1. Infection Prevention in Dialysis Settings
A Continuing Education (CE) Training Course for
Outpatient Hemodialysis Healthcare Workers
Hello and welcome to “Infection Prevention in Dialysis Settings,” a continuing education training course for outpatient hemodialysis healthcare workers. This training course was developed by the Centers for Disease Control and Prevention or CDC.
This training course includes audio. Please adjust your computer’s volume or enable your computer’s audio devices.

2. Introduction to this Course
This course is for outpatient hemodialysis healthcare workers, including technicians and nurses.
You will learn about the following topics in this course:
Infections that patients can get from dialysis
Infection control recommendations for outpatient hemodialysis healthcare workers
Educating your patients and their caregivers
Course Objectives – by the end of this course, you should be able to:
List three ways to prevent catheter infections in hemodialysis patients
Describe how to safely carry medications
Describe how to effectively perform hand hygiene
If you want to receive continuing education (CE) credit for completing this course, you must complete a course assessment and evaluation.
This training course is for outpatient hemodialysis healthcare workers, including technicians and nurses. You will learn about the following topics in this course:
Infections that patients can get from dialysis
Infection control recommendations for outpatient hemodialysis healthcare workers, and
Educating your patients and their caregivers.
The course objectives are as follows:
By the end of this course, you should be able to:
List three ways to prevent catheter infections in hemodialysis patients
Describe how to safely carry medications
Describe how to effectively perform hand hygiene
If you want to receive continuing education (CE) credit for completing this course, you must complete a course assessment and evaluation. There are instructions at the end of the course that will direct you on how to receive CE credit.

3. Course Contents
Lesson 1: Infections that Patients Can Get from Hemodialysis
Lesson 2: Standard Precautions for all Healthcare Workers in all Healthcare Settings
Lesson 3: Specific Infection Control Recommendations for Outpatient Hemodialysis Healthcare Workers
Lesson 4: Infection Control Policies and Practices for Outpatient Hemodialysis Facilities
Lesson 5: Educating your Patients and their Caregivers
Recap: Preventing Infections in Hemodialysis Settings
Course Assessment
This course is comprised of the following lessons:
Lesson 1: Infections that Patients Can Get from Hemodialysis
Lesson 2: Standard Precautions for all Healthcare Workers in all Healthcare Settings
Lesson 3: Specific Infection Control Recommendations for Outpatient Hemodialysis Healthcare Workers
Lesson 4: Infection Control Policies and Practices for Outpatient Hemodialysis Facilities
Lesson 5: Educating your Patients and their Caregivers
Following these lessons there is a brief recap of course material, followed by the course assessment.

4. Infections that Patients Can Get from Hemodialysis
Lesson 1: Infections
Infections that Patients Can Get from Hemodialysis
In the first lesson, we will discuss infections that patients can get from hemodialysis. We will begin with a patient’s story, followed by the reasons dialysis patients are at risk for infection, and some statistics on dialysis infections. Then we will review how infections happen in general, how they can be spread in outpatient hemodialysis facilities, and what you can do to prevent the spread of infections.
Photo provided by Stephanie Booth, used with permission

5. A Patient’s Story Brian Hess 22-year old hemodialysis patient
Central venous access port became infected
Healthcare workers tried to eliminate my infection for several weeks using antibiotics
Ultimately my central venous access port had to be removed to clear the infection
First we’d like to share a personal story about Brian Hess, a 22 year old patient receiving outpatient hemodialysis. At the time of his infection he was new to living on his own and trying to finish a college degree. His central venous access port became infected and once the port and the connecting lines became infected, his healthcare workers could not seem to get rid of the infection. They tried to eliminate the infection for several weeks using antibiotics, but in the end, they were only able to clear the infection by removing the port and all parts of his infected access. Brian learned very well how central venous access ports are so likely to become infected and stay that way. He writes, “the entire year was very taxing for me both physically and mentally.” Brian’s story shows how an infection can cause loss of the vascular access, which is the patient’s lifeline.
Photo provided by Brian Hess, used with permission

6. Why are Dialysis Patients at Risk for Infection?
Patients who undergo hemodialysis have a higher risk of infection, due to the following factors:
Frequent use of catheters or insertion of needles to access the bloodstream
Weakened immune systems
Frequent hospital stays and surgery
So why are dialysis patients like Brian at risk for infection? Hemodialysis patients are at a high risk for infection because the process of hemodialysis requires the frequent use of catheters or insertion of needles to access the bloodstream. Also, hemodialysis patients have weakened immune systems, which increases their risk for infection, and they require frequent hospitalizations and surgery where they might acquire an infection.

