1. Human Safety in Dialysis Units
Dr.T.V.Rao MD
Dr.T.V.Rao MD

2. Renal Failure and Technology for Survival
Dr.T.V.Rao MD

3. Dialysis is a complex procedure needs good understanding to prevent infections
Dr.T.V.Rao MD

4. Developing countries lacks
The countries that fall under the category of emerging economies lack the technical, human and economical resources needed to establish well-formed policies for treatment of end-stage renal disease (ESRD), making it a political and economic challenge. There is a deficiency of organized data on the practice of dialysis in developing countries, which is mostly attributed to the lack of renal registries.
Dr.T.V.Rao MD

5. INFECTIONS IN HEMODIALYSIS UNIT patients are at risk with
Bacterial infections
Viral infections like Hepatitis B and C
HIV infection
Dr.T.V.Rao MD

6. How do you care for the access point?
Vascular access is a vital part of hemodialysis. Take special care to prevent injury and infection:
Keep the access area clean.
Dr.T.V.Rao MD

7. Creating our own Standard Operating procedures
Dr.T.V.Rao MD

8. Basic Principles of Medical Asepsis
Clean Technique used to prevent the spread of microorganisms
Hand washing AGAIN
Carry soiled items away from body
Do not place soiled items on floor
Client instructed not to cough, sneeze, breathe on anyone; expectorate into tissues; cover mouth and nose when coughing and sneezing; (Airborne)
Dr.T.V.Rao MD

9. Hand Hygiene
Unwashed hands of healthcare workers are the major route of transmission of microorganisms in healthcare settings.
Hand hygiene is includes hand washing with soap and water, and/or applying an alcohol- based hand rub )
Dr.T.V.Rao MD

10. Hand washing facilities
Hand hygiene facilities should be located as close as possible to the point of contact with 2 to 3 patients and dialysis equipment.
Dr.T.V.Rao MD

11. Handwashing we can do better
Five Key Factors
Time: 15 seconds
Water: warm
Soap: 1 teaspoon liquid
Friction: rub in circular motions from fingers to 1 inch above wrist if not visibly soiled (moving from dirtiest to cleanest) and 1 inch above area of contamination
Drying: begin with fingers and move upward
DRY HANDS FIRST THAN TURN OFF FAUCET WITH PAPER TOWEL
Dr.T.V.Rao MD

12. We lack standards ???
One hand wash basin should be provided for every 2-3 dialysis stations in the main dialysis area and a minimum of one in an isolation room.
Dr.T.V.Rao MD

13. Gloves & Hand Hygiene Hand hygiene Intravascular catheters
Use soap & water or alcohol-based antiseptic hand rub
Visibly soiled vs. not visibly soiled
Intravascular catheters
Staff should wear clean or sterile gloves when changing the dressing on IV catheters
Hand hygiene performed before & after palpating catheter insertion sites, as well as before & after accessing or dressing an IV catheter
Dr.T.V.Rao MD

14. Blood spills
For minor spills on surfaces (e.g. benches, counter tops):
Wipe up with paper towel soaked in undiluted 1% sodium hypochlorite and then wash with neutral detergent and hot water and allow to dry.
• For major blood spills
Cover with chlorine powder (10,000 ppm available chlorine) and leave for two minutes OR Limit spread using paper towels and slowly flood contaminated area with undiluted sodium hypochlorite
Dr.T.V.Rao MD

15. Many drug resistant bacteria ..
Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE), Extended Spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, Carbapenem-resistant Acinetobacter baumannii (CRAB) and Clostridium difficile (antibiotic associated diarrhoea).
Dr.T.V.Rao MD

16. Practising Universal Precautions
Face protection (eyewear/goggles, masks) is required to protect the mucous membranes of the eyes, nose and mouth when performing procedures that may generate splashes or sprays of blood or body fluids (e.g. during initiation and termination of dialysis).
Dr.T.V.Rao MD

17. Blood Borne Virus Screening and Management
All patients should be tested for HBV, HCV and HIV on admission to the dialysis unit including after transfer from another unit
Recheck time ???
All maintenance dialysis patients should be retested at regular every 6 months for HBV, HCV and HIV infection.
Dr.T.V.Rao MD

18. Anti-HBs titers
Anti-HBs titres should be checked 4 weeks after the last dose and at 6 monthly intervals thereafter.
Non-responders (anti-HBs titers < 10 IU/ml) should receive 3 more doses of the vaccine.
Dr.T.V.Rao MD

19. Hepatitis B vaccination
Hepatitis: “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” (precautions, testing, immunization, isolation, surveillance, response, training
Dr.T.V.Rao MD

