1. Infection Control in CKD A Culture of Safety Leona Dinnan, RN, CDN

2. Objectives Identify Infection Control Practices Required in the dialysis environment Introduction of the ESRD Condition for Coverage (CfC): Infection Control Identify 5 major routes of infection transmission in dialysis Understand NHSN: Definition of Dialysis Event

3. Functions of the Normal Kidney The kidney's ◦ Regulate body chemistry ◦ Regulate body water (BP) ◦ Remove the end products of metabolism ◦ Remove products not utilized by the body ◦ Aides in the production of Red Blood Cells

4. KDOQI Stages of Kidney Disease StageGFRDescriptionTreatment1 190+Normal kidney function findings point to kidney disease Observation, control of blood pressure 260-89Mildly reduced kidney function Observation, control of blood pressure and risk factors 3A 3B 45-59 30-44 Moderately reduced kidney function Observation control of blood pressure and risk factors 415-29Severely reduced kidney function Planning for End stage renal failure 5<15 or on dialysis Very severe or end stage kidney failure Treatment choices

5. Population with CKD  The incidence of recognized CKD in people ages 65 and older more than doubled between 2000 and 2008.  One in 10 American adults, more than 20 million, have some level of CKD.  At the end of 2009, more than 871,000 people were being treated for ESRD.  Between 1980 and 2009, the prevalent rate for ESRD increased nearly 600 percent, from 290 to 1,738 cases per million. United States Renal Data System’s 2010 Annual Data Report and 2011 Annual Data Report.

6. Facts Increased risk of infection related hospitalization found in individuals with early stages of Kidney disease Stage 3 & 4 patients had an 80 percent more at risk for pulmonary infection like pneumonia compared to participants with normal renal function March American journal of Kidney Diseases

7. Dialysis Dialysis is a Greek word meaning "loosing from something" Hemo:Blood Peritoneum: The serous membrane that lines the walls of the abdominal cavity and folds inward to enclose the viscera

8. Dialysis

9. Access for Dialysis With hemodialysis we access the blood through an A/V Fistula, Graft, or Catheter Peritoneal dialysis we access the blood vessels through the peritoneal cavity using a Tenckhoff catheter.

10. National Burden of Dialysis Infections In the US, there are about 370,000 people relying on hemodialysis About 75,000 people receive hemodialysis through a central line Central lines have a higher risk of infection than a fistula or graft CDC estimates 37,000 central line- associated bloodstream infections may have occurred in U.S. hemodialysis patients in 2008 A Cause for Concern

11. Infections in Dialysis Patients Bloodstream infections are a dangerous complication of dialysis 1 in 4 patients who get a bloodstream infection caused by S. aureus (staph) bacteria can face complications such as: ◦ Endocarditis (infected heart valve) ◦ Osteomyelitis (infected bone) Total costs for each infection can be more than $20,000 Bloodstream infections can cause sepsis (a potentially deadly condition) Up to 1 in 5 patients with an infection die within 12 weeks

12. Infections : A Major Patient Safety Problem in Dialysis – 2 nd Leading Cause Of Death Infections: A Major Patient Safety Problem in Dialysis – 2 nd Leading Cause Of Death 12 UM-KECC, 2009 15,000 dialysis patients die annually due to infections Approximately 15,000 dialysis patients die annually due to infections

13. The “Perfect Storm” in Hemodialysis High risk for spread of blood- borne and other pathogens Staff caring for multiple patients Short “changeover” times Lots of potential blood exposure 13 ESRD patients are immunosuppressed

14. How Are Infections Spread in Dialysis? Five potential “routes” 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 14

15. How Are Infections Spread in Dialysis? (cont.) 4. From inadequate vascular access care Vascular access is the primary portal for dialysis patient infections Central Venous Catheters (CVC) have 7 times higher infection rates than AV fistula (AVF) 5. From virulent pathogens Hepatitis B virus remains viable and transmittable for at least 7 days on surfaces In 1974 6.2% of hemodialysis patients acquired hepatitis B-some facilities had as high as 30% HBV+ 15

