apic ic challenges in dialysis - coastline apic...
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APIC IC Challenges in Dialysis
Danilo B. Concepcion,CBNT, CCHT-AOperations Manager, Renal Service
The views and opinions are those of the author and does not reflect those of St.
Joseph Hospital or any other organization.
* Infections2nd Leading
Cause Of Death17.0%
48.0%5.0%
4.0%
26.0%
Infection
Cardiac
CerebrovascularDiseaseMalignant Disease
All Other
UM-KECC, 2009
Approximately 15,000 dialysis patients die annually due to infections 2
*Temporal and spatial issues
*Water and dialysate
*Staffing matrix
*Dissolved particles can move either way across the membrane.*From blood to the dialysate.*From dialysate to the blood.
*They will move from area of higher to lower concentration.
*Very important that precise electrolyte level of dialysate is known. *This will determine what is removed
or given to the patient.
Hollow fiber Fiber wall
40 microns
Why Is Infection Prevention Such a Challenge in Dialysis?
High risk for spread of blood-borne and
other pathogens
Staff caring for multiple
patients w/short “changeover”
times
No physical separation of
individual treatment stations
Lots of potential
blood exposure
immunosuppressed dialysis patients
The in-center hemodialysis patient treatment reality:
compounded by…13
Recent Studies Illustrate How the Dialysis Facility Can Become a “Box of Bugs”
Organisms remain viable on surfaces for prolonged periods
Hepatitis B >1 week Influenza 1-2 days MRSA 7 days to 7
months VRE 5 days to 4
months C. difficile spore 5 monthsKramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006
Healthcare workers touch as many as 7 surfaces after touching a contaminated one!
McLaughlin AC, Walsh F. Am J Infect Control 39(6):456-463, 201114
How Are Infections Spread in Dialysis?
Five main sources of pathogen transmission:1. On the hands of staff going between
patients & between common areas and patients
2. From ineffectively disinfected equipment & environmental surfaces
3. From contaminated supplies & medications
4. From inadequate vascular access care5. From virulent pathogens (e.g. hepatitis B)
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Dialysis Patient Infections Can Be Prevented by:
Following good infection prevention and control practices
The Centers for Disease Control and Prevention (CDC) has guidelines for these practices in
dialysis facilities
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The CDC Guidelines
*Address general practices (wash hands, clean & disinfect equipment, etc.)
*Do not include details for application of the guidelines (what parts of the equipment need to be disinfected, etc.)
Remember the lesson from the Patient Safety Movement…
Staff need clear directions in what is expected of them in their duties…
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National Opportunity To Improve Infection Control In ESRD
The NOTICE Initiative is funded by theDepartment of Health and Human
Servicesto support the renal community in
improving infection control
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Infection Control Checklists for Dialysis
*Initiation of Dialysis with CVC*CVC Exit Site Care *Discontinuation of Dialysis and Post Care of CVC
*Initiation of Dialysis with AVF/G *Discontinuation of Dialysis and Post Care of AVF/G*Parenteral Medication Preparation/Administration
*Cleaning & Disinfection of the Dialysis Station *Supply Management & Contamination Prevention
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Note: It is not required that the patient has vacated the dialysis station before disinfection and preparation of the machine can be conducted.
If the patient remains in the chair during disinfection, strictly adhere to separation b/t the patient and the disinfected/prepared machine.
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The Infection Control Checklists Don’t Address Everything on How to Protect Patients from
HAI…
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*Separate isolation room*February 9, 2009 all new facilities must have a separate
isolation room (waiver)…
*Separate isolation area
* If there are current HBV+ patients on census, the isolation area/room can not be used for HBV- patients on other shifts or days due to the risk of cross-contamination.
*Separate dedicated supplies and equipment, including blood glucose monitors. *Labeled “isolation”
*Concentrate containers
*Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another (e.g., during the same shift or during patient change-over).*If a staff member assigned to care for an HVB+ patient must concurrently care for someone other than another HBV+ patient, the additional patient must be HBV immune
The more pure and endotoxin free the water and dialysate, the fewer Chronic Inflammatory Disease (CID) processes seen in patients over time
Fluid Bacteria (CFU/ml)
Endotoxin (EU/ml)
Water used for dialysate, reprocessing of hemodialyzers, germicide production
200 / 50 action level
2 / 1 action level
Dialysate 200 / 50 action level
2 / 1 action level
Minimum Frequency Monthly Monthly
Allowable LevelBacteria (cfu/ml) Endotoxin (EU/ml)
Standard (AAMIRD52) <200 <2
Standard (EDTA-ERA BPG) <100 <0.25
Standard (Swedish Pharmocopoeia) <100 <0.25
Ultrapure <0.1 <0.03Sterile 10-6 <0.03
Dialysate Quality for Hemodialysis
*Distribution/Loop System*Central systems at
least once a month*Disinfects water inlet
line to hemodialysis machines
*Portables
*Dialysis Machines*Daily OP*Acute setting
*Bicarbonate mixing systems *daily rinse
*Weekly disinfect
*Individual bicarbonate concentrate containers *should rinsed and
inverted to drain at end of each day
*disinfected weekly
*Culture media should be trypticase soy agar (TSA) or equivalent*No blood or chocolate agar
*Incubate at 35-37o C for 48 hours*May want to go to 72 hours
*Count colonies with a magnifying device*Shall not exceed 200 cfu/ml / 50 cfu action level
*Collected during or at the termination of dialysis at or beyond the point where the dialysate leaves the hemodialyzer.
*AAMI: Two machines per month*Each machine at least once annually
*The total viable bacteria count shall not exceed 200 cfu/ml.
*V178 IG: the final decision of whether to discontinue dialysis rests with the medical director of a facility.
*V179 IG: “Promptly” would be met if action is taken within 48 hours of receiving the results of testing.”
*By-products of water-borne gram negative bacteria
*Reside in the cell wall*Released when the bacteria dies*Enter bloodstream
*Build-up in Reprocessed Hemodialyzers*Back Diffusion**Back Filtration**Sense Bacteria/Endotoxin
*Do disinfect the ports with LAL testing*<2 EU
*> 1EU action level
*Current testing can be done in-center*Perform a control with each batch of tests*Outside labs usually require freezing or refrigerated
specimen and have better sensitivities
*Frequency*monthly*If suspected endotoxin reaction
*Malnutrition
*Low albumin
*Muscle protein wasting
*Protein catabolism
*Increased CRP
*Atherosclerosis
*Low cholesterol synthesis
*Increased ferritinlevels*Resistance to EPO therapy
*Bone disease, cysts, fractures
*Sleep disorders*Anti-endotoxinantibodies
*Improper water treatment system design*Loop
*Holding tanks
*UV/Ultrafilters
*Improper maintenance of water treatment system and delivery system (dialysis machine)*Disinfection schedule
*Improper disinfectant
A key concept in ensuring compliance with the
bacteriological control requirements is that
disinfection schedules should be designed to
prevent bacterial proliferation, rather than
being designed to eliminate bacteria once they
have proliferated to an unacceptable level.