20. Hepatitis B is a major concern
The most common viral infection in dialysis patients in developing countries is hepatitis B . There is little data on the incidence and prevalence of HBV in the dialysis population of developing economies, however rough estimates indicate that 5% of India’s general population is infected whereas 6%-36% of the dialysis population is infected.
Dr.T.V.Rao MD

21. Hepatitis C a Emerging Problem
HCV has become apparent in dialysis populations as a growing concern as there is no vaccine available for this strain. The increase in spread of the infection is mostly attributed to the cross-contamination of patients due to inadequately trained staff and the reuse of disposables. HIV infection is not a major concern of the dialysis population in developing countries, even in Africa where high HIV rates predominate.
Dr.T.V.Rao MD

22. HIV not great threat ?
HIV infection is not a major concern of the dialysis population in developing countries, even in Africa where high HIV rates predominate.
Dr.T.V.Rao MD

23. HBV+ Isolation Room/Area New regulations
Effective Feb 9, 2009, every new facility MUST include an isolation room for treatment of HBV+ patients, unless the facility is granted a waiver of this requirement
For existing units in which a separate room is not possible, there must be a separate area for HBsAg positive patients
Dr.T.V.Rao MD

24. Simple sanitary measures
Sanitary Environment: “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients.” (includes procedures and comprehensive program
Dr.T.V.Rao MD

25. Cleaning of dialysis machines and chairs/beds
Dialysis machines should be internally disinfected, externally cleaned (and disinfected if indicated), and dried after each patient.
The exterior of the machine should be effectively cleaned using protocols following manufacturer’s instructions.
Special attention should be given to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients’ blood.
Dr.T.V.Rao MD

26. Cleaning of dialysis machines and chairs/beds
Cleaning of non-critical surfaces (e.g. dialysis bed or chair, countertops, external surfaces of dialysis machines and equipment) should be done with neutral detergent and warm water.
Do not waste on chemicals – they are counterproductive
Dr.T.V.Rao MD

27. If the patient infected with Blood borne infection
Clean with neutral detergent and water, and then
Disinfect with sodium hypochlorite 1% (1,000 ppm available chlorine; 1:10 dilution).
Remove chlorine residues from metallic surfaces with water as Sodium hypochlorite in high concentrations (>500 ppm) is corrosive to metals.
Dr.T.V.Rao MD

28. How staff get infected
Contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel.
Dr.T.V.Rao MD

29. If you are injured
If you suffer an accidental contaminated needle stick injury, you should immediately wash the wound thoroughly with soap and water, then report it to your employer. Do not hesitate. Universal precautions require that all blood and other body fluids be treated as though they were contagious. In the wake of a needle stick injury,
Dr.T.V.Rao MD

30. Basic investigations and treatments
Take blood for virology, (HIV, hepatitis B, hepatitis C) from the injured worker. Start PEP where appropriate and consider the need for antibiotic therapy or hepatitis B immunization. Recheck HIV status 3 months later and hepatitis serology 3 and 6 months later.
Anti retroviral treatments if warranted
Dr.T.V.Rao MD

31. Safer ways to discard needles
Discard contaminated sharps immediately and without recapping in puncture- and liquid-proof containers that are closed, sealed and destroyed before completely full.
Dr.T.V.Rao MD

32. Glove the Hands Hand Hygiene, Gloves and PPE: Moving Target
Current guidance is gloves whenever providing patient care or touching a machine surface, and change required both ways in going from one to the other
Medical record, both paper and electronic present PPE challenge
“Holding sites” requires glove(s) for patient or visitor
Dr.T.V.Rao MD

33. Environmental Surveillance
When conducting any form of environmental sampling, identify existing comparative standards and fully document departures from standard methods
B. Select a high-volume air sampling device if anticipated levels of microbial airborne contamination are expected to be low .
C. Do not use settle plates to quantify the concentration of airborne fungal spores
D. When sampling water, choose growth media and incubation conditions that will facilitate recovery of waterborne organisms
Dr.T.V.Rao MD

34. Proper Documentation
Medical and administrative records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility.
Dr.T.V.Rao MD

35. Care of Environment Additional Specifics:
“splash zone” nothing considered clean in it
Medication prep: no delivery carts, clean prep
Isolation Room or agreement, two station separation for pre-reg facilities
Catheter reduction and Precautions
Water and Dialysate Cultures
Documentation of audits, “breaks” action
Dr.T.V.Rao MD

36. Active Surveillance Component
The infection prevention and control program must include an active surveillance component that covers both hospital patients and personnel working in the hospital.
Surveillance includes infection detection,
data collection and analysis, monitoring, and evaluation of preventive interventions
Dr.T.V.Rao MD

