Quality improvement in hemodialysis: A systematic review

The predominant modality of renal replacement therapy, hemodialysis (HD), is a specialized area associated with a heightened susceptibility to infections, partly due to patients' vulnerability, the invasiveness of procedures necessitating vascular access, and the cyclical nature of the treatment. These factors, along with a notable incidence of infections, present a significant public health challenge owing to their implications on both human health and economic resources. Mortality rates in dialysis patients are markedly elevated, typically ranging from 10 to 20%, primarily linked to cardiovascular (40%) and infectious (10%) etiologies. Enhancing the caliber of care, patient safety, and clinical outcomes represents a pivotal focal point for healthcare systems globally. Nevertheless, could the adherence to universally acknowledged and validated benchmarks engender variability in outcomes within hemodialysis environments? Can interventions aim at improving quality lead to positive outcomes by reducing infections and improving results for patients undergoing hemodialysis? To respond to these inquiries, a systematic review based on the PRISMA guidelines was carried out over 14 years across various databases, identifying cases of quality improvement initiatives and detailing their effectiveness in infection prevention and quality-centred approaches to risk management. Multiple forms of interventions aimed at enhancing quality have been outlined and considered relevant, including (i) integrating the PDCA (Plan-Do-Check-Act) cycle with oversight of risk factors, (ii) utilizing the Failure Mode, Effects, and Criticality Analysis (FMECA) framework, (iii) applying LEAN management principles, and (iv) strictly following the guidelines established by the Centers for Disease Control and Prevention (CDC) and the kidney disease: Improving Global Outcomes (KDIGO). Adopting these quality approaches has significantly reduced infection rates in hemodialysis contexts. However, these quality improvement interventions are elementary and not comprehensive, with limited long-term effectiveness. A comprehensive management initiative must therefore bring together successful improvement practices, pertinent methodologies, and current quality standards to establish an integral management system based on quality control, quality assurance, and continuous improvement.