Post on 14-Dec-2015
Infection Control Issues in the Dialysis Setting
Stuart L. Goldstein, MD Helen Currier, RN, BSN, CNNAssociate Professor of Pediatrics Assistant DirectorBaylor College of Medicine Renal Dialysis and PheresisMedical Director, Renal Dialysis Unit Texas Children’s HospitalTexas Children’s Hospital Houston, TexasHouston, 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 admissionssince 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: infectionFigure 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 for Medicare & Medicaid Services (CMS) DSHS CDC
QA/QI
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 bleach (intermediate level) Immediate
Disinfection Procedures
Bloodborne Pathogen Challenges
Hepatitis B virus Hepatitis C virus HIV
Nephrology Nursing Standards of Practice and Guidelines for Care (2005)
Hepatitis B
Desired Patient Outcomes The patient will not convert to HbsAg+ statusHepatitis B will not be transmitted in the
dialysis unit
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
Nephrology Nursing Standards of Practice and Guidelines for Care (2005)
Hepatitis C
Desired Patient Outcomes The patient will not convert to a positive anti-
HCV statusThe patient with a positive anti-HCV will not
transmit the disease
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 anti-HCV
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
Nephrology Nursing Standards of Practice and Guidelines for Care (2005)
Tuberculosis
Desired patient outcomesThe patient will not convert from a negative to
a positive tuberculosis (TB) skin testThe patient will not progress to active TB
diseaseThe patient with active TB will not transmit the
disease
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
InterventionProvide TB screening per current CDC
recommendations IC policies and procedures that are consistent
with current CDC guidelinesCoordinate care with other health care
providers and agencies, e.g. local health department, as indicated
Tuberculosis
Patient EducationRationale for TB surveillanceTeach respiratory IC practicesReinforce importance of adherence to
prescribed medication regimenTeach 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 patient contact All machine contact All medication preparation
Gloves must be changed Between patients Between machines When moving from one area to another
Nephrology Nursing Standards of Practice and Guidelines for Care (2005)
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
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 hygienic practices Care of vascular access; Washing prior to dialysis Glove use when holding vascular access site to stop
bleeding Peritoneal catheter exit site care
Use 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 ratesMRSACatheter related bacteremiaCatheter exit site and tunnel infectionsPeritonitis
Surveillance for Hepatitis virus susceptibility status
05
101520253035404550556065707580859095
100%
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
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
ESRD Network of TexasFacility Name
Facility Infection Trends
Percent of Facility Census with Infections By Type During Month
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 CFUAAMI action level is 50 CFU
Maximal level of endotoxin must not exceed 2 EU/mlAAMI action level is 1 EU/ml
Testing Sites
Testing Sites