7. Infections in Dialysis Patients
Dialysis patients are at risk of getting hepatitis B and C infections and bloodstream infections
Hepatitis B and C are bloodborne viral infections that can cause chronic (life-long) disease involving inflammation (swelling) of the liver
Hepatitis B and C viruses can live on surfaces and be spread without visible blood
A bloodstream infection is a serious infection that can occur when bacteria or other germs get into the blood
One way bacteria can enter the bloodstream is through a vascular access (catheter, fistula, or graft)
This slide describes the kinds of infections that hemodialysis patients are at risk of getting, including Hepatitis B and Hepatitis C infections, and bloodstream infections. Hepatitis B and C are bloodborne viral infections that can cause lifelong disease involving swelling of the liver. Of particular concern in the dialysis setting is the fact that the hepatitis B and C viruses can live on surfaces like dialysis chairs and machines and can be spread even when you don’t see any blood. A bloodstream infection is a serious infection that can occur when bacteria or other germs get into the blood. One way bacteria can enter the bloodstream is through a vascular access.

8. Infections in Dialysis Patients
Bloodstream infections are a dangerous complication of dialysis
1 in 4 patients who get a bloodstream infection caused by S. aureus (staph) bacteria can face complications such as:
Endocarditis (infected heart valve)
Osteomyelitis (infected bone)
Total costs for each infection can be more than $20,000
Bloodstream infections can cause sepsis (a potentially deadly condition)
Up to 1 in 5 patients with an infection die within 12 weeks
Bloodstream infections are a dangerous complication of dialysis. As many as one in four or 25% of patients who get a bloodstream infection caused by staph bacteria will face complications such as endocarditis, which is an infected heart valve, or osteomyelitis, which is an infection of the bone. The total costs to treat an infection can be more than $20,000 for hospitalized patients. Bloodstream infections can also lead to sepsis, a potentially deadly condition, and up to one in five or 20% of hospitalized patients with an infection die within 12 weeks.

9. National Burden of Dialysis Infections
A Cause for Concern
In the US, there are about 370,000 people relying on hemodialysis
About 75,000 people receive hemodialysis through a central line
Central lines have a higher risk of infection than a fistula or graft
CDC estimates 37,000 central line-associated bloodstream infections may have occurred in U.S. hemodialysis patients in 2008
In this slide we consider just how common infections are among dialysis patients, especially those with central lines. In the United States, there are about 370,000 people relying on hemodialysis care. About 75,000 people receive hemodialysis through a central line. Central lines have a higher risk of infection than a fistula or graft. The CDC estimates that 37,000 central line associated bloodstream infections may have occurred in U.S. hemodialysis patients in Healthcare workers and dialysis facilities can do several things to prevent bloodstream infections and protect patients.

10. How Do Infections Happen?
Contact
Droplet
Airborne
SOURCE
HOST
Three elements must be present for an infection to occur:
A source of germs (like bacteria or viruses)
A susceptible host, meaning a person who is at risk of getting an infection from the germs
A way for the germs to move from the source to the host
There are three ways in which germs move from the source to the host: Contact, Droplet, and Airborne Transmission
First it’s important to understand how these infections are happening in order to prevent them. Three elements must be present for an infection to occur:
The first is a source of germs like bacteria or viruses. Often the source is a person who may or may not appear to be sick, but the source can also be surfaces in the environment.
The second is a susceptible host, meaning a person who is at risk of getting an infection from the germs. This person must have a way for the germs to enter the body like vascular access ports, other cuts or breaks in the skin, and even mucous membranes like the eyes, nose, and mouth.
The third is a way for the germs to move from the source to the host in healthcare settings. There are three ways in which germs move from the source to the host, shown above in the red arrows: Contact, Droplet, and Airborne Transmission. On the next slide we will review these three transmission routes in detail.

11. Your Role in Contact Transmission
SOURCE
DIALYSIS
PATIENT A
HOST B
Healthcare Worker Hands
During dialysis, infections like Hepatitis B and C and bloodstream infections, like those caused by staph bacteria, are spread most commonly by contact transmission.
Contact transmission occurs when a person with germs, known as the source, touches an object or surface which contaminates that object or surface, or is touched by a healthcare worker, which contaminates the healthcare worker. Another person, known as the host, touches the contaminated object or surface, or is touched by the same healthcare worker, and germs enter their body through their mucous membranes or breaks in the skin and cause infection.
A common mode of transmission is by healthcare worker hands. For example, healthcare workers may spread germs after touching an infected body site on one patient and then touching another patient’s catheter port for example, if they do not perform hand hygiene.
Also, patient-care devices like blood pressure cuffs or glucometers may transmit pathogens if they are contaminated with blood or body fluids and then shared between patients without first cleaning and disinfecting.
During dialysis, infections can be spread by Contact Transmission
Most commonly by healthcare worker hands!
Photo provided by Stephanie Booth, used with permission

12. Spread of Respiratory Infections
Droplet
SOURCE
HOST
Airborne
Respiratory infections are typically spread through Droplet or Airborne transmission.
With Droplet Transmission, an infected person, known as the source, coughs, sneezes or talks, which creates droplets that carry germs from the infected person to another person known as the host. These droplets only travel a short distance and enter through the mucous membranes such as the eyes, nose, or mouth of the host to cause infection.
With Airborne Transmission, an infected person known as the source coughs or sneezes, which creates particles of germs in the air that can remain contagious over time and travel long distances. Another person known as the host inhales or breathes in these particles, possibly without ever being in the same room with the source, and can get the infection.
Certain infections are spread primarily by certain routes. For example, the flu is spread primarily by droplet transmission while tuberculosis is spread by airborne transmission.
Although not as common as germs spread by contact transmission, germs like the flu and tuberculosis can be spread in dialysis units.
Certain infections are spread by certain routes:
Flu may be spread by Droplet Transmission
Tuberculosis is spread by Airborne Transmission

