Presentation on theme: "APIC IC Challenges in Dialysis"— Presentation transcript:
1APIC IC Challenges in Dialysis Danilo B. Concepcion,CBNT, CCHT-A Operations Manager, Renal ServiceThe views and opinions are those of the author and does not reflect those of St. Joseph Hospital or any other organization.
2Infections: A Major Patient Safety Problem in Dialysis – 2nd Leading Cause Of Death UM-KECC, 2009Approximately 15,000 dialysis patients die annually due to infections
3IC Challenges in Dialysis Temporal and spatial issuesWater and dialysateStaffing matrix
11DIFFUSION 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.
12MMWR 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
13Why Is Infection Prevention Such a Challenge in Dialysis? The in-center hemodialysis patient treatment reality:High risk for spread of blood-borne and other pathogensStaff caring for multiple patients w/short “changeover” timesNo physical separation of individual treatment stationsLots of potential blood exposureimmunosuppressed dialysis patientscompounded by…
14Organisms 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 periodsHepatitis B >1 weekInfluenza daysMRSA days to 7 monthsVRE days to 4 monthsC. difficile spore monthsKramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006Healthcare workers touch as many as 7 surfaces after touching a contaminated one!McLaughlin AC, Walsh F. Am J Infect Control 39(6): , 2011
15How 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)
16Dialysis Patient Infections Can Be Prevented by: Following good infection prevention and control practicesThe Centers for Disease Control and Prevention (CDC) has guidelines for these practices in dialysis facilities
17Remember the lesson from the Patient Safety Movement… The CDC GuidelinesAddress 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…
18NOTICE! National Opportunity To Improve Infection Control In ESRD The NOTICE Initiative is funded by theDepartment of Health and Human Servicesto support the renal community inimproving infection controlWe 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.
19Infection Control Checklists for Dialysis Initiation of Dialysis with CVCCVC Exit Site CareDiscontinuation of Dialysis and Post Care of CVCInitiation of Dialysis with AVF/GDiscontinuation of Dialysis and Post Care of AVF/GParenteral Medication Preparation/AdministrationCleaning & Disinfection of the Dialysis StationSupply Management & Contamination Prevention
28Note: 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.
32The Infection Control Checklists Don’t Address Everything on How to Protect Patients from HAI…
33V120 Blood Contaminating a Pressure Transducer Filter
34V128 Isolation of HBV+ Patients Separate isolation roomFebruary 9, 2009 all new facilities must have a separate isolation room (waiver)…Separate isolation areaIf 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.
35V130Separate dedicated supplies and equipment, including blood glucose monitors.Labeled “isolation”Concentrate containers
36V131Staff 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
37Dialysate 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
39Definitions of Quality for Dialysis ReferenceAllowable water TVCAction level water TVCAllowable Level water EUAction Level water EURD52:2004<200<221ANSI/AAMI/ISO 13959<10050<0.250.125ANSI/AAMI/ISO 23500ANSI/AAMI/ISO 11663Ultrapure<0.1<0.03Infusable (Sterile)Not listed in the standardsReferenceAllowable dialysate TVCAction level dialysate TVCAllowable Level dialysate EUAction Level dialysate EURD52:2004<200<2501ANSI/AAMI/ISO 13959<100<0.50.25ANSI/AAMI/ISO 23500ANSI/AAMI/ISO 11663Ultrapure<0.1<0.03Infusable (Sterile)10-6Chemical Contaminant maximum allowable levels equal in all references.
40Disinfection Frequency Distribution/Loop SystemCentral systems at least once a monthDisinfects water inlet line to hemodialysis machinesPortablesDialysis MachinesDaily OPAcute settingBicarbonate mixing systemsdaily rinseWeekly disinfectIndividual bicarbonate concentrate containersshould rinsed and inverted to drain at end of each daydisinfected weekly
41Bacteria Testing Methods Culture media should be trypticase soy agar (TSA) or equivalentNo blood or chocolate agarIncubate at 35-37o C for 48 hoursMay want to go to 72 hoursCount colonies with a magnifying deviceShall not exceed 200 cfu/ml / 50 cfu action level
42Bacteriology 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 monthEach machine at least once annuallyThe total viable bacteria count shall not exceed 200 cfu/ml.
43Bacteriology of waterV178 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.”
44Endotoxins By-products of water-borne gram negative bacteria Reside in the cell wallReleased when the bacteria diesEnter bloodstreamBuild-up in Reprocessed HemodialyzersBack Diffusion*Back Filtration*Sense Bacteria/Endotoxin
45Limulus Amebocyte Lysate (LAL) Assay Do disinfect the ports with LAL testing<2 EU> 1EU action levelCurrent testing can be done in-centerPerform a control with each batch of testsOutside labs usually require freezing or refrigerated specimen and have better sensitivitiesFrequencymonthlyIf suspected endotoxin reaction
46Long-term Effects Attributed to Chronic Micro-Inflammation MalnutritionLow albuminMuscle protein wastingProtein catabolismIncreased CRPAtherosclerosisLow cholesterol synthesisIncreased ferritinlevelsResistance to EPO therapyBone disease, cysts, fracturesSleep disordersAnti- endotoxinantibodies
47Causes That Contribute to Growth Improper water treatment system designLoopHolding tanksUV/UltrafiltersImproper maintenance of water treatment system and delivery system (dialysis machine)Disinfection scheduleImproper disinfectant
48DisinfectionA 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.