Sunday, August 16, 2009



As an unapologetic, outspoken advocate, for patients in all health care settings, including dialysis units, I felt dutybound to respond to the RBT Roundtable discussion - Infection Control, posted on August 11, 2009.
I certainly support all that was stated by those professionals, and would like to add the perspective of a patient advocate, family member of a dialysis patient, and friend of several dialysis patients.

This Roundtable comes at an opportune time as recent posts at have addressed the H1N1 and how dialysis patients could be affected. On August 9, 2009, I posted my suggestions for dialysis facilities, the basic of basics, in response to several comprehensive posts regarding H1N1 written by Bill Peckham, patient activist and Peter Laird, M.D. I would suggest everyone read these most-informative posts.
My post was a result of four avenues I traveled - (1) my review of many dialysis facility survey findings, (2) my communication with patients, and their loved ones, (3) my communication with health care professionals, at various levels, working in dialysis units, in several states and (4) my onsite visits to dialysis facilities. These points that I posted are basics and should not be a problem for units to implement.

Is it not of great concern to know that (preventable) infection continues, after many, many years, to be the number two cause of death among the dialysis population? If you are not concerned, you should be. Additionally, as frightening, is the fact that hospital-related preventable errors that resulted in death, harm and injury have not significantly declined since the IOMs (Institute of Medicine) report, “To Err Is Human” in 1999. Knowing these two aforementioned, only proves my point, of which I have been shouting-out for years - patients, and their loved ones, must be their own advocates, or advocates for their loved ones, to ensure they receive quality safe delivery of care. Not being part of the ‘status-quo’, my candor, often, not taken seriously by providers, only tells me that for years that which I have been communicating clearly says ---- something is wrong with delivery of care if we have not seen any noteworthy decline in the numbers of acquired infections. So, I ask providers, once again, to please, please take a closer look at what is going on in your units. Of course, I am not, and do not want anyone to assume that I am stating that all facilities do not implement effective infection controls, however, it is evident that there is a problem that needs to be addressed in many facilities. I remember reading a publication, some years back, of which stated that those who work in ICU, dialysis units and other settings, believe that it is part of the natural process for these patients to acquire an infection. Hopefully, this is no longer a thought. However, I have had a few nurses state, to me, infection is expected in a dialysis patient. I am here to disagree, and state that if staff implement correct practices and the patient does his or her part, perhaps infection can be avoided. Many of these infections are preventable and are a result of cross contamination.

(1) Is the renal community doing a good job with infection control? Why or why not?

As an advocate, knowing that infection remains the number two cause of death among the dialysis population, I would have to say that the renal community is not doing a good job with infection control. If they were, perhaps we would see a significant decline in the numbers of healthcare-associated (dialysis) acquired infections. If there was effective implementation of infection control practices, along with a decrease in the numbers of acquired infection, then we could clearly state that the renal community is doing a good job.

The renal community, knowing that infection is the number two cause of death, has not, in my opinion, stepped-up their focus on infection control. Because policies and procedures read well, does not mean that these are being implemented appropriately. I do not believe that (1) there has been an increase in unit-supervision to ensure that staff are implementing effective infection control practices, (2) staff are being thoroughly trained and educated in infection control practices, including consequences for not implementing such, (3) those who are providing education (educators, inservice staff, etc) are adequately trained or educated in infection control, (4) patients, for the most part, feel comfortable in continually having to address the lack of infection control in their units, due to fear of retaliation, or knowing that with all there voiced concerns practices remain the same, without change, (5) patients are included in unit committees that address infection control in order to obtain patient input as to their experiences, (6) patients are fully educated in all aspects of infection control either what the patient’s responsibility is or what the staff’s responsibility is. Additionally, my three avenues of obtaining information tell me that not much has changed as far as ensuring that staff are implementing effective infection controls. However, the data speaks for itself, as do surveys that cite observations of staff not conducting correct practices.

How can dialysis centers better combat infection?

On August 9th, 2009, after reading several mindful posts regarding the flu and dialysis patients, I posted what I believe would help patients avoid acquiring the flu. However, these suggestions, of course, are for prevention of any infection that can be acquired in a dialysis unit.