13. What Can You do to Prevent the Spread of Infections?
Understand and Follow the
Basics of Infection Control
All healthcare workers are expected to follow Standard Precautions for infection control.
Standard Precautions are reviewed in Lesson 2
In addition, CDC has developed specific recommendations tailored for hemodialysis healthcare workers, recognizing the increased risks for infection.
These dialysis-specific recommendations are reviewed in Lesson 3
Now that we know how infections can be spread, we turn our attention to what healthcare workers like you can do to prevent the spread of infections. The answer is simple – understand and follow the basics of infection control as a routine part of your practice.
All healthcare workers, no matter where they practice, are expected to follow Standard Precautions for infection control. In lesson 2 we will review the main concepts of Standard Precautions.
In addition, CDC has developed specific recommendations that are tailored for hemodialysis healthcare workers that take into account the increased risks for infection that are present in outpatient hemodialysis facilities. In lesson 3 we will review the main concepts of the dialysis-specific recommendations to prevent infections.

14. Lesson 2: Standard Precautions
Standard Precautions for all Healthcare Workers in All Healthcare Settings
In this lesson, we will review Standard Precautions. Standard Precautions are a set of CDC recommendations that assume that any patient can have an infection. They are intended to be applied to the care of all patients in all healthcare settings.
PPE photo provided by Rosetta Jackson, used with permission

15. Standard Precautions for all Healthcare Workers
All healthcare workers are expected to follow Standard Precautions for infection control. This includes performing hand hygiene, using personal protective equipment or PPE, and following safe injection practices. We will review these concepts in more detail in the next few slides.
Perform hand hygiene
Use personal protective equipment (PPE)
Follow safe injection practices

16. How to perform hand hygiene
When hands are visibly soiled with blood or other body fluids, wash hands with soap and water
If hands are not visibly soiled, use an alcohol-based hand rub
At least 15 seconds
The first concept of Standard Precautions is to perform hand hygiene. Hand hygiene is one of the most important ways to prevent the spread of infections. Hand hygiene is a general term that applies to either washing hands with soap and water or using an alcohol-based hand rub product.
When your hands are visibly dirty, especially with blood or other body fluids, it is best to wash them with soap and water. To wash your hands properly, wet your hands with water and use liquid soap if possible. Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing your hands for at least 15 seconds. Rinse your hands well under running water and dry them using a paper towel if possible.
If your hands are not visibly dirty, use an alcohol-based hand rub. Follow the directions on the bottle for how much of the product to use. Rub your hands together and rub the product all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing until your hands are dry. If enough product was used, it should take at least 15 seconds of rubbing before your hands feel dry. When using an alcohol-based hand rub, you should not rinse your hands with water or dry them with a towel.
Remember that hand hygiene is one of the most important ways for you to prevent the spread of infections.
Remember: hand hygiene is one of the most important ways for you to prevent the spread of infections

17. Perform Hand Hygiene When you should perform hand hygiene
Before you touch a patient
Before you inject or infuse a medication
Before you cannulate a fistula/graft or access a catheter
After you touch a patient
After you touch blood, body fluids, mucous membranes, wound dressings, or dialysis fluids (e.g., spent dialysate)
After you touch medical equipment or other items at the dialysis station
After you remove gloves
Remember: perform hand hygiene between each patient or station
There are many times in the course of patient care that it is necessary for you to perform hand hygiene, including:
Before you touch a patient
Before you inject or infuse a medication
Before you cannulate a fistula or graft or access a catheter
After you touch a patient
After you touch blood, body fluids, mucous membranes, wound dressings, or dialysis fluids like spent dialysate
After you touch medical equipment or other items at the dialysis station
After you remove gloves
If you follow these guidelines for performing hand hygiene, you will greatly reduce the chances of spreading an infection from one patient to another.

18. Use Personal Protective Equipment (PPE) Correctly
For your own protection and to protect patients
Wear gloves, a gown, and/or face protection when you think you may come into contact with blood or other potentially infectious materials
Change gloves during patient care if the hands will move from a contaminated body-site to a clean body-site
Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment)
Do not wear the same pair of gloves for the care of more than one patient
The next concept within Standard Precautions is using personal protective equipment or PPE. Using PPE is for your own protection from infections and using it correctly will also protect your patients. In all healthcare settings, you are expected to wear gloves, a gown, or face protection such as a face shield, or goggles and a face mask when you think you may come into contact with blood or other potentially infected body fluids, mucous membranes, or nonintact skin. Because of the risk for blood exposure in hemodialysis settings, glove use is recommended for all patient care in outpatient dialysis facilities. We will discuss this more in detail in the next lesson.
While using PPE is for your own protection from infections, you need to be mindful to change your PPE, especially gloves, at certain times so that your gloves do not spread infections from patient to patient. Change your gloves if you will be touching a clean body site after a contaminated body site. Remove your gloves after contact with a patient and/or the surrounding environment, including medical equipment. And finally, do not wear the same pair of gloves for the care of more than one patient.
These practices will help you use personal protective equipment properly.

