1. APIC IC Challenges in Dialysis
Danilo B. Concepcion,CBNT, CCHT-A Operations Manager, Renal Service
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
Approximately 15,000 dialysis patients die annually due to infections

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

9. HOLLOW FIBERS
Hollow fiber
Fiber wall

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. Why Is Infection Prevention Such a Challenge in Dialysis?
The in-center hemodialysis patient treatment reality:
High risk for spread of blood-borne and other pathogens
Staff caring for multiple patients w/short “changeover” times
No physical separation of individual treatment stations
Lots of potential blood exposure
immunosuppressed dialysis patients
compounded by…

14. Organisms remain viable on surfaces for prolonged periods
Recent Studies Illustrate How the Dialysis Facility Can Become a “Box of Bugs”
Organisms remain viable on surfaces for prolonged periods
Hepatitis B >1 week
Influenza days
MRSA days to 7 months
VRE days to 4 months
C. difficile spore 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): , 2011

15. How Are Infections Spread in Dialysis?
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 virulent pathogens (e.g. hepatitis B)

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

17. Remember the lesson from the Patient Safety Movement…
The CDC Guidelines
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 clear directions in what is expected of them in their duties…

18. NOTICE! 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
We are VERY excited to tell you about the NOTICE Initiative. It is a truly collaborative endeavor involving dialysis providers, networks, and government agencies. The goal of the initiative is to reduce infections in dialysis patients through improved direct care delivery practices.

19. Infection Control Checklists for Dialysis
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

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 separation b/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. V120 Blood Contaminating a Pressure Transducer Filter

34. V128 Isolation of HBV+ Patients
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.

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

36. V131
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

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

39. Definitions of Quality for Dialysis
Reference
Allowable water TVC
Action level water TVC
Allowable Level water EU
Action Level water EU
RD52:2004
<200
<2 2 1
ANSI/AAMI/ISO 13959
<100 50
<0.25
0.125
ANSI/AAMI/ISO 23500
ANSI/AAMI/ISO 11663
Ultrapure
<0.1
<0.03
Infusable (Sterile)
Not listed in the standards
Reference
Allowable dialysate TVC
Action level dialysate TVC
Allowable Level dialysate EU
Action Level dialysate EU
RD52:2004
<200
<2 50 1
ANSI/AAMI/ISO 13959
<100
<0.5
0.25
ANSI/AAMI/ISO 23500
ANSI/AAMI/ISO 11663
Ultrapure
<0.1
<0.03
Infusable (Sterile)
10-6
Chemical Contaminant maximum allowable levels equal in all references.

40. Disinfection Frequency
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

41. Bacteria Testing Methods
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

42. Bacteriology of the Dialysate
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.

43. Bacteriology of water
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.”

44. Endotoxins 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

45. Limulus Amebocyte Lysate (LAL) Assay
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

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. Causes That Contribute to Growth
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

48. Disinfection
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.