Search

OBJECTIVETo 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.SETTING AND PARTICIPANTSThirty-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.MEASUREMENTSTrained 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.RESULTSThere 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.CONCLUSIONSOur 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

Background.Several studies demonstrating that central line–associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.Methods.We conducted a collaborative cohort study to evaluate the impact of the national “On the CUSP: Stop BSI” program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.Results.A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16–18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50–0.65) at 16–18 months after implementation.Conclusion.Coincident with the implementation of the national “On the CUSP: Stop BSI” program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

This essay extends problematic integration theory and related theories of uncertainty management to communication about serious illness and death. These extensions (a) note that theorizing must focus on multiple, interrelated uncertainties rather than a single such uncertainty; (b) explain how communication with others often problematizes efforts to cope with illness-related uncertainties; and (c) identify specific factors that may influence how persons choose to cope with these uncertainties. The essay describes implications for ongoing efforts to improve communication with persons nearing death. Specifically, they point to 5 incorrect assumptions that limit the effectiveness of current efforts to encourage persons to talk about their end-of-life preferences with others in a process referred to as advance care planning and then suggest concrete changes derived from this framework that can improve the advance care planning process and enhance the quality of end-of- life care.

Improving the care of persons at the end of their lives is a major priority of medical associations and patient advocacy groups. Central to this effort is the need to better prepare health care surrogates so that they will be able to respect the dying person's wishes if that person loses decision making capacity. But efforts to facilitate communication between dying persons, their surrogates, and health care providers have not been fully successful. We conducted a telephone survey of 174 randomly selected adults from a mid‐sized university community to determine whom people wanted to function as their surrogate, to test the hypothesis that overconfidence in the surrogate's ability may impede communication, and to examine gender differences in communication preferences with surrogates. Spouses were the most frequently selected surrogate, followed by an adult child. Women were more likely to be selected than men were. As expected, persons overestimated their surrogates’ abilities to represent their interest...

Although withdrawal from dialysis is relatively common among dialysis patients, little is known about the patients' consideration of withdrawal during advance care planning. We studied a stratified random sample of 400 hemodialysis patients in two geographic areas (all six dialysis units within 75 miles of Morgantown, WV, and all nine dialysis units in Rochester, NY) by reviewing responses to a questionnaire addressing issues of advance care planning. Interviews were performed by trained interviewers during a routine hemodialysis treatment. Fifty-one percent of the patients had completed an advance directive (29% had a living will and a health care proxy, 22% had a living will or proxy). Patients who had completed advance directives were more likely to have notified their decision makers of their roles (91% with a living will and health care proxy, 81% with a living will or proxy v 55% who had no advance directive; P < 0.01). Most patients had not discussed their wishes for specific interventions in the event of permanent coma: 41% had discussed mechanical ventilation; 35%, tube feedings; 25%, cardiopulmonary resuscitation; and only 18% had discussed stopping dialysis. Patients who had completed a living will and proxy were most likely to have discussed end-of-life care, but stopping dialysis was the least often discussed intervention, even in this patient subset. Sixty-nine percent had discussed mechanical ventilation; 55%, tube feedings; 43%, cardiopulmonary resuscitation; and only 31% had discussed stopping dialysis (all P < 0.001). Although withdrawal from dialysis is relatively common, it is rarely discussed in advance care planning by dialysis patients. Dialysis unit staff and nephrologists should address issues involving withdrawal from dialysis with their chronic dialysis patients.

Inappropriate efforts to manage uncertainty may account for difficulties associated with communication about serious illness. This study tested a series of predictions concerning the relationship between the amount of uncertainty associated with a communicative task and health care providers’ comfort levels when engaging in that task. A mailed survey of 540 home health care nurses confirmed expectations that discussions of future or more serious health problems will create more discomfort than discussions of present or less serious problems, that unstructured conversations produce more discomfort than structured discussions, and that comfort discussing serious illness would be positively associated with extent of communication about patients’ treatment preferences and the likelihood of learning these preferences.

This article investigates the importance of treatment requests made by patients with kidney failure and other life-threalening conditions on nephrologists' treatment decisions A total of 535 nephrologists from the U.S., Canada, and Britain returned mailed surveys in which they read 5 scenarios and then indicated how the patient described in the scenario should be treated. Results revealed that when patients communicated their preferences, nephrologists were significantly more likely to provide dialysis. Although there were no differences among the 3 countries when treatment preferences were not expressed, Americans were much more likely to provide dialysis when requested by Ihe patient. Whereas most nephrologists agreed to change treatment decisions at the request of the patient, American doctors were less likely to comply with requests to terminate dialysis and were more likely to agree to provide dialysis for incompetent patients they initially refused to dialyze if asked to do so by the family. In the ...