19. Follow Safe Injection Practices
Medications are injected directly or indirectly into the patient’s bloodstream
Any germs that have entered the medication vial or syringe can cause serious infections in the patient
Germs also can be introduced at the time of injection (e.g. contaminated injection port)
The last concept within Standard Precautions is following safe injection practices. Safe injection practices are a basic expectation any time injections are administered. Over the last decade, syringe reuse and misuse of medication vials have resulted in dozens of outbreaks of bloodborne viruses such as hepatitis B and hepatitis C, including in dialysis centers.
Medications are injected directly or indirectly into the patient’s bloodstream, therefore any germs that have entered the medication vial or syringe can cause serious infections in the patient. Germs also can be introduced at the time of injection, for example, through a contaminated injection port.

20. Follow Safe Injection Practices
Three things you need to know:
Needles and syringes are single use devices. They should not be used for more than one patient.
Do not administer medications from a single-dose vial or IV bag to multiple patients.
Perform hand hygiene and cleanse the access port before injecting into it.
Saline bags are always single patient use
Here are the three things you should know about safe injection practices:
First, needles and syringes are single use devices. You should never use them for more than one patient or reuse them to draw up additional medication.
Second, do not administer medications from a single-dose vial or IV bag to multiple patients. Bags of saline or medication are single-use items.
And finally, perform hand hygiene and cleanse any catheter or IV access port before injecting into it or withdrawing from it.
These practices will help prevent the spread of bloodborne viruses and other germs.

21. Lesson 3: Recommendations
Specific Infection Control Recommendations for Outpatient Hemodialysis Healthcare Workers
Now that we have reviewed the main concepts of Standard Precautions, in this lesson we will review the specific infection control recommendations for outpatient hemodialysis settings. Healthcare workers are expected to follow these recommendations in addition to Standard Precautions to help prevent the spread of infections in dialysis facilities.

22. Specific Infection Control Precautions for Hemodialysis Healthcare Workers
Wear gloves and other personal protective equipment (PPE) for all patient care
Promote vascular access safety
Separate clean areas from contaminated areas
Use medication vials safely
Clean and disinfect the dialysis station between patients
Perform safe handling of dialyzers
Some of the specific infection control recommendations for outpatient hemodialysis healthcare workers include:
Wear gloves and other personal protective equipment or PPE for all patient care
Promote vascular access safety
Clean and disinfect the dialysis station between patients
Separate clean areas from contaminated areas
Use medication vials safely
Perform safe handling of dialyzers
We will learn more about each of these concepts in the following slides.

23. Wear Gloves During Patient Care
For your own protection
Wear disposable gloves when caring for the patient or touching equipment at the dialysis station
Wear gloves when cleaning surfaces in the environment or medical equipment
Remember to remove gloves and perform hand hygiene between each patient or station, and if moving from a contaminated to clean area of the same patient or within the same dialysis station
The first dialysis specific infection control recommendation is to wear gloves during patient care. You should wear gloves for your own protection from infections, and you have to use them correctly to protect your patients from infections. During the process of hemodialysis, exposure to blood and contaminated items can be expected; therefore, gloves are required in the dialysis environment whenever caring for a patient or touching equipment or surfaces at the dialysis station. Gloves should also be worn when cleaning surfaces in the environment or medical equipment. Remember to remove your gloves and perform hand hygiene between each patient or station and if moving from a contaminated to a clean area of the same patient or within the same dialysis station.
These practices will help prevent the spread of infections.

24. Use Personal Protective Equipment (PPE)
For your own protection
In addition to gloves, you should wear gowns and face protection to protect yourself as needed:
During initiation and termination of dialysis
When cleaning dialyzers
When handling lab samples
PPE should be changed if it becomes dirty
Similarly, while personal protective equipment is a concept of Standard Precautions, it is also a concept of dialysis-specific infection control recommendations. You should wear gloves, gowns, and face protection such as a face shield or goggles and a face mask to protect yourself when performing procedures during which blood splashes might occur. This includes during initiation and termination of dialysis, when cleaning dial yzers, and when spinning blood samples. Personal protective equipment should be changed if it becomes soiled with blood, body fluids, secretions, or excretions.
Photo provided by Rosetta Jackson, used with permission

