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Variation in Infection Prevention Practices in Dialysis Facilities: Results From the National Opportunity to Improve Infection Control in ESRD (End-Stage Renal Disease) Project

  • Carol E. Chenoweth (a1), Stephen C. Hines (a2), Kendall K. Hall (a3), Rajiv Saran (a1), John D. Kalbfleisch (a1), Teri Spencer (a4), Kelly M. Frank (a5), Diane Carlson (a6), Jan Deane (a6), Erik Roys (a1), Natalie Scholz (a1), Casey Parrotte (a1) and Joseph M. Messana (a1)...



To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection.


Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status.


Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012.


There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%–92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%–100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation.


Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.

Infect Control Hosp Epidemiol 2015;36(7):802–806


Corresponding author

Address correspondence to Carol E. Chenoweth, MD, 3119 Taubman Center, University of Michigan Medical Center, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5378 (


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1. Centers for Disease Control and Prevention. Vital signs: central line–associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011;60:243248.
2. Patel, PR, Kallen, AJ, Arduino, MJ. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients. Am J Kidney Dis 2010;56:566577.
3. US Renal Data System. USRDS 2009 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, 2009.
4. National Kidney Foundation. KDOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006;48:S1322.
5. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Morb Mortal Wkly Rep 2001;50:143; Available at:
6. O’Grady, NP, Alexander, M, Burns, MA, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter–related infections. Clin Infect Dis 2011;52:e162e193.
7. Centers for Disease Control and Prevention. Infection control requirements for dialysis facilities and clarification regarding guidance on parenteral medication vials. MMWR Morb Mortal Wkly Rep 2008;57:875876. Available at:
8. Department of Health and Human Services (HHS). Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities. Fed Regist 2008;73:20293. Available at:
9. Pisoni, RL, Arrington, CJ, Albert, JM, et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. Am J Kidney Dis 2009;53:475491.
10. University of Michigan Kidney Epidemiology and Cost Center. Guide to the Dialsysis Facility Reports: Overview, Methodology, and Interpretation, July 2014. Available at:
11. Shimokura, G, Weber, DJ, Miller, WC, Wurtzel, H, Alter, MJ. Factors associated with personal protective equipment and hand hygiene among hemodialysis staff. Am J Infect Control 2006;34:100107.
12. Shimokura, G, Chai, F, Weber, DJ, et al. Patient-care practices associated with an increased prevalence of hepatitis C virus infection among chronic hemodialysis patients. Infect Control Hosp Epidemiol 2011;32:415424.
13. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related infections in the ICU. N Engl J Med 2006;355:27252732.
14. Fakih, MG, Watson, SR, Greene, MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med 2012;172:255260.
15. Klevens, RM, Edwards, JR, Andrus, ML, et al. NHSN Participants in Outpatient Dialysis Surveillance. Dialysis surveillance report: National Healthcare Safety Network (NHSN)–data summary for 2006. Semin Dial 2008;21:2428.
16. Centers for Disease Control and Prevention. Reducing bloodstream infections in an outpatient hemodialysis center—New Jersey, 2008–2011. MMWR Morb Mortal Wkly Rep 2012;61:169173.
17. Patel, PR, Yi, SH, Booth, S, et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013;62:322330.


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