37. Multi Drug resistance Organisms need attention
MULTI-DRUG RESISTANT ORGANISMS (MDROs)
And Communicable Disease Outbreaks Require
Close Monitoring, Tracking, Reporting
Prevention of transmission
Identification of infected and Exposed
Particular attention to ambulatory care (eg ER)
And have Individual challenges
Dr.T.V.Rao MD

38. We have to Train our own Manpower
A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.
CDC has defined “infection control professional” as “a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control.”
Dr.T.V.Rao MD

39. Training is Continuous
Isolation procedures and requirements for infected and at risk or immunosuppressed nursing home residents.
Use of and in-service education regarding standard precautions, (e.g., universal precautions/body substance isolation).
Hand washing, respiratory protection, linen handling, housekeeping, needle and hazardous waste disposal, as well as other means for limiting the spread of communicable organisms.
Dr.T.V.Rao MD

40. Chronic Dialysis Facilities have a self audit
Survey of this Condition requires:
observations of care delivery,
interviews with staff and patients,
review of medical records, facility logs, policies and procedures and quality assessment and performance improvement (QAPI) documentation.
Dr.T.V.Rao MD

41. Disinfection of Haemodialysis Machines
As per manufacturers instructions
The development of bacterial biofilms in the hydraulic circuit of haemodialysis machines can be prevented by frequent use of chemical and heat disinfection strategies.
Frequent bleaching is not recommended because of possible damage to the machine.
Dr.T.V.Rao MD

42. Patient Safety Principles (required)
Components
Patient Safety Principles (required)
Sharps Safety
Decreasing Patient & Provider Conflict
Missed Treatments
Health Literacy
Patient Self-Managed Care
Stenosis Surveillance
Hand Hygiene
Flu Vaccination
Slips, Trips and Falls
Medication Reconciliation
Emergency Preparedness
Transplantation (new)
Dr.T.V.Rao MD

43. Staff training a MUST
All staff in dialysis units should be trained in infection prevention and control practices including
Proper hand hygiene technique
Appropriate use of personal protection equipment
Modes of transmission for BBV, pathogenic bacteria, and other microorganisms Infection Control Precautions for Dialysis Units
Rationale for segregating patients
Correct techniques for initiation, care, and maintenance of dialysis access sites.
Dr.T.V.Rao MD

44. Common Patient Safety Complaints
Staff are not washing their hands
Staff do not change gloves between patients
Staff not wearing appropriate PPE
Given the wrong medication
Given the wrong dialyzer
Staff not performing safe procedure (catheter care)
Staff unskilled in cannulation
Staff not performing appropriate patient assessments
Dr.T.V.Rao MD

45. What is Self audit
Medical and administrative records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility.
If deficient practices noted in infection control, techniques are multiple, pervasive, or of an extent to present a risk to patient health and safety, Condition level non-compliance should be considered.
Dr.T.V.Rao MD

46. Chronic Dialysis Facilities have a self audit
Survey of this Condition requires:
observations of care delivery,
interviews with staff and patients,
review of medical records, facility logs, policies and procedures and quality assessment and performance improvement (QAPI) documentation.
Dr.T.V.Rao MD

47. Have a self audit
Medical and administrative records should demonstrate recognition of any potential infection and actions taken to decrease the transmission of infection within the dialysis facility.
If deficient practices noted in infection control, techniques are multiple, pervasive, or of an extent to present a risk to patient health and safety, Condition level non-compliance should be considered.
Dr.T.V.Rao MD

48. A Safety Network: Proposed Goals
Improve safety by creating and disseminating knowledge necessary to detect and respond to current and emerging healthcare safety threats
Monitor the cause, frequency and impact of targeted safety events
Establish priorities for safety promotion programs
Disseminate lessons learned
Protect confidentiality
Reduce reporting burden and ensure local access to healthcare safety information
Monitor progress toward achieving local, state, and federal patient safety goals
A Safety Network: Proposed Goals
Improve safety by creating and disseminating knowledge necessary to detect and respond to current and emerging healthcare safety threats
Monitor the cause, frequency and impact of targeted safety events
Establish priorities for safety promotion programs
Disseminate lessons learned
Protect confidentiality
Reduce reporting burden and ensure local access to healthcare safety information
Monitor progress toward achieving local, state, and federal patient safety goals
Dr.T.V.Rao MD

49. Practice! Practice! Practice!
The greatest gift in learning something new is putting that knowledge into practice and then sharing what you know with someone else.
Practice! Practice! Practice!
We are all winners if we practice a little
Dr.T.V.Rao MD

50. Follow me for more articles of interest on Issues of infections
Dr.T.V.Rao MD

51. Programme created by Dr. T. V
Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World
Dr.T.V.Rao MD