25. Basic Steps in Fistula/Graft Care
Cannulation Procedure:
Wash the site
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Apply skin antiseptic and allow it to dry
Insert needle using aseptic technique
Remove gloves and perform hand hygiene
The next concept in the dialysis-specific infection control recommendations is practicing vascular access safety. As we learned in lesson 1, infections are all too common, particularly with central lines. In the next four slides, we will review the cannulation and decannulation procedures for patients who have fistulas or grafts, followed by the connection and disconnection procedures for patients who have catheters.
One concept that we will mention in these next several slides is aseptic technique. When performing a procedure such as cannulating a fistula or graft, aseptic technique means taking great care not to contaminate the fistula or graft site before or during the procedure.
Here we describe the cannulation procedure for patients with fistulas or grafts:
Have the patient wash the site with soap and water
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Apply skin antiseptic such as chlorhexidine, povidone iodine, or alcohol to the site and allow it to dry
Perform cannulation being careful not to contaminate the area that has been cleansed
Remove gloves and perform hand hygiene
CDC recommends using safety needles to decrease your chances of getting a needlestick.
Aseptic technique means taking great care to not contaminate the fistula or graft site before or during the cannulation or decannulation procedure
Photo provided by Stephanie Booth, used with permission

26. Basic Steps in Fistula/Graft Care
Decannulation Procedure:
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Remove needles using aseptic technique
Apply clean gauze/bandage to site
Compress the site with clean gloves
Remove gloves and perform hand hygiene
When the patient has completed treatment, here are the steps for the decannulation procedure in patients with fistulas or grafts:\
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Activate the safety devices on the needles to prevent a needlestick, remove needles using aseptic technique and dispose of them in a proper sharps container
Apply clean gauze or a bandage to site
Compress the site with clean gloves
Remove gloves and perform hand hygiene

27. Basic Steps in Catheter Care
Catheter Connection Procedure:
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Apply antiseptic to catheter hub and allow it to dry
Connect the catheter to blood lines using aseptic technique
Unclamp the catheter
Remove gloves and perform hand hygiene
Practicing vascular access safety is of particular importance in patients with catheters or central lines, as the risk of infection is highest in these patients. To properly perform a catheter connection procedure, use the following steps:
Perform hand hygiene.
Put on a new, clean pair of gloves. Some centers may choose to use sterile gloves.
Wear proper face protection. A face mask may be required in your center.
While keeping the catheter clamped, apply antiseptic to the catheter hub, which is the end of the catheter, and allow it to dry. Be careful not to contaminate the catheter hub after applying the antiseptic.
Connect the catheter to blood lines using aseptic technique. Keep the catheter clamped until after it’s connected to avoid allowing air to enter the catheter.
Unclamp the catheter once it is connected.
Remove gloves and perform hand hygiene.

28. Basic Steps in Catheter Care
Catheter Disconnection Procedure:
Perform hand hygiene
Put on a new, clean pair of gloves
Wear proper face protection
Disconnect the catheter from blood lines using aseptic technique
Apply antiseptic to catheter hub and allow it to dry
Replace caps using aseptic technique
Make sure the catheter remains clamped
Remove gloves and perform hand hygiene
When the patient has completed treatment, here are the steps for the disconnection procedure in patients with catheters:
Perform hand hygiene.
Put on a new, clean pair of gloves. Some centers may choose to use sterile gloves.
Wear proper face protection. A face mask may be required in your center.
After clamping the catheter, disconnect the catheter from the blood lines using aseptic technique.
Apply antiseptic to the catheter hub and allow it to dry.
Replace caps using aseptic technique.
Check to make sure the catheter remains properly clamped.
Remove gloves and perform hand hygiene.

29. Catheter Exit Site Care
Perform hand hygiene
Put on a new, clean pair of gloves
Wear a face mask if required
Apply antiseptic to catheter exit site and allow it to dry
Apply antimicrobial ointment
Apply clean dressing to exit site
Remove gloves and perform hand hygiene
Here are the additional steps for caring for a catheter exit site. This can be done anytime prior to, during, or after dialysis treatment:
Perform hand hygiene
Put on a new, clean pair of gloves. Some centers may choose to use sterile gloves.
Wear a face mask if required in your center.
Apply antiseptic to catheter exit site and allow it to dry
Apply antimicrobial ointment
Apply clean dressing to exit site
Remove gloves and perform hand hygiene
Photo provided by Stephanie Booth, used with permission

30. Separate Clean Areas from Contaminated Areas
Clean areas should be used for the preparation, handling and storage of medications and unused supplies and equipment
Your center should have clean medication and clean supply areas
Contaminated areas are where used supplies and equipment are handled
Do not handle or store medications or clean supplies in the same area as where used equipment or blood samples are handled
Remember: Treatment stations are contaminated areas!
Clean area
The next concept in the dialysis-specific infection control recommendations is keeping clean areas separate from contaminated areas.
Clean areas should be clearly designated and used only for the preparation, handling and storage of medications and unused supplies and equipment.
In your center, there should be clean medication and clean supply areas. Ideally these are in a separate room, physically separate from the rest of the treatment area, which allows you to better maintain the cleanliness of the area.
Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.
Do not handle or store medications or clean supplies in the same area as where used equipment or blood samples are handled.
Remember: treatment stations are contaminated areas!
Photo provided by Stephanie Booth, used with permission

