The goal of the quality improvement project reported here was to increase the proportion of peritoneal dialysis (PD) patients receiving adequate dialysis as defined by the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines. Our approach was to increase the frequency with which we measured PD adequacy and changed prescriptions in response to low adequacy values. We developed 3 indicators, each one subdivided to reflect differences by type of PD and time on PD. Our improvement goal was to achieve the midpoint between baseline performance on those indicators and 100%, equating to a 50% reduction in failure rate (RFR). At baseline, the project included 122 facilities with 1,517 patients (data from October 1999 to March 2000). At re-measurement, we had 117 facilities with 1,372 patients (data from January 2001 to June 2001). In addition to obtaining facility-specific feedback reports, we conducted educational intervention workshops to which all PD providers were invited. After the workshops, "mandatory intervention" facilities submitted improvement plans that were reviewed by the PD Adequacy Work Group to determine if improvement actions were appropriately focused on identified root causes. Not all intervention facilities attended the workshops, and some facilities attended voluntarily. Overall, the Network 5 results showed a statistically significant improvement in measuring PD adequacy (84% baseline to 92% re-measurement), with a corresponding 51% RFR. Improvement in desired levels of adequacy was also statistically significant (55% baseline to 64% re-measurement), with a 21% RFR. Analysis by the intervention group showed that "mandatory intervention" facilities improved more than did "voluntary" facilities in measuring adequacy and in reaching desired levels, and that the differences were statistically significant. Quality improvement efforts that focused on improving the adequacy of PD in Network 5 were accomplished.

BACKGROUND Vancomycin-resistant enterococci (VRE) are increasing in prevalence at many institutions, and are often reported in dialysis patients. We studied the prevalence of and risk factors for VRE at seven outpatient hemodialysis centers (three in Baltimore, MD, USA, and four in Richmond, VA, USA). METHODS Rectal or stool cultures were performed on consenting hemodialysis patients during December 1997 to April 1998. Consenting patients were recultured during May to July 1998 (median 120 days later). Clinical and laboratory data and functional status (1 to 10 scale: 1, normal function; 9, home attendant, not totally disabled; 10, disabled, living at home) were recorded. RESULTS Of 478 cultures performed, 20 (4.2%) were positive for VRE. Among the seven centers, the prevalence of VRE-positive cultures varied from 1.0 to 7.9%. Independently significant risk factors for a VRE-positive culture were a functional score of 9 to 10 (odds ratio 6.9, P < 0.001), antimicrobial receipt within 90 days before culture (odds ratio 6.1, P < 0.001), and a history of injection drug use (odds ratio 5.4, P = 0.004). CONCLUSIONS VRE-colonized patients were present at all seven participating centers, suggesting that careful infection-control precautions should be used at all centers to limit transmission. In agreement with previous studies, VRE colonization was more frequent in patients who had received antimicrobial agents recently, underscoring the importance of judicious antimicrobial use in limiting selection for this potential pathogen.

Vascular access infections are a major cause of morbidity and mortality in hemodialysis patients, and the use of antimicrobials to treat such infections contributes to the emergence and spread of antimicrobial-resistant bacteria. To determine the incidence of and risk factors for vascular access infections, we studied hemodialysis patients at 7 outpatient dialysis centers (4 in Richmond, VA, and 3 in Baltimore, MD) during December 1997 to July 1998. Vascular access infections were defined as local signs (pus or redness) at the vascular access site or a positive blood culture with no known source other than the vascular access; and hospitalization or receipt of an intravenous (IV) antimicrobial. A total of 796 patients were followed for 4,134 patient-months. The vascular access infection rate was 3.5[sol ]100 patient-months, ie, patients had a 3.5[percnt] risk of infection each month. Independent risk factors were the specific dialysis unit where the patient was treated (relative hazard varying from 1.0 to 4.1 among the 7 centers), catheter access (relative hazard, 2.1 v implanted access), albumin level (relative hazard, 2.4 for lowest v highest quartile), urea reduction ratio (relative hazard, 2.2 for lowest v highest quartile), and hospitalizations during the previous 90 days (relative hazard, 4.9 for [ge ]6 v zero hospitalizations). These data confirm that vascular access infections are common in hemodialysis patients and that infection rates differ substantially among different centers. Catheter use should be minimized to reduce these infections. Additionally, the possibility that improved serum albumin and urea reduction ratio could reduce vascular access infections should be evaluated.