APIC IC Challenges in Dialysis

1. Danilo B. Concepcion,CBNT, CCHT-AOperations Manager, Renal Servicedanilo.concepcion@stjoe.org714-771-8944 APIC IC Challenges in Dialysis The views and opinions are those of the author and does not reflect those of St. Joseph Hospital or any other organization.

2. Infections: A Major Patient Safety Problem in Dialysis – 2nd Leading Cause Of Death UM-KECC, 2009 Approximately15,000 dialysis patients die annually due to infections

3. Temporal and spatial issues • Water and dialysate • Staffing matrix IC Challenges in Dialysis

9. Hollow fiber Fiber wall HOLLOW FIBERS

11. DIFFUSION IN THE DIALYZER • Dissolved particles can move either way across the membrane. • From blood to the dialysate. • From dialysate to the blood. • They will move from area of higher to lower concentration. • Very important that precise electrolyte level of dialysate is known. • This will determine what is removed or given to the patient.

12. MMWR Vol. 50/No.RR-5, page 23 “Hemodialysis in Acute-Care Settings” states: For patients with acute renal failure who receive hemodialysis in acute-care settings, Standard Precautions as applied in all health-care settings are sufficient to prevent transmission of bloodborne viruses. However, when chronic hemodialysis patients receive maintenance hemodialysis while hospitalized, infection control precautions specifically designed for chronic hemodialysis units should be applied to these patients. If both acute and chronic renal failure patients receive hemodialysis in the same unit, these infection control precautions should be applied to all patients

13. The in-center hemodialysis patient treatment reality: immunosuppressed dialysis patients Why Is Infection Prevention Such a Challenge in Dialysis? compounded by…

14. Organisms remain viable on surfaces for prolonged periods • Hepatitis B >1 week • Influenza 1-2 days • MRSA 7 days to 7 months • VRE 5 days to 4 months • C. difficile spore 5 months Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006 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 Recent Studies Illustrate How the Dialysis Facility Can Become a “Box of Bugs”

15. Five main sources 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 4. From inadequate vascular access care 5. From virulentpathogens (e.g. hepatitis B) How Are Infections Spread in Dialysis?

16. Following good infection prevention and control practices The Centers for Disease Control and Prevention (CDC) has guidelines for these practices in dialysis facilities Dialysis Patient Infections Can Be Prevented by:

17. Address general practices (wash hands, clean & disinfect equipment, etc.) • Do not include details for application of the guidelines (what parts of the equipment need to be disinfected, etc.) Remember the lesson from the Patient Safety Movement… Staff need cleardirections in what is expected of them in their duties… The CDC Guidelines

18. National Opportunity To Improve Infection Control In ESRD The NOTICE Initiative is funded by the Department of Health and Human Services to support the renal community in improving infection control NOTICE!

19. Initiation of Dialysis with CVC • CVC Exit Site Care • Discontinuation of Dialysis and Post Care of CVC • Initiation of Dialysis with AVF/G • Discontinuation of Dialysis and Post Care of AVF/G • Parenteral Medication Preparation/Administration • Cleaning & Disinfection of the Dialysis Station • Supply Management & Contamination Prevention Infection Control Checklists for Dialysis

28. Note: It is not required that the patient has vacated the dialysis station before disinfection and preparation of the machine can be conducted. If the patient remains in the chair during disinfection, strictly adhere to separationb/t the patient and the disinfected/prepared machine.

32. The Infection Control Checklists Don’t Address Everything on How to Protect Patients from HAI…

33. V120Blood Contaminating a Pressure Transducer Filter

34. Separate isolation room • February 9, 2009 all new facilities must have a separate isolation room (waiver)… • Separate isolation area • If there are current HBV+ patients on census, the isolation area/room can not be used for HBV- patients on other shifts or days due to the risk of cross-contamination. V128 Isolation of HBV+ Patients

35. Separate dedicated supplies and equipment, including blood glucose monitors. • Labeled “isolation” • Concentrate containers V130

36. Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another (e.g., during the same shift or during patient change-over). • If a staff member assigned to care for an HVB+ patient must concurrently care for someone other than another HBV+ patient, the additional patient must be HBV immune V131

37. The more pure and endotoxin free the water and dialysate, the fewer Chronic Inflammatory Disease (CID) processes seen in patients over time Dialysate is the largest contact material a patient’s blood touches

39. Definitions of Quality for Dialysis Chemical Contaminant maximum allowable levels equal in all references.

40. Distribution/Loop System • Central systems at least once a month • Disinfects water inlet line to hemodialysis machines • Portables • Dialysis Machines • Daily OP • Acute setting • Bicarbonate mixing systems • daily rinse • Weekly disinfect • Individual bicarbonate concentrate containers • should rinsed and inverted to drain at end of each day • disinfected weekly Disinfection Frequency

41. Culture media should be trypticase soy agar (TSA) or equivalent • No blood or chocolate agar • Incubate at 35-37o C for 48 hours • May want to go to 72 hours • Count colonies with a magnifying device • Shall not exceed 200 cfu/ml / 50 cfu action level Bacteria Testing Methods

42. Collected during or at the termination of dialysis at or beyond the point where the dialysate leaves the hemodialyzer. • AAMI: Two machines per month • Each machine at least once annually • The total viable bacteria count shall not exceed 200 cfu/ml. Bacteriology of the Dialysate

43. V178 IG: the final decision of whether to discontinue dialysis rests with the medical director of a facility. • V179 IG: “Promptly” would be met if action is taken within 48 hours of receiving the results of testing.” Bacteriology of water

44. By-products of water-borne gram negative bacteria • Reside in the cell wall • Released when the bacteria dies • Enter bloodstream • Build-up in Reprocessed Hemodialyzers • Back Diffusion* • Back Filtration* • Sense Bacteria/Endotoxin Endotoxins

45. Do disinfect the ports with LAL testing • <2 EU • > 1EU action level • Current testing can be done in-center • Perform a control with each batch of tests • Outside labs usually require freezing or refrigerated specimen and have better sensitivities • Frequency • monthly • If suspected endotoxin reaction Limulus Amebocyte Lysate (LAL) Assay

46. Long-term Effects Attributed to Chronic Micro-Inflammation Malnutrition Low albumin Muscle protein wasting Protein catabolism Increased CRP Atherosclerosis Low cholesterol synthesis Increased ferritinlevels Resistance to EPO therapy Bone disease, cysts, fractures Sleep disorders Anti-endotoxinantibodies

47. Improper water treatment system design • Loop • Holding tanks • UV/Ultrafilters • Improper maintenance of water treatment system and delivery system (dialysis machine) • Disinfection schedule • Improper disinfectant Causes That Contribute to Growth

48. A key concept in ensuring compliance with the bacteriological control requirements is that disinfection schedules should be designed to prevent bacterial proliferation, rather than being designed to eliminate bacteria once they have proliferated to an unacceptable level. Disinfection