31. Dedicate Supplies to a Single Patient
Any item taken to a patient’s dialysis station could become contaminated
Items taken into the dialysis station should either be:
Disposed of, or
Cleaned and disinfected before being taken to a common clean area or used on another patient
Unused medications or supplies taken to the patient’s station should not be returned to a common clean area (e.g., medication vials, syringes, alcohol swabs)
The next concept in the dialysis-specific infection control recommendations is to dedicate supplies to a single patient. Any item taken to a patient’s dialysis station could become contaminated with blood or other body fluids.
Patient care items taken into the dialysis station should either be:
Disposed of, or
Cleaned and disinfected before being taken to a common clean area or used on another patient.
Unused medications or supplies, for example, medication vials, syringes, or alcohol swabs, that are taken to the patient’s station should not be returned to a common clean area.
Photo provided by Marshia Coe and Teresa Hoosier, used with permission

32. Safe Use of Medication Vials
Prepare all individual patient doses in a clean area away from dialysis stations
Prepare doses as close as possible to the time of use
Do not carry medications from station to station
Do not prepare or store medications at patient stations
CDC recommends that dialysis facilities:
Use single-dose vials whenever possible and dispose of them immediately after use
The next concept in the dialysis-specific infection control recommendations is to practice safe use of medication vials. These recommendations are part of safe injection practices under standard precautions for all healthcare workers.
Most of your patients will require injected medications such as heparin, saline, or erythropoietin. When preparing these medications:
Prepare all individual patient doses in a clean area away from dialysis stations.
Prepare doses as close as possible to the time of use, meaning, do not draw up medications in advance.
Do not carry medications from station to station.
Do not prepare or store medications at patient stations.
CDC recommends that dialysis facilities:
Use single-dose vials whenever possible and dispose of them immediately after use.

33. Guidelines for Carrying Medications
Do not use the same medication cart to deliver medications to multiple patients
Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets
Be sure to prepare the medication in a clean area away from the patient station and bring it to the patient station for that patient only at the time of use
The next concept in the dialysis-specific infection control recommendations is to carry medications properly in order to avoid spreading infections.
These guidelines include:
Do not use the same medication cart to deliver medications to multiple patients.
Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets.
Be sure to prepare the medication in a clean area away from the patient station and bring it to the patient station for that patient only at the time of use.

34. Cleaning and Disinfecting the Dialysis Station
Cleaning and disinfection reduce the risk of spreading an infection
Cleaning is done using cleaning detergent, water and friction, and is intended to remove blood, body fluids, and other contaminants from objects and surfaces
Disinfection is a process that kills many or all remaining infection-causing germs on clean objects and surfaces
Use an EPA-registered hospital disinfectant
Follow label instructions for proper dilution
Wear gloves during the cleaning/disinfection process
The next concept in the dialysis-specific infection control recommendations is cleaning and disinfecting the dialysis station. Both cleaning and disinfection are performed to reduce the risk of spreading an infection.
Cleaning is done using cleaning detergent and water and is intended to remove blood and body fluids from objects and surfaces.
Disinfection is a process that kills many or all of the remaining germs on clean objects and surfaces. To properly perform disinfection, use an EPA-registered hospital disinfectant. Follow the label instructions for proper dilution.
Note that different disinfectants will have different instructions for making up the solution and this can vary for routine disinfection versus cleaning up a blood spill. Be sure to check the label.
Also, be sure to wear gloves and other PPE that is recommended on the product’s label during the cleaning and disinfection process.

35. Disinfecting the Dialysis Station
All equipment and surfaces are considered to be contaminated after a dialysis session and therefore must be disinfected
After the patient leaves the station, disinfect the dialysis station (including chairs, trays, countertops, and machines) after each patient treatment
Wipe all surfaces
Surfaces should be wet with disinfectant and allowed to air dry
Give special attention to cleaning control panels on the dialysis machines and other commonly touched surfaces
Empty and disinfect all surfaces of prime waste containers
Disinfection is performed specifically because blood and germs can contaminate surfaces and spread infections without being visible to the naked eye. It is important to follow thorough disinfection procedures even when you don’t see blood.
The disinfection process should not begin until the patient has completed treatment and has left the station.
Disinfect the dialysis station including chairs, trays, countertops, and machines after each patient treatment
Wipe all surfaces
Surfaces should be wet with disinfectant and allowed to air dry
Give special attention to cleaning control panels on the dialysis machines and other commonly touched surfaces
Empty and disinfect all surfaces of prime waste containers and make sure these are dry before using them
Be careful not to contact the surfaces with used or contaminated items once the disinfectant is applied.
Photo provided by Stephanie Booth, used with permission

