Abstract: TH-PO886

Reduction in Rates of Blood Stream Infection Associated with Adoption of TeamSTEPPS as a Framework for Improved Hemodialysis Facility Workflows

Session Information

  • Dialysis: Infection
    November 02, 2017 | Location: Hall H, Morial Convention Center
    Abstract Time: 10:00 AM - 10:00 AM

Category: Dialysis

  • 610 Dialysis: Infection


  • Jackson, Jerry W., FMC Patient Safety Council, Mountain Brk, Alabama, United States
  • Ofsthun, Norma J., Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Meredith, Carol, Fresenius Kidney Care, Downers Grove, Illinois, United States
  • Goldberg, Marcy Eber, Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Onta, Uddar, Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Maddux, Franklin W., Fresenius Medical Care North America, Waltham, Massachusetts, United States

Blood Stream Infection (BSI) remains one of the most serious adverse events affecting end stage renal disease (ESRD) patients. Multiple barriers and situational factors impede infection control in ambulatory hemodialysis (HD) facilities. We implemented a Quality Improvement Project (QIP) and analyzed its impact on BSI rates in HD facilities.


We deployed the QIP in 97 Fresenius Kidney Care facilities from January 2016 through March 2017. After performing a Failure Mode and Effects Analysis, we identified 55 HD workflow steps (distributed throughout the HD treatment) with high-risk for infection. The QIP design included training and observational auditing for the high-risk steps, use of TeamSTEPPS training to instill team-oriented care and to reduce barriers to infection control, ongoing coaching and feedback for caregivers in the use of TeamSTEPPS tools, incorporation of an infection control data set for analysis and action-planning during QAPI, and closed-loop communication pathways. The facilities were divided into Low, Mid and Top participatory subgroups based on monthly reported process metrics. Mean BSI rate by subgroup during 2015 was used for baseline. Implementation BSI rates by subgroup were followed Q1 2016 through Q1 2017.


We studied data from a mean census of 10,988 patients. Mean baseline BSI rates (expressed as BSI episodes/1,000 HD treatments) by subgroup were: Low, 0.32; Mid, 0.46; Top, 0.46. Data collected at the end of the QIP showed changes in mean BSI rates of (+) 4.6%, (-) 23.7%, and (-) 32.2% for the Low, Mid and Top subgroups, respectively (Figure 1).


These findings suggest the use of TeamSTEPPS combined with the other interventions of this QIP might be associated with a reduction in dialysis associated blood stream infections.


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