16. Why Hand Hygiene & Surface Disinfection Are Vital Organisms remain viable on surfaces for prolonged periods Hepatitis B>1 week Influenza1-2 days MRSA7 days to 7 months VRE5 days to 4 months C. difficile spore5 months 16 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, 2011 Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006

17. Providing a Culture of Safety Education Self Assessment & Surveillance Regulatory Reviews

18. ESRD Regulation Timeline 1976: First ESRD regulations published 70’s-90’s: Technical updates 1994: Community Forum Meeting to begin complete rewrite of ESRD regulations April 2008: New ESRD regulations published September 2008: New ESRD Interpretive Guidelines

19. Infection Control From two tags to a separate Condition (29 tags) Adopts ◦ CDC’s 2001 Recommendations for Prevention of Infections in Hemodialysis ◦ CDC’s 2002 Guidelines for the Prevention of Catheter-Related Infections

20. Conditions for Coverage 494.30 V111-V148 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas

21. Potential Infection Transmission “Route” #1: On the Hands of the Staff Wear gloves, perform hand hygiene (HH) (V113) Sufficient number of sinks w/warm H 2 O & soap (V114) Locations listed in IG PPE appropriate to task (V115) 21

22. “Route” #2: Ineffectively Disinfected Equipment & Surfaces Cleaning & disinfecting contaminated surfaces & equipment (V122) HD machine transducer protectors changed when wet (V120) 22

23. “Route” #3: Contaminated Supplies & Medications Clean and dirty areas designated and (V117)-for supplies and medications Supply carts (V119) Kept sufficient distance from dialysis stations Not moved between stations Staff do not keep supplies in pockets Items taken to dialysis station are disposed, dedicated, or disinfected before use on another patient (V116) 23

24. “Route” #3: Contaminated Supplies & Medications (cont.) Medications prepared in clean area away from dialysis stations (V117) Single use vials and solution bags used for one patient only (V118) Staff adhere to aseptic techniques for medication administration (V143) 24

25. “Route” #4: Inadequate Vascular Access Care CVC access and care to prevent contamination (V147) Monitor CVC-related blood stream infections (CLABSIs) (V148) 25

26. “Route” #5: Virulent Pathogens Surveillance of patients’ HBV status prior to admission and ongoing (V124) Vaccination of all susceptible patients & staff (V126) Isolation of HBV+ patients Isolation room/area or waiver (V128-129)-use your tan laminate! Dedicate ALL equipment to isolation (V130) Staffing-protect susceptible patients (V131) 26

27. NHSN Outpatient dialysis facilities report "Dialysis Events" to the CDC through NHSN.

28. Dialysis Event Type: IV Antimicrobial Start  Report all outpatient intravenous antibiotic and antifungal starts regardless of the reason for treatment and regardless of duration of treatment  Include starts unrelated to vascular access problems  Report outpatient starts that are continuations of inpatient treatment  Report all IV antibiotic starts, not just vancomycin  Do not report IV antiviral starts

29. Dialysis Event Type: Positive Blood Culture  Report all positive blood cultures collected as an outpatient or collected within 1 calendar day after a hospital admission or ER visit  Even if the patient does not receive treatment  Even if the infection is not related to dialysis

30. Dialysis Event Type: Pus, Redness or Increased Swelling at the Vascular Access Site  Report each new outpatient episode of pus, greater than expected redness or greater than expected swelling at a vascular access site  Even if the patient does not receive treatment  Always report pus  Report redness or swelling if they are more than expected and suspicious for infection

31. Additional Information: Dialysis Event Combinations  A Dialysis Event report may have multiple parts, combining:  IV antimicrobial start  Positive blood culture  Pus, redness or increased swelling at vascular access site  For example, if a positive blood culture is the reason that a patient is treated with IV antimicrobials, this is part of the same group of events and they are reported together.

32. Quality Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” William A. Foster

33. Thank You