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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Programme created by Dr. T. V Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD