Infection Control Issues in the Dialysis Setting
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Transcript Infection Control Issues in the Dialysis Setting
Infection Control Issues
in the Dialysis Setting
Stuart L. Goldstein, MD
Associate Professor of Pediatrics
Baylor College of Medicine
Medical Director, Renal Dialysis Unit
Texas Children’s Hospital
Houston, Texas
Helen Currier, RN, BSN, CNN
Assistant Director
Renal Dialysis and Pheresis
Texas Children’s Hospital
Houston, Texas
Infections in the Dialysis Setting
Significant cause of hospitalization
Significant cause of mortality
Data compiled from the United States
Renal Data System (USRDS)
Change in hospital admissions
since 1993
Figure 6.3
Period prevalent
dialysis patients. Rates
adjusted for age,
gender, race, and
primary diagnosis.
ESRD patients 2005
used as reference
cohort.
Adjusted admissions for principal
diagnoses, by modality
Figure 6.5
Period prevalent ESRD
patients; adjusted for
age, gender, race, &
primary diagnosis.
ESRD patients, 2005,
used as reference
cohort.
Adjusted cause-specific
hospital admissions, by age
Figure 6.7
Dialysis patients, 2005,
used as reference
cohort. Rates adjusted
for gender, race, &
primary diagnosis.
Period prevalent
dialysis patients age 20
& older. At the end of
1998 a new ICD-9-CM
code was added for
infections due to
internal devices in
peritoneal dialysis
patients; data prior to
this date are omitted.
Infections in this
category include those
related to vascular
access devices or
peritoneal dialysis
catheters.
Percent change in hospitalization rates for
prevalent dialysis patients, 1995–2005, by
demographic characteristics & primary diagnosis
Figure 6.6
Period prevalent
dialysis patients; rates
for all patients are
adjusted for age,
gender, race, &
primary diagnosis;
rates by one factor are
adjusted for the
remaining three. Direct
comparison of adjusted
rates is appropriate
only within each graph,
not between graphs.
Dialysis patients, 2005,
used as reference
cohort. Vascular access
data include
hemodialysis patients
only.
Geographic variations in cause-specific
admissions, per 1,000 patient-years, 2005,
by state: HD, infection
Figure 6.10 (continued)
Period prevalent
hemodialysis patients,
2005. Excludes patients
residing in Puerto Rico
& the Territories.
Percent change in infectious admission
rates, 1995–2005, by state
Figure 6.11 (continued)
Period prevalent
hemodialysis patients,
1995–2005. Excludes
patients residing in
Puerto Rico & the
Territories.
All-cause mortality:
patients with major diseases, 2005
Figure 6.15
ESRD & general Medicare patients with diagnosis in 2005; adjusted for gender & race. Medicare patients, 2005, used as
reference cohort.
Survival rates after major disease diagnosis
in the ESRD & general populations
Figure 6.17
Prevalent general Medicare & ESRD patients with diagnosis between 1992 & 2004.
Medicare patients, 2005, used as reference cohort.
Adjusted cause-specific mortality:
infection
Figure 6.21
Incident dialysis
patients. Rates by age
adjusted for gender,
race, & primary
diagnosis; rates by race
adjusted for age,
gender, & primary
diagnosis. Incident
ESRD patients, 1996,
used as reference
cohort.
Outline
Review dialysis treatment procedure/logistics
Challenges for infection control
Blood
borne pathogens
Respiratory
Contact contamination
Regulatory requirements
Center
DSHS
CDC
QA/QI
for Medicare & Medicaid Services (CMS)
Dialysis Procedures
Hemodialysis
Blood
cleaned directly through a closed
extracorporeal circuit
Blood accessed via
Arterio-venous fistula (AVF)
Arterio-venous graft (AVG)
Percutaneous central venous catheter
Can
be performed in-center or at home
Peritoneal Dialysis
Catheter
placed percutaneously into peritoneal cavity
Patient exchanges fluid via that catheter at various
intervals during the day or night
Performed at home
Hemodialysis Logistics
Patients dialyze for 3-4 hours thrice weekly
Open
ward setting
Unit schedules can run up to 4 shifts per day
depending on census
Patients
follow each other in same chair
Same machines
Different disposables
Dialyzers re-used for same patient up to 10 treatments
Nurse/Technician to patient ratio 1:1 to 1:4
depending on acuity
Disinfection Procedures
Patient station surfaces
Any
soap
Between each patient shift
Medical Equipment
Hospital
disinfectant (low level)
Between patient use
Blood spills
Tuberculocidal/1:100
Immediate
bleach (intermediate level)
Disinfection Procedures
Bloodborne Pathogen Challenges
Hepatitis B virus
Hepatitis C virus
HIV
Hepatitis B
Desired Patient Outcomes
The
patient will not convert to HbsAg+ status
Hepatitis B will not be transmitted in the
dialysis unit
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Hepatitis Susceptibility Testing
Hepatitis B Vaccination
Hep B vaccine dose
is higher for patients
with ESRD
40 mg
Hepatitis B Vaccination
HepB+ Patient Management
Hepatitis B virus is readily
transmitted across the
dialysis filter membrane
Hepatitis B+ patients
require isolation in
separate room (new
units) or a separate area
Do not re-use dialyzers
Patient education
Hepatitis C
Desired Patient Outcomes
The
patient will not convert to a positive antiHCV status
The patient with a positive anti-HCV will not
transmit the disease
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Hepatitis C
Monitor hepatitis C surveillance laboratory test
results
Antibody
to hepatitis C virus (anti-HCV) and alanine
aminotransferase (ALT) on admission for all patients
ALT monthly for anti-HCV negative patients
Anti-HCV semiannually for all negative anti-HCV
patients
Supplemental or confirmatory testing with more
