Presentation on theme: "Infection Control Issues in the Dialysis Setting"— Presentation transcript:
1 Infection Control Issues in the Dialysis Setting Stuart L. Goldstein, MD Helen Currier, RN, BSN, CNNAssociate Professor of Pediatrics Assistant DirectorBaylor College of Medicine Renal Dialysis and PheresisMedical Director, Renal Dialysis Unit Texas Children’s HospitalTexas Children’s Hospital Houston, TexasHouston, Texas
2 Infections in the Dialysis Setting Significant cause of hospitalizationSignificant cause of mortalityData 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 6.6Period 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 controlBlood borne pathogensRespiratoryContact contaminationRegulatory requirementsCenter for Medicare & Medicaid Services (CMS)DSHSCDCQA/QI
13 Dialysis Procedures Hemodialysis Peritoneal Dialysis Blood cleaned directly through a closed extracorporeal circuitBlood accessed viaArterio-venous fistula (AVF)Arterio-venous graft (AVG)Percutaneous central venous catheterCan be performed in-center or at homePeritoneal DialysisCatheter placed percutaneously into peritoneal cavityPatient exchanges fluid via that catheter at various intervals during the day or nightPerformed at home
14 Hemodialysis Logistics Patients dialyze for 3-4 hours thrice weeklyOpen ward settingUnit schedules can run up to 4 shifts per day depending on censusPatients follow each other in same chairSame machinesDifferent disposablesDialyzers re-used for same patient up to 10 treatmentsNurse/Technician to patient ratio 1:1 to 1:4 depending on acuity
15 Disinfection Procedures Patient station surfacesAny soapBetween each patient shiftMedical EquipmentHospital disinfectant (low level)Between patient useBlood spillsTuberculocidal/1:100 bleach (intermediate level)Immediate
17 Bloodborne Pathogen Challenges Hepatitis B virusHepatitis C virusHIV
18 Hepatitis B Desired Patient Outcomes The patient will not convert to HbsAg+ statusHepatitis B will not be transmitted in the dialysis unitNephrology Nursing Standards of Practice and Guidelines for Care (2005)
22 HepB+ Patient Management Hepatitis B virus is readily transmitted across the dialysis filter membraneHepatitis B+ patients require isolation in separate room (new units) or a separate areaDo not re-use dialyzersPatient education
23 Hepatitis C Desired Patient Outcomes The patient will not convert to a positive anti-HCV statusThe patient with a positive anti-HCV will not transmit the diseaseNephrology 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 patientsALT monthly for anti-HCV negative patientsAnti-HCV semiannually for all negative anti-HCV patientsSupplemental or confirmatory testing with more specific assays for patients with an initial positive anti-HCV
26 HepC+ Patient Management Hepatitis C is NOT readily transmitted across the dialysis filter membranePatient isolation is not requiredMachine isolation is not recommendedMay re-use dialyzers
27 HIV Routine surveillance not required Isolation not required May re-use dialyzers
28 Respiratory Infection Control Challenges Host TransmissionTuberculosisVaricellaImmunocompromised Host SusceptibilityESRD complicates other systemic illnessStem cell transplantationSolid organ transplantation
29 Respiratory Infection Control Measures Isolation rooms required for all new dialysis unitsNegative pressure is usualOnly one room required per unitMask isolationAll patients with suspected TB or VZV should be isolated or wear masks during evaluationNegative 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 testThe patient will not progress to active TB diseaseThe patient with active TB will not transmit the diseaseNephrology Nursing Standards of Practice and Guidelines for Care (2005)
31 TuberculosisMonitor laboratory test results related to TB screening, diagnosis, and treatmentMantoux skin testCXRSputum smear and cultureAssess for S/S of TBProductive or persistent coughCloudy or blood-tinged sputumUnexplained weight lossNight sweatsElicit hx of exposure to TB
32 TuberculosisAssess for risk factors that increase the risk of development of active TB disease after exposureImmunosuppressionHIVHx of TB or + skin test without treatment or completion of prescribed medicationMonitor adherence to home medication regimen for patients receiving therapy
33 Tuberculosis Intervention Provide TB screening per current CDC recommendationsIC policies and procedures that are consistent with current CDC guidelinesCoordinate 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 practicesReinforce importance of adherence to prescribed medication regimenTeach S/S of disease progression to report to nurse
35 Hand Hygiene Educational Design Objectives1. Identify risk for infection in the hospital or home2. List one hand hygiene myth and one hand hygiene fact.3. Identify key steps for hand washing:* Soap and water*Alcohol-based hand sanitizer4. Demonstrate correct hand washing techniques:*Soap and water5. 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 ContentI. Germs: What are they?II. Reducing the risk of infectionIII. Myths and FactsIV. Lesson on hand washing techniquesA. Steps for soap and waterB. Steps for alcohol- based hand sanitizersV. When to wash handsVI. Issues unique to children
36 Contact Contamination Nurse/technical staff care for >1 patient at a timeCaregivers must wear appropriate personal protective equipmentGloves, gowns and masks with face shields when accessing AVF, AVG, catheterGloves must be used forAll patient contactAll machine contactAll medication preparationGloves must be changedBetween patientsBetween machinesWhen 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 sepsisThe patient’s risk for bacterial colonization or infection due to a drug-resistant organism will be reducedNephrology Nursing Standards of Practice and Guidelines for Care (2005)
38 Bacterial Infection Assessment Intervention Laboratory analyses/culturesAvoid culturing vascular catheter tips surrounding skin or catheter hubCatheter exit site or wound culturesCollaborate with MD/APN to avoid over use of vancomycinMonitor 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 educationPotential for bacterial colonization and infection of accessImportance 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 dialysisGlove use when holding vascular access site to stop bleedingPeritoneal catheter exit site careUse of prophylactic antibiotic therapynew PD catheterTopical exit site antibiotics (mupirocin, gentamicin)Importance of immunizations
41 Unit QA/QI PracticesOngoing assessment of current and trend analyses of relevant infection ratesMRSACatheter related bacteremiaCatheter exit site and tunnel infectionsPeritonitisSurveillance for Hepatitis virus susceptibility status
42 Facility Infection Trends Percent of Facility Census with Infections By Type During Month Facility NameESRD Network of Texas
44 Water Treatment System Testing/Standards (AAMI) Testing performed monthlyMaximal level of bacteria in water to prepare dialysis fluid/reprocess dialyzers must NOT EXCEED 200 CFUAAMI action level is 50 CFUMaximal level of endotoxin must not exceed 2 EU/mlAAMI action level is 1 EU/ml