36. Safe Handling of Dialyzers and Blood Tubing
Before removing or transporting used dialyzers and blood tubing, cap dialyzer ports and clamp tubing
Place all used dialyzers and tubing in leak-proof containers for transport from station to reprocessing or disposal area
If dialyzers are reused, follow published methods (e.g., AAMI standards) for reprocessing
AAMI is the Association for the Advancement of Medical Instrumentation
The last concept in the dialysis-specific infection control recommendations is to practice safe handling of used dialyzers and blood tubing.
Before removing or transporting used dialyzers and blood tubing, cap dialyzer ports and clamp tubing. Place all used dialyzers and tubing in leak-proof containers for transport from station to reprocessing or disposal area. If dialyzers are reused, initiate reprocessing immediately after use and follow published methods, for example, AAMI standards, for reprocessing the dialyzers.
Photo provided by Stephanie Booth, used with permission

37. Lesson 4: Policies and Practices
Infection Control Policies and Practices for Outpatient Hemodialysis Facilities
We have reviewed how infections are spread from patient to patient in dialysis facilities, as well as standard precautions for all healthcare workers and the dialysis-specific infection control recommendations. In this lesson, we will review the infection control policies and practices for outpatient hemodialysis facilities. These are important for dialysis nurses and technicians to be aware of.

38. Infection Control Policies and Practices for Dialysis Facilities
Vaccination of dialysis staff and patients
Preventing the spread of hepatitis B
Preventing the spread of bacterial infections
Infection control policies and practices for dialysis facilities include the following concepts:
Vaccination of dialysis staff and patients
Preventing the spread of Hepatitis B
Preventing the spread of bacterial infections
We will review these concepts in greater detail in the next few slides.

39. Vaccine-Preventable Infections
Influenza
Influenza or the “flu” is a respiratory infection that infects the nose, throat, and lungs
The flu is spread mainly by droplets that are made when people with flu cough, sneeze or talk
The single best way to prevent the flu is to get a flu vaccine each year
Hepatitis B
Hepatitis B is a serious infection that affects the liver. It can cause acute (short-term) or chronic (long-term) infection and liver cancer
Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person
Hepatitis B vaccine can prevent hepatitis B infection
First we’d like to review two infections that dialysis patients and staff are at a high risk of spreading.
Influenza or the “flu” is a respiratory infection that infects the nose, throat, and lungs. Every year, thousands of people die from the flu. The flu is spread mainly by droplets that are made when people with flu cough, sneeze or talk. The single best way to prevent the flu is to get a flu vaccine each year.
Hepatitis B is a serious infection that affects the liver. It can cause acute short-term or chronic long-term infection as well as liver cancer. Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person.
Hepatitis B vaccine can prevent hepatitis B infection. Because it can be easily spread due to all of the blood in the dialysis environment, it is important to vaccinate anyone who has never been vaccinated and lacks immunity. This applies to both patients and dialysis healthcare workers.

40. Take Care of Yourself Get Vaccinated
Get the flu vaccine each year
Complete the hepatitis B vaccine series
It is important to take care of yourself and be a role model for your patient while working in a dialysis center. All dialysis healthcare workers should get the flu vaccine each year and complete the Hepatitis B vaccine series to protect themselves from these infections.
Healthcare workers can have the flu and spread it even if they don’t feel sick. Getting the flu vaccine lessens your chances of spreading the flu to your patients or family members such as older adults or infants.

41. Vaccination and Routine Testing of Hemodialysis Patients
Vaccinate all susceptible patients against:
Hepatitis B
Recommended vaccines for patients include:
Influenza (inactivated)
Pneumococcal
Conduct routine testing for:
Hepatitis B virus
Hepatitis C virus
In addition to taking care of yourself, it is important to vaccinate and perform routine testing of hemodialysis patients. This includes:
Vaccinate all susceptible patients against Hepatitis B. In this case, susceptible means any patient who has never been vaccinated and lacks immunity to hepatitis B virus. Ideally, patients should be vaccinated against Hepatitis B before they require dialysis.
In addition, it is recommended that dialysis patients receive the inactivated influenza vaccine each year and the pneumococcal vaccine.
Hemodialysis patients should be routinely tested for: Hepatitis B and Hepatitis C virus.
In addition, all healthcare workers should receive the influenza vaccine annually and dialysis healthcare workers also should receive the Hepatitis B vaccine series.

42. Preventing the Spread of Hepatitis B
Dialyze hepatitis B (HBsAg+) patients in a separate room using separate machines, equipment, instruments, and supplies
Be sure to use a separate gown when treating these patients
Staff members caring for patients with hepatitis B (HBsAg+) should not care for HBV-susceptible patients at the same time (e.g., during the same shift or during patient changeover)
The next infection control policy for dialysis facilities is to properly manage patients who have Hepatitis B in order to prevent the spread of the infection.
With these patients, follow the same infection control recommendations, including standard precautions and the dialysis-specific infection control recommendations, as you would for all patients. In addition, dialyze patients with Hepatitis B in a separate room using separate machines, equipment, instruments, and supplies. Be sure to use a separate gown when treating these patients.
Staff members who are caring for patients with Hepatitis B should not care for patients who are susceptible to hepatitis B at the same time, for example during the same shift or during patient changeover.
Some centers have designated one person to care for Hepatitis B patients to help prevent the spread of hepatitis B virus from patient to patient.
HBsAg+ means hepatitis B surface antigen (a lab test for hepatitis B virus) was positive
HBV-susceptible means anyone who has never been infected and lacks immunity to hepatitis B virus

