Dr.T.V.Rao MD 1

Human Safety in Dialysis Units

Dr.T.V.Rao MD

Dr.T.V.Rao MD 2

Renal Failure and Technology for Survival

Dr.T.V.Rao MD 3

Dialysis is a complex procedure needs good understanding to prevent infections

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Developing countries lacks

• The countries that fall under the category of emerging economies lack the technical, human and economical resources needed to establish well-formed policies for treatment of end-stage renal disease (ESRD), making it a political and economic challenge. There is a deficiency of organized data on the practice of dialysis in developing countries, which is mostly attributed to the lack of renal registries.

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INFECTIONS IN HEMODIALYSIS UNITpatients are at risk with

• Bacterial infections • Viral infections

like Hepatitis B and C• HIV infection

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How do you care for the access point?

• Vascular access is a vital part of hemodialysis. Take special care to prevent injury and infection:

• Keep the access area clean.

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Creating our own Standard Operating procedures

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Basic Principles of Medical Asepsis

• Clean Technique used to prevent the spread of microorganisms

• Hand washing AGAIN• Carry soiled items away from body• Do not place soiled items on floor• Client instructed not to cough, sneeze,

breathe on anyone; expectorate into tissues; cover mouth and nose when coughing and sneezing; (Airborne)

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Hand Hygiene

• Unwashed hands of healthcare workers are the major route of transmission of microorganisms in healthcare settings.

• Hand hygiene is includes hand washing with soap and water, and/or applying an alcohol- based hand rub )

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Hand washing facilities

• Hand hygiene facilities should be located as close as possible to the point of contact with 2 to 3 patients and dialysis equipment.

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Handwashingwe can do better

• Five Key Factors– Time: 15 seconds– Water: warm– Soap: 1 teaspoon liquid– Friction: rub in circular motions from fingers to 1

inch above wrist if not visibly soiled (moving from dirtiest to cleanest) and 1 inch above area of contamination

– Drying: begin with fingers and move upwardDRY HANDS FIRST THAN TURN OFF FAUCET WITH

PAPER TOWEL

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We lack standards ??? • One hand wash

basin should be provided for every 2-3 dialysis stations in the main dialysis area and a minimum of one in an isolation room.

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Gloves & Hand Hygiene• Hand hygiene – Use soap & water or alcohol-based antiseptic

hand rub – Visibly soiled vs. not visibly soiled

• Intravascular catheters- Staff should wear clean or sterile gloves

when changing the dressing on IV catheters- Hand hygiene performed before & after

palpating catheter insertion sites, as well as before & after accessing or dressing an IV catheter

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Blood spills

• For minor spills on surfaces (e.g. benches, counter tops): • Wipe up with paper towel soaked in undiluted 1%

sodium hypochlorite and then wash with neutral detergent and hot water and allow to dry.

• • For major blood spills • Cover with chlorine powder (10,000 ppm available

chlorine) and leave for two minutes OR Limit spread using paper towels and slowly flood contaminated area with undiluted sodium hypochlorite

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Many drug resistant bacteria ..

• Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE), Extended Spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, Carbapenem-resistant Acinetobacter baumannii (CRAB) and Clostridium difficile (antibiotic associated diarrhoea).

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Practising Universal Precautions

• Face protection (eyewear/goggles, masks) is required to protect the mucous membranes of the eyes, nose and mouth when performing procedures that may generate splashes or sprays of blood or body fluids (e.g. during initiation and termination of dialysis).

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Blood Borne Virus Screening and Management

• All patients should be tested for HBV, HCV and HIV on admission to the dialysis unit including after transfer from another unit

• Recheck time ???• All maintenance dialysis

patients should be retested at regular every 6 months for HBV, HCV and HIV infection.

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Anti-HBs titers

• Anti-HBs titres should be checked 4 weeks after the last dose and at 6 monthly intervals thereafter.

• Non-responders (anti-HBs titers < 10 IU/ml) should receive 3 more doses of the vaccine.