specific assays for patients with an initial positive antiHCV
Hepatitis C Surveillance
HepC+ Patient Management
Hepatitis C is NOT readily transmitted
across the dialysis filter membrane
Patient isolation is not required
Machine isolation is not recommended
May re-use dialyzers
HIV
Routine surveillance not required
Isolation not required
May re-use dialyzers
Respiratory Infection Control Challenges
Host Transmission
Tuberculosis
Varicella
Immunocompromised Host Susceptibility
ESRD
complicates other systemic illness
Stem cell transplantation
Solid organ transplantation
Respiratory Infection Control Measures
Isolation rooms required for all new dialysis units
Negative
pressure is usual
Only one room required per unit
Mask isolation
All patients with suspected TB or VZV should be
isolated or wear masks during evaluation
Negative pressure rooms should have at least 6
air exchanges per hour
Tuberculosis
Desired patient outcomes
The
patient will not convert from a negative to
a positive tuberculosis (TB) skin test
The patient will not progress to active TB
disease
The patient with active TB will not transmit the
disease
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Tuberculosis
Monitor laboratory test results related to TB
screening, diagnosis, and treatment
Mantoux
skin test
CXR
Sputum
smear and culture
Assess for S/S of TB
Productive
or persistent cough
Cloudy or blood-tinged sputum
Unexplained weight loss
Night sweats
Elicit hx of exposure to TB
Tuberculosis
Assess for risk factors that increase the risk of
development of active TB disease after
exposure
Immunosuppression
HIV
Hx
of TB or + skin test without treatment or
completion of prescribed medication
Monitor adherence to home medication regimen
for patients receiving therapy
Tuberculosis
Intervention
Provide
TB screening per current CDC
recommendations
IC policies and procedures that are consistent
with current CDC guidelines
Coordinate care with other health care
providers and agencies, e.g. local health
department, as indicated
Tuberculosis
Patient Education
Rationale
for TB surveillance
Teach respiratory IC practices
Reinforce importance of adherence to
prescribed medication regimen
Teach S/S of disease progression to report to
nurse
Hand Hygiene Educational
Design
Objectives
1. Identify risk for infection in the
hospital or home
2. List one hand hygiene myth and
one hand hygiene fact.
3. Identify key steps for hand
washing:
* Soap and water
*Alcohol-based hand sanitizer
4. Demonstrate correct hand
washing techniques:
*Soap and water
*Alcohol-based hand sanitizer
5. Name four instances when hands
should be washed to limit the
transfer of bacteria, viruses and
other microbes.
6. Identify hand washing issues
unique to children.
Related Content
I. Germs: What are they?
II. Reducing the risk of infection
III. Myths and Facts
IV. Lesson on hand washing
techniques
A. Steps for soap and
water
B. Steps for alcohol- based
hand sanitizers
V. When to wash hands
VI. Issues unique to children
Contact Contamination
Nurse/technical staff care for >1 patient at a time
Caregivers must wear appropriate personal
protective equipment
Gloves,
gowns and masks with face shields when
accessing AVF, AVG, catheter
Gloves must be used for
All
All
patient contact
machine contact
All medication preparation
Gloves must be changed
Between patients
Between machines
When moving from one
area to another
Bacterial Infection
Desired Patient Outcomes
The
patient will be free of signs and
symptoms associated with localized infection
or sepsis
The patient’s risk for bacterial colonization or
infection due to a drug-resistant organism will
be reduced
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Bacterial Infection
Assessment
Intervention
Laboratory
analyses/cultures
Avoid culturing vascular catheter tips surrounding skin or
catheter hub
Catheter exit site or wound cultures
Collaborate
with MD/APN to avoid over use of
vancomycin
Monitor patient response, e.g. resolution of infection,
development of sepsis
Bacterial Infection
Intervention
Unit
infection control policies and procedures
consistent with the CDC guidelines (2001)
Patient education
Potential
for bacterial colonization and infection of
access
Importance of permanent vascular access placement
rather than long-term use of a hemodialysis catheter
Bacterial Infection
Patient education
Good
Care of vascular access;
Washing prior to dialysis
Glove use when holding vascular access site to stop
bleeding
Peritoneal catheter exit site care
Use
hygienic practices
of prophylactic antibiotic therapy
new PD catheter
Topical exit site antibiotics (mupirocin, gentamicin)
Importance
of immunizations
Unit QA/QI Practices
Ongoing assessment of current and trend
analyses of relevant infection rates
MRSA
Catheter
related bacteremia
Catheter exit site and tunnel infections
Peritonitis
Surveillance for Hepatitis virus
susceptibility status
Facility Infection Trends
Percent of Facility Census with Infections By Type During Month
%100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Jan
Feb
Graft/Fistula
45
40
Catheter
23
28
Wound/Limb
5
10
Sepsis/Bacteremia
2
3
HBaAg+
0
0
MRA-VRE
2
4
Other
23
15
Facility Name
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
ESRD Network of Texas
The Water Treatment System
Water Treatment System Testing/Standards
(AAMI)
Testing performed monthly
Maximal level of bacteria in water to
prepare dialysis fluid/reprocess dialyzers
must NOT EXCEED 200 CFU
AAMI
action level is 50 CFU
Maximal level of endotoxin must not
exceed 2 EU/ml
AAMI
action level is 1 EU/ml
Testing Sites
Testing Sites