1) Re-educate staff in effective infection control practices to prevent the spread of infectious agents.
(2) Remind staff that they are not excluded from this flu and that they, too, can bring home infectious agents, to their families including children
(3) Increase unit surveillance e.g. increase observations of staff to ensure implementation of effective infection control practices, esp. hand hygiene. Of course, staff who are observing MUST be well-educated ineffective practices.
(keeping in mind, many surveys support the fact that there is lack of supervision, staff education, and unit-level oversight in regards to ensuring implementation of effective infection control practices.)
(4) Encourage staff to staff communication if observations indicate lack of effective infection controls
(5)Increase unit-level oversight of disinfection of equipment. (Often patients cough and sneeze on such items as televisions, chair arms, arm rests, blood pressure cuffs, etc.) Without thorough disinfection, transmission of infectious agents will be transferred from patient to patient. Ex: A patient coughs or sneezes on a television, that is used by all patients who sit in that chair. If there is not effective disinfection of the tv, e.g. wiping down w/ disinfecant, the next patient will touch the tv set and then those nasty germs, from the previous patient, are now on the hands of the next patient.
(6) Teaching patients correct way to cough, sneeze and teaching proper hand hygiene.
(7) Place alcohol dispensers close to entrances and exits, that patients and staff use, so that hand hygience can be user-friendly
(8) Educate patients on infection control practices that staff will be implementing in order to prevent the transmission of infection.
(9) Encourage patients to ask staff if they have washed their hands, e.g. prior to donning gloves, before taking supplies off of treatment carts,
(10) Encourage patients to speak up if they observe staff not implementing effective infection controls,

Patients should be able to speak up if they observe incorrect procedures without the fear of any covert or overt retaliation from staff. Many patients will not speak up due to fear of retaliation. Many patients, and their family members, have stated that when asking a question, or questioning a practice that might place a patient in harm’s way, often they are met with a facial expression or body language that clearly says, “Do not ask me again, anything”. Providers need to be aware that retaliation is alive and well. Staff need to understand that a patient has a right to question anything that is being done to their body. In a recent post at , Peter Laird, a physician speaks of the retaliation that he and his family experienced as a result of addressing the lack of infection control. Hence, it does not matter if the patient has medical background, or not, retaliation is here. Providers need to understand patients have a right to protect themselves from unsafe care. The lack of effective infection controls being implemented is an unsafe practice.

When patients, regardless of their professional background, ethnic origin, religion, etc., meet with retaliation, then something is drastically wrong within the dialysis setting. Dialysis patients must be able to bring forth concerns related to lack of effective infection controls without any fear of retaliation or other inappropriate actions by staff.

Quality Improvement programs that are effective will be able to identify the root cause of preventable errors such as acquired infections. Determining such as latent cause, human cause, or physical cause, will help in preventing future negative outcomes.
Many facility survey reports that I reviewed showed, that although there were in place QI programs/committees, they were ineffective. Many of these identified infections, but no evidence of why these infections were occurring. It has been stated, that with the inability of states to inspect facilities timely, that the new mandated QI Condition will help improve care. In my opinion, this is unreasonable and will not take the place of a survey. Too many times, preventable negative outcomes get to the QI committee too late. If only there had been appropriate unit supervision to ensure staff were conducting safe infection control practices! In preventing negative outcomes, e.g. infection, staff must be alert to those practices that are ineffective.

A dialysis setting culture that encourages staff to openly address an observation of a coworker not implementing effective practices must be a priority. There is a secret code that says, in many facilities, that if a staff observes a practice that is incorrect that they do not tattletale on their coworker. The cohesiveness in some units can be most detrimental to patients.

What is the role of the patient in preventing infection?

The role of the patient is to be as educated and empowered as he or she wants, as it is the patient’s choice, and this must be respected by staff. If staff are educating patients, then it is expected that their training and education will be sufficient which will result in patients receiving correct information in response to their questions.

.Patients, and their loved ones, take on a responsibility to ensure that they do not acquire an infection. However, again, staff must educate patient on what the patient needs to be doing in order to prevent an infection.

The internet provides valuable information, however, we must keep in mind that many patients still do not have access to a computer, nor do they want to. Once, someone said to me that a patient could always go to the library to get information, but, I am a strong believer that unless we meet the educational needs of all patients, we are doing a great disservice. Many elderly patients are discounted because of their age, when, in fact, these patients often want to be as educated as possible.

It is my opinion, that if a patient and/or family member is educated in the area of infection control, then one of the major responsibilities is to ensure that staff are implementing correct practices to prevent an infection. Furthermore, the role of the patient is to bring forth, to the attention of staff, that which they observe which can place a patient in a potential situation of acquiring an infection. This is often met with staff resistance which can, and often does, lead to retaliation.

In conclusion, on behalf of advocates striving for quality safe care, we challenge the dialysis providers to take a close look and admit when something is wrong. If the AMA can support hospitals admitting when mistakes are made, then our expectations of dialysis providers should be the same. Our hope is that providers will, in fact, seriously look at their facilities and realize that there are things that need to be changed. To admit a mistake is better then to deny it and push it under the table.

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