1. Infection Control Issues in the Dialysis Setting
Stuart L. Goldstein, MD Helen Currier, RN, BSN, CNN
Associate Professor of Pediatrics Assistant Director
Baylor College of Medicine Renal Dialysis and Pheresis
Medical Director, Renal Dialysis Unit Texas Children’s Hospital
Texas Children’s Hospital Houston, Texas
Houston, Texas

2. Infections in the Dialysis Setting
Significant cause of hospitalization
Significant cause of mortality
Data compiled from the United States Renal Data System (USRDS)

3. 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.

4. 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.

5. 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.

6. 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.

7. Geographic variations in cause-specific admissions, per 1,000 patient-years, 2005, by state: HD, infection Figure 6.10 (continued)
Period prevalent hemodialysis patients, Excludes patients residing in Puerto Rico & the Territories.

8. 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.

9. 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.

10. Survival rates after major disease diagnosis in the ESRD & general populations Figure 6.17
Prevalent general Medicare & ESRD patients with diagnosis between 1992 & Medicare patients, 2005, used as reference cohort.

11. 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.

12. 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

13. Dialysis Procedures Hemodialysis Peritoneal Dialysis
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

14. 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

15. 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

16. Disinfection Procedures

17. Bloodborne Pathogen Challenges
Hepatitis B virus
Hepatitis C virus
HIV

18. 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)

19. Hepatitis Susceptibility Testing

20. Hepatitis B Vaccination
Hep B vaccine dose is higher for patients with ESRD
40 mg

21. Hepatitis B Vaccination

22. 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

23. Hepatitis C Desired Patient Outcomes
The patient will not convert to a positive anti-HCV status
The patient with a positive anti-HCV will not transmit the disease
Nephrology Nursing Standards of Practice and Guidelines for Care (2005)

24. 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

25. Hepatitis C Surveillance

26. 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

27. HIV Routine surveillance not required Isolation not required
May re-use dialyzers

28. Respiratory Infection Control Challenges
Host Transmission
Tuberculosis
Varicella
Immunocompromised Host Susceptibility
ESRD complicates other systemic illness
Stem cell transplantation
Solid organ transplantation

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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

35. 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
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

36. 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

37. 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)

38. 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

39. Bacterial Infection Intervention Patient education
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

40. 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

41. 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

42. Facility Infection Trends Percent of Facility Census with Infections By Type During Month
Facility Name
ESRD Network of Texas

43. The Water Treatment System

44. 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

45. Testing Sites

46. Testing Sites