative by again, contacting either Children’s Hospital
Association or Alicia or myself.>>Thanks [cross-talk] Just to clarify,
Alicia were you saying that most of the tools are available publicly?>>Many of the tools are available on the
website and again I’m trying to search out some folks and confirm that as well. And we’re certainly happy to
share, I mean one of the goals of the Children’s Hospital Association is
to spread what we have learned in SCOPE. Beyond the SCOPE collaborative. And so you know this kind of
forum and sharing the information with other dialysis units is
certainly part of the mission of the Children’s Hospital Association. So, we’ll try to make sure we
get those things available.>>That’s all the time we have today
for answering questions for those of you who submitted questions that weren’t answered
we’ll try to send out some information to address some of those by
email after the presentation. I did want to just mention one other
comment that was submitted, not a question, that just says kudos to all of those who
were involved in the SCOPE collaborative. This is a true collaborative effort so
wanted to pass that along to the presenters and anybody else from SCOPE
who might be joining today. So before we end today’s
webinar I wanted to mention that to receive continuing education you must
complete and pass the posttest activity at, at least 75% or greater and
complete the webinar evaluation. So when you close out of this webinar
a post-meeting web page will appear that will have detailed instructions about completing the continuing
education posttest and evaluation. For those on the phone who currently
aren’t logged in to ready talk online to obtain CE please go to www.cdc.gov/tceonline. The access code for this webinar is WC0131. A follow up email will also be sent out
this afternoon with detailed instructions about completing the continuing
education post test and evaluation. With that I’d like to once again thank
our speakers as well as all of you for taking the time to join us today and for
your commitment to keeping patients safer.


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