Dialysis Infection Prevention: Facts You Need To Know

As a dialysis medical professional, you know the importance of preventing patient infections. According to the Centers for Disease Control and Prevention (CDC), bloodstream and other types of infection are the second leading cause of death among hemodialysis patients, and pose a significant threat to patient safety.* In Dialysis Centers where multiple patients receive dialysis concurrently, there are opportunities for transmission of infectious agents, directly or indirectly, via contaminated devices, equipment and supplies, environmental surfaces, or by person-to-person interactions. **

Healthcare providers are the front-line fighters in preventing dialysis related infections. By faithfully following infection prevention recommendations and protocols, healthcare providers lead the charge in fighting off these infections. There are numerous guidelines and practices for reducing dialysis infection risks. The CDC has outlined the best practices in their document “Dialysis Safety, Infection Prevention Tools”, (see resources at bottom of article). The CDC website provides copies of their protocols that can be printed with your organization’s logo to reinforce these practices among your staff, patients, and visitors.

EDUCATION AND COMPLIANCE IS CRITICAL

Included in the CDC best practices are activities that focus on staff actions and behaviors. These include following hand hygiene protocols and employing protective equipment to shield contact between patients, staff, and infectious agents. Gloves, gowns, masks, and eye and face shields should be utilized when indicated.

Dialysis Centers that have equipment that include easily accessible gloves and antibacterial hand sanitizers both reinforce protocol and minimize staff time stepping away from direct patient care areas (e.g. to obtain new gloves or hand sanitization from a supply cabinet or station). Infection Prevention Stands can facilitate this.

Easy access also translates into higher levels of staff compliance. Staff training and regular observation of staff behavior should be a core component of any infection prevention program. Patient and family education regarding infection risk and steps that can be taken to prevent infection are also important to consider (including hand hygiene, recognizing early signs of infection, and instructions for early infection intervention).

ENVIRONMENTAL FACTORS PLAY A ROLE

In addition to staff hygiene, there are many environmental actions your center can employ to reduce dialysis infection risks. All environmental surfaces have the potential to host various pathogens that can be a source of infection transmission. Cleaning and disinfecting these surfaces and machines with a disinfectant solution labeled for use in a health-care setting is recommended (in accordance with the machine manufacturer's recommendations).
Another level of available protection are carts and workstations that include a built-in antimicrobial powder coating that offer additional protection. These carts and workstations are easy to clean and maintain. Antimicrobial powder coatings are also available within the tops and posts of carts to provide a comprehensive barrier to pathogens and reduce infection transmission risks.

SCRUB-THE-HUB AND OTHER PROTOCOLS

The CDC and the National Kidney Foundation have outlined several steps in their “Scrub-the-Hub” protocol. This protocol outlines in detail the proper technique to connect and disconnect a catheter during dialysis, as well as the aseptic use of the catheter hubs. The guidelines recommend scrubbing of the access port with an appropriate antiseptic for needleless intravascular catheter systems. The ongoing maintenance of dialysis catheter hubs with an appropriate antiseptic is discussed as part of the core intervention for dialysis bloodstream infection prevention.

SAFE INJECTION PRACTICES

The CDC and APIC (Association. for Professionals in Infection Control and Epidemiology) outline the principles of aseptic technique for dialysis infection prevention***.

These principles cover:

• Single use medications and solutions
• Multi-dose medications
• Medication preparation
• Transportation of medications and solutions
• Disposal or storage of medications
• Use of medication carts and delivery

Generally these principles restrict the delivery, administration, and transportation of medications and solutions to individual patients to prevent transmission of pathogens between patients and treatment areas.

IMMUNIZATIONS AND INFLUENZA

Hepatitis B virus (HBV) transmission prevention in dialysis centers has been an important part of infection control for many years. Vaccination is recommended for all patients undergoing chronic hemodialysis and all healthcare providers who administer care. In addition to vaccination, both patients and staff should have post-vaccination testing and yearly booster doses if the testing indicates that antibody levels are insufficient.

Dialysis patients with chronic kidney disease are also at higher risk for developing complications from seasonal influenza (flu). It is recommended that these patients receive annual vaccinations
to prevent infection with the flu.

CARE AND PREVENTION OF INFECTION FROM VASCULAR ACCESS

Healthcare regulatory agencies are united in their recommendation that vascular access should be via native AV fistula whenever possible. AV Graft is the second option and the use of catheters should be avoided in order to reduce dialysis related infections. The agencies have developed clear protocols to minimize risk of infections from vascular access. These protocols include disinfecting the catheter hub, and inadvertent introduction of antiseptic solutions into the bloodstream.

INFECTION TRACKING AND DATA ANALYSIS

The final component of a dialysis infection prevention program is a comprehensive infection surveillance and tracking system. Many EMR or other electronic systems include functionality to track infections and generate comparative reports to determine infection rates and demonstrate progress of prevention efforts. The CDC’s national healthcare safety network Dialysis Event Protocol provides a wealth of comparative data for participating facilities. In addition to providing important feedback to healthcare facilities, participation allows the CDC the ability to track local, state, and national trends and improve prevention protocols.
In addition to allowing facilities to categorize hemodialysis patients by type of vascular access used, NHSN provides a variety of analysis options including line listings, rate tables, and control charts, which can be used to better inform quality improvement decisions.

The Centers for Medicare and Medicaid Services (CMS) published a final rule encouraging all end stage renal disease (ESRD) facilities to track quality indicators through NHSN by following the Dialysis Event Protocol. In addition to the CDC, there are additional organizations that provide comparative data including;

• The United States Renal Data System (USRDS), www.usrds.org
• CMS Dialysis Facility Compare (DFC), which allows consumers to review and compare facility characteristics and quality information on all Medicare approved dialysis facilities in the US, www.cms.hhs.gov/DialysisFacilityCompare

MAKING IMPROVEMENTS

Dialysis infection prevention is the shared responsibility of healthcare facilities, providers, staff, and patients. A united approach of staff training, implementation of best practice protocols, selection, and maintenance of equipment and education will provide your patients with effective treatment in a quality focused setting. There is a wealth of protocols and guidelines to assist your efforts. Quality improvement activities are the cornerstone to your organization’s prevention efforts.

WEB RESOURCES FOR DIALYSIS INFECTION PREVENTION:
*https://www.cdc.gov/nhsn/dialysis/index.html
**https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm
***http://text.apic.org/toc/basic-principles-of-infection-prevention-practice/aseptic-technique