Patient-Centered Observations of Outpatient Hemodialysis: An Exploratory Systems Approach to Understanding Infection...

Infection remains the second leading cause of death in patients with ESKD on hemodialysis. This exploratory analysis sought to characterize interruptions and non-routine events (NREs), in the outpatient dialysis setting, with particular interest in the relationships between interruptions and NREs and infection prevention and control (IPC) activities.

We conducted a mixed-methods, observational, exploratory study of 45 patients and their dialysis teams across four U.S. dialysis facilities (99 total outpatient hemodialysis treatments hours observed). Structured observations were focused on the team surrounding an individual patient for the duration of their dialysis session using a modified Line Operations Safety Audit (LOSA) approach. Quantitative analyses were conducted.

A technician simultaneously caring for four patients can experience a median of 64 interruptions, or 16 per patient (range 3-50) during their treatment time. The phases with greatest risk of infection (i.e., connection, disconnection) had a significantly higher time required to complete (with NRE: connection 14:37, disconnection 13:41; without NRE: connection 7:32, disconnection 8:18). Thirty-seven of 45 patients experienced at least one NRE during clinical care, defined as a patient-related clinical event (e.g., long clotting time) or an operational variation (e.g., transportation problem). Findings are exploratory in nature and provide support for future hypothesis generation and testing.

Interruptions and NREs were frequent in the outpatient dialysis work system, and connection and disconnection times were longer when an NRE was present. Since these disruptions occurred during phases that include IPC-related activities, they may introduce competing demands that could challenge consistent adherence, though adherence was not directly measured. These exploratory findings may inform the design of workflows and processes that better support IPC and patient safety in the outpatient dialysis setting.