Physicians are legally and ethically required to obtain informed consent from patients prior to providing medical care. However, the chronically ill elderly may poorly understand the facts that are needed for them to make informed choices, and they also may wish to avoid discussing potentially discouraging information. Interviews of 142 elderly hemodialysis patients were conducted to determine whether informed consent for performing dialysis had been obtained and to explore potential causes of inadequate informed consent. As predicted, most patients lacked information needed to render fully informed consent. However, when we examined potential causes for the very low levels of knowledge reported by patients, we found that patients’ education level, cognitive capacity, and willingness to discuss medical contingencies were stronger predictors of informed consent than were the communicative practices of doctors. Neither doctors’ willingness to promptly disclose the need for dialysis nor their willin...

End-of-life (EOL) decisions made by and for elderly patients often perpetuate unwanted suffering at great expense. Recent efforts to improve the decision-making process have been ineffective. In this article, we argue that Babrow's (1992, 1995) problematic integration (PI) theory can enhance understandings of flaws in EOL decisions. Face-to-face interviews of 142 elderly hernodialysis patients were con- ducted to test predictions derived from the theory. Results supported the prediction that doctors would often fail to disclose the need for dialysis until a decision had to be made.

Communication competence may play an important role in interactions between health care providers and patients. Because exactly what constitutes effective and appropriate communication in conversations with seriously ill, older adults is not clear, it is difficult to know haw such conversations can be improved. In this study we conducted face‐to‐face interviews with 142 randomly selected, older dialysis patients to determine if they believed it was appropriate to inform them of their medical condition, discuss treatment alternatives, and involve them in medical decision making. Results confirmed the expectation that most such individuals believe it is appropriate to be informed about their condition and options, but do not believe it is appropriate to involve them in medical decision making. Respondents who were older, less educated, and who had diminished cognitive capacity perceived involvement as particularly inappropriate. Results suggest that many seriously ill, older adults may have communication be...

While constructivists assert that RCQ‐based indicators reflect differences in construct system development, this essay tests the claim that these indicators reflect variation in referential communication skill instead. Study one compared the constructivist claim that RCQ responses are spontaneous and natural with the contrasting claim that these responses are intentional and other‐directed referential messages. After completing the RCQ participants answered questions about their behavior. Results confirmed the expectation that participants would view their responses as intentional, referential communication directed towards a particular type of recipient. Study two compared the constructivist claim that there should be no relationship between the number of abstract descriptors and a measure of verbal efficiency (words per descriptor) with the expectation derived from referential communication research that greater skill should be reflected by more appropriate descriptors and more verbal efficiency. The co...

Decisions made by and for elderly patients nearing death frequently perpetuate unwanted suffering and dependence. This article extends the argument that Babrow's (1992, 1995) problematic integration theory can provide insights into why communication fails to produce desired outcomes for such patients. Open-ended responses obtained in face-to-face interviews with 142 elderly dialysis patients and mailed surveys of 393 dialysis unit nurses were examined to better understand how patients and nurses reconciled incompatible probabilistic and evaluativejudgments. Results indicate that patients seek information that will enable them to cope with debilitating dialysis treatments rather than information nurses believe is necessary for them to make informed choices about whether to undergo such treatments. The tension between the information patients want to successfully cope with life and the information they need to decide intelligently about treatments that forestall death constitutes a key reason why communication about end-of-life issues is frequently flawed. Our analysis of these communication flaws leads to specific recommendations for how this tension can be eased, which in turn may better prepare patients to make the transition from coping with life to coping with death.

Most patients do not participate in advance care planning with physicians.To examine patients' preferences for involving their physicians and families in advance care planning.Face-to-face interviews with randomly selected patients.Community-based dialysis units in one rural and one urban region.400 hemodialysis patients.Questions about whom patients involve in advance care planning, whom patients would like to include in this planning, and patients' reactions to state legislation on surrogate decision makers in end-of-life care.Patients more frequently discussed preferences for end-of-life care with family members than with physicians (50% compared with 6%; P0.001). More patients wanted to include family members in future discussions of advance care planning than wanted to include physicians (91% compared with 36%; P0.001). Patients were most comfortable with legislation that granted their family end-of-life decision-making authority in the event of their own incapacity (P0.001).Most patients want to include their families more than their physicians in advance care planning.