43. Preventing the Spread of Bacterial Infections
Hemodialysis patients who might be at increased risk for spreading germs to other patients include those with:
An infected skin wound with drainage that is not contained by dressings
Fecal incontinence or uncontrolled diarrhea
For these patients use the following precautions:
Wear a gown and gloves when you are caring for the patient and remove the gown and gloves when you are finished caring for the patient
Do not wear the same gown when caring for other patients
Dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the room)
Patients with respiratory illness and a fever are at risk of spreading bacterial and viral respiratory infections
These patients should be dialyzed at least 6 feet away from other patient stations or any shared supplies
The last infection control policy for dialysis facilities is to properly manage dialysis patients with bacterial infections to prevent the spread of these infections. This applies to patients who have an infected skin wound with drainage that is not contained by dressings and patients with fecal incontinence or uncontrolled diarrhea. Of course these patients will come for their dialysis treatment when they are sick, and they pose a risk to other patients. You should alert your clinic or nurse manager if you notice a patient with any of these symptoms. And, remember you should always follow standard precautions and the dialysis-specific infection control recommendations, including strict attention to hand hygiene.
In addition, you should wear a gown when you are caring for the patient and remove the gown when you are finished caring for the patient. Make sure you do not wear the same gown or gloves when caring for other patients. Patients with these conditions should be dialyzed at a station with as few adjacent stations as possible, for example at the end or corner of the room.
Patients with respiratory illness and a fever are at risk of spreading bacterial and viral respiratory infections.  Because these infections are often spread by droplet transmission, these patients should be dialyzed at least 6 feet away from other patient stations or any shared supplies, including computer keyboards for example.  They should be encouraged to follow proper cough etiquette like coughing into a tissue, discarding it, and performing frequent hand hygiene.  If tissues are not available, patients can cough into their elbow.  For all of these patients, it is essential that staff perform hand hygiene and change gloves between patients.

44. Educating your Patients and their Caregivers
Lesson 5: Education
Educating your Patients and their Caregivers
In this final lesson we will review important concepts to discuss with your patients and their caregivers.

45. How to Recognize an Infection
Advise patients to inform you if they notice any of the following possible signs of infection:
Fever
The access site is:
Swollen (bulging),
red,
warm, or
has pus
Severe pain at the access site
Remember: infections of the vascular
access site can be life threatening
First, please advise all patients and their caregivers on how to recognize an infection. They should tell you or another healthcare worker if they notice any of the following signs of infection:
Fever
The access site is swollen or bulging, red, warm, or there is pus at the site
Severe pain at the access site
Remember that infections of the vascular access site can be life threatening.

46. Training and Education of Patients and their Caregivers
When a new patient starts dialysis and on an annual basis, review:
Personal hygiene and hand hygiene technique
Patient responsibility for proper care of the access site and recognition of signs of infection
Recommended vaccinations (including hepatitis B, influenza, and pneumococcal)
Reasons for selecting a fistula or graft over a catheter to lower the risk of infection
As a matter of routine, when a new patient starts dialysis and on an annual basis, please review:
Personal hygiene and hand washing technique.
Patient responsibility for proper care of the access site and recognition of signs of infection.
Recommended vaccinations including hepatitis B, influenza, and pneumococcal.
And if the patient is a potential candidate for a fistula or graft, the reasons they should choose these access types instead of a catheter.
These practices will help lower their risk of infections.

47. Preventing Infections in Hemodialysis Settings
Recap
Preventing Infections in Hemodialysis Settings
In the following slides we will briefly review what you have learned in this course.
Photo provided by Stephanie Booth, used with permission

48. Key Infection Prevention Practices
Perform hand hygiene frequently and change gloves
Maintain separate clean areas for supplies and medications and separate contaminated areas for used items
Practice proper handling and delivery of patient supplies and medications
Perform effective cleaning and disinfection of dialysis equipment and environmental surfaces
Carefully handle medications and the patient’s vascular access to avoid contamination
Remember: Use aseptic technique every time!
The following are key infection prevention practices to keep in mind:
Perform hand hygiene frequently and change your gloves at appropriate times
Maintain separate clean and contaminated areas
Practice proper handling and delivery of patient supplies and medications
Perform effective cleaning and disinfection of dialysis equipment and environmental surfaces
Carefully handle medications and the patient’s vascular access to avoid contamination

49. Conclusion
Infections that patients can get while receiving dialysis are serious and preventable!
Healthcare workers like you following infection control precautions and other safe care practices are the key to prevention
Infection prevention is everyone’s responsibility
In conclusion, infections that patients can get while receiving dialysis are serious and preventable! Healthcare workers like you following infection control precautions and other safe care practices are the key to prevention. Infection prevention is everyone’s responsibility.

50. Course Assessment: Instructions
Now that you have completed the course material, you will begin the course assessment. For the following questions, select the answer choice or choices which are most appropriate. Following the course assessment, there are instructions that will direct you on how to receive CE credit.