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Hepatitis B vaccination• Hepatitis:

“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” (precautions, testing, immunization, isolation, surveillance, response, training

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Hepatitis B is a major concern

• The most common viral infection in dialysis patients in developing countries is hepatitis B . There is little data on the incidence and prevalence of HBV in the dialysis population of developing economies, however rough estimates indicate that 5% of India’s general population is infected whereas 6%-36% of the dialysis population is infected.

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Hepatitis C a Emerging Problem• HCV has become apparent in dialysis populations

as a growing concern as there is no vaccine available for this strain. The increase in spread of the infection is mostly attributed to the cross-contamination of patients due to inadequately trained staff and the reuse of disposables. HIV infection is not a major concern of the dialysis population in developing countries, even in Africa where high HIV rates predominate.

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HIV not great threat ?• HIV infection is not a

major concern of the dialysis population in developing countries, even in Africa where high HIV rates predominate.

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HBV+ Isolation Room/AreaNew regulations

• Effective Feb 9, 2009, every new facility MUST include an isolation room for treatment of HBV+ patients, unless the facility is granted a waiver of this requirement

• For existing units in which a separate room is not possible, there must be a separate area for HBsAg positive patients

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Simple sanitary measures • Sanitary Environment:

“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients.” (includes procedures and comprehensive program

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Cleaning of dialysis machines and chairs/beds

• Dialysis machines should be internally disinfected, externally cleaned (and disinfected if indicated), and dried after each patient.

• The exterior of the machine should be effectively cleaned using protocols following manufacturer’s instructions.

• Special attention should be given to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients’ blood.

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Cleaning of dialysis machines and chairs/beds

• Cleaning of non-critical surfaces (e.g. dialysis bed or chair, countertops, external surfaces of dialysis machines and equipment) should be done with neutral detergent and warm water.

• Do not waste on chemicals – they are counterproductive

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If the patient infected with Blood borne infection

• Clean with neutral detergent and water, and

then • Disinfect with sodium hypochlorite 1% (1,000

ppm available chlorine; 1:10 dilution). • Remove chlorine residues from metallic

surfaces with water as Sodium hypochlorite in high concentrations (>500 ppm) is corrosive to metals.

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How staff get infected• Contaminated

devices, equipment and supplies, environmental surfaces, or hands of personnel.

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• If you suffer an accidental contaminated needle stick injury, you should immediately wash the wound thoroughly with soap and water, then report it to your employer. Do not hesitate. Universal precautions require that all blood and other body fluids be treated as though they were contagious. In the wake of a needle stick injury,

If you are injured

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• Take blood for virology, (HIV, hepatitis B, hepatitis C) from the injured worker. Start PEP where appropriate and consider the need for antibiotic therapy or hepatitis B immunization. Recheck HIV status 3 months later and hepatitis serology 3 and 6 months later.

• Anti retroviral treatments if warranted

Basic investigations and treatments

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• Discard contaminated sharps immediately and without recapping in puncture- and liquid-proof containers that are closed, sealed and destroyed before completely full.

Safer ways to discard needles

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Glove the Hands

Hand Hygiene, Gloves and PPE: Moving Target• Current guidance is gloves whenever providing

patient care or touching a machine surface, and change required both ways in going from one to the other• Medical record, both paper and electronic

present PPE challenge• “Holding sites” requires glove(s) for patient or

visitor

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Environmental Surveillance

• When conducting any form of environmental sampling, identify existing comparative standards and fully document departures from standard methods

• B. Select a high-volume air sampling device if anticipated levels of microbial airborne contamination are expected to be low .

• C. Do not use settle plates to quantify the concentration of airborne fungal spores

• D. When sampling water, choose growth media and incubation conditions that will facilitate recovery of waterborne organisms

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Proper Documentation• Medical and administrative

records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility.

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Care of Environment

Additional Specifics:• “splash zone” nothing considered clean in it• Medication prep: no delivery carts, clean prep• Isolation Room or agreement, two station

separation for pre-reg facilities• Catheter reduction and Precautions• Water and Dialysate Cultures• Documentation of audits, “breaks” action

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Active Surveillance Component

The infection prevention and control program must include an active surveillance component that covers both hospital patients and personnel working in the hospital. Surveillance includes infection detection,data collection and analysis, monitoring, and evaluation of preventive interventions

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Multi Drug resistance Organisms need attention

MULTI-DRUG RESISTANT ORGANISMS (MDROs)And Communicable Disease Outbreaks Require• Close Monitoring, Tracking, Reporting• Prevention of transmission• Identification of infected and Exposed• Particular attention to ambulatory care (eg ER)And have Individual challenges

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We have to Train our own Manpower

• A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

• CDC has defined “infection control professional” as “a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control.”

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Training is Continuous • Isolation procedures and requirements for infected

and at risk or immunosuppressed nursing home residents. • Use of and in-service education regarding standard

precautions, (e.g., universal precautions/body substance isolation). • Hand washing, respiratory protection, linen

handling, housekeeping, needle and hazardous waste disposal, as well as other means for limiting the spread of communicable organisms.

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Chronic Dialysis Facilitieshave a self audit

Survey of this Condition requires:• observations of care delivery,• interviews with staff and patients,• review of medical records, facility logs,

policies and procedures and quality assessment and performance improvement (QAPI) documentation.

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Disinfection of Haemodialysis Machines

• As per manufacturers instructions• The development of bacterial biofilms in

the hydraulic circuit of haemodialysis machines can be prevented by frequent use of chemical and heat disinfection strategies.

• Frequent bleaching is not recommended because of possible damage to the machine.

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Components

• Hand Hygiene• Flu Vaccination• Slips, Trips and Falls• Medication

Reconciliation• Emergency

Preparedness• Transplantation (new)

• Sharps Safety• Decreasing Patient &

Provider Conflict• Missed Treatments• Health Literacy• Patient Self-Managed

Care• Stenosis Surveillance

Patient Safety Principles (required)

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Staff training a MUST

• All staff in dialysis units should be trained in infection prevention and control practices including

• Proper hand hygiene technique • Appropriate use of personal protection equipment • Modes of transmission for BBV, pathogenic bacteria, and

other microorganisms Infection Control Precautions for Dialysis Units

• Rationale for segregating patients • Correct techniques for initiation, care, and maintenance of

dialysis access sites.

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Common Patient Safety Complaints

• Staff are not washing their hands• Staff do not change gloves between patients• Staff not wearing appropriate PPE• Given the wrong medication• Given the wrong dialyzer• Staff not performing safe procedure (catheter care)• Staff unskilled in cannulation

• Staff not performing appropriate patient assessments

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What is Self auditMedical and administrative records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility. If deficient practices noted in infection control, techniques are multiple, pervasive, or of an extent to present a risk to patient health and safety, Condition level non-compliance should be considered.

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Chronic Dialysis Facilitieshave a self audit

Survey of this Condition requires:• observations of care delivery,• interviews with staff and patients,• review of medical records, facility logs,

policies and procedures and quality assessment and performance improvement (QAPI) documentation.

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Have a self audit

Medical and administrative records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility. If deficient practices noted in infection control, techniques are multiple, pervasive, or of an extent to present a risk to patient health and safety, Condition level non-compliance should be considered.

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A Safety Network: Proposed Goals• Improve safety by creating and disseminating

knowledge necessary to detect and respond to current and emerging healthcare safety threats – Monitor the cause, frequency and impact of targeted

safety events– Establish priorities for safety promotion programs– Disseminate lessons learned

• Protect confidentiality• Reduce reporting burden and ensure local access

to healthcare safety information • Monitor progress toward achieving local, state,

and federal patient safety goals

• The greatest gift in learning something new is putting that

knowledge into practice and then sharing what you know with

someone else.• Practice! Practice! Practice!• We are all winners if we

practice a little

49Dr.T.V.Rao MD

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