Bugs Away: Infection Control Practices in Dialysis Away: Infection Control Practices in Dialysis Barbara Dommert-Breckler, RN BSN Quality Improvement Director Northwest Renal Network/ESRD

Bugs Away: Infection Control Practices in Dialysis

Barbara Dommert-Breckler, RN BSN

Quality Improvement Director

Northwest Renal Network/ESRD Network 18

Objectives

• Identify five risk factors associated with infections in dialysis patients

• List five evidence based interventions which reduce bloodstream infections in dialysis patients

• Identify ways to engage patients in infection control

Would you allow a nurse or doctor to examine you or a loved one without washing their hands?

Should our patient expect less?

Bloodstream Infections in Hemodialysis Patients

• There are 661,648 prevalent cases of ESRD as of December 31, 2013

• About eight in ten of these patients start treatment through a central line (a major risk factor for BSI)

• Infection is one of the leading causes of hospitalizations for ESRD patients

USRDS 2015 Annual Data Report

Why a Higher Infection Risk?

• Renal failure results in impairment of white blood cells and neutrophil function

• Due to weakened immune system response, Staphylococcal bacteria (normal skin flora) are much more likely to invade the body

• Inability to activate lymphocytes to a state where they are effective in protecting against viral and fungal infections

Why a Higher Infection Risk?

• Vascular access device is an impenetrable foreign object - white blood cells cannot eradicate the infection

• Medications may further suppress the immune system and predispose to infection

• Persistent opening in the skin (access site) allows bacteria to enter unchecked

• Contamination can occur during access and de-access because of improper technique

Impact of Infections- Hospitalizations

• Rate of admissions for infection is 30% greater than in 1993.

• Overall national hospital admission rate per patient year is 1.87 (2011) for hemodialysis patients a decrease from 1.90 (2010). Peritoneal rate remained steady at 1.70

• The percentage of Medicare patients admitted with septicemia during 2012-2015:

• Nationally: 10.9% California: 11.9%

USRDS 2016 ADR/ 2017 DFR

Infections in Dialysis Patients

• Dialysis patients are at risk for Hepatitis B and C infections

• Hepatitis B &C are blood-borne, viral pathogens which can cause serious acute and/or chronic liver disease

• Hepatitis B and C viruses can live on surfaces and be spread without visible blood for how long????

Hemodialysis-Associated HCV Outbreaks

Since 2008 1833 Patients Screened

79 Outbreak Associated Infections

• Failure to consistently change gloves and perform hand

hygiene between patients.

• Breaches in medication preparation and administration practices

• Breaches in environmental cleaning and disinfection practices

http://www.cdc.gov/hepatitis/Statistics/HealthcareOutbreakTable.htm

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 change over)

• HBsAg+ - 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

Following CDC Protocols Cuts Dialysis Bloodstream Infections in Half

Published online 15May2013

CDC Approach to BSI Prevention in Dialysis Facilities

• Surveillance and Feedback using NHSN

• Patient Education and Engagement

Patient Empowerment

• Teach safe care of the access site

– Use antibacterial soap to wash access site every day

– Wash access site before each dialysis treatment

• Teach them safe practices

– Do not scratch their access site or touch it after it has been disinfected

– Avoid coughing or sneezing on the access site during treatment

Patient Empowerment

• Encourage involvement in their care

– Have patients ask doctors and nurses to explain why a

central line is needed, how long it will be placed, and if they can use a fistula or graft

– Encourage caregiver hand hygiene before donning gloves prior to vascular access

– Patient and nurse must wear a mask when catheter (not fistula or graft) is connected or disconnected

Patient Empowerment

• Encourage involvement in their care

– Have patients complete hand hygiene audits

– “Speak up” platform

BSI Project – CDC Audits

CVC On/Off

Hand Hygiene

AVF/AVG Cannulation

Dialysis Station

Disinfection

Medication Injection

Safety

30+10 20

10

20

10

Learn CDC Recommended

Practices

Implement CDC Recommended

Practices

Audit CDC Recommended

Practices

Provide Feedback on Adherence

BSI Project

Alternate Methods of Patient Engagement

– Show videos over clinic TVs

– Begin engagement at the door – a culture of 100% staff escorting patients

– Quizzes & Trivia contests

– Replacing flyers with return demonstrations

CDC Approach to BSI Prevention in Dialysis Facilities

Staff education and competency

http://www.cdc.gov/dialysis/prevention-tools/index.html

Educate and Practice

• Perform competency evaluation for skills upon hire and every 6-12 months

• Provide regular infection prevention education

Encourage staff to use “cheat sheets”

(They need to be wiped down too.)

Observe and Critique

How to Use the Audit Tool: Opportunities

• Each audit includes multiple observations.

– An observation is an opportunity to perform hand hygiene (when warranted)

• If an opportunity is observed and hand hygiene is performed, the observation is marked a success:

The third observation was not successful because the warranted opportunity for hand

hygiene was missed.

The first two observations were successful because hand hygiene was warranted and

was performed.

Newest CDC Audit Tool

CDC Approach to BSI Prevention in Dialysis Facilities

Reduce Central Venous Catheters

0

10

20

30

40

50

60

70

0 10 20 30 40 50

dea

ths

per

10

0 p

ati

ent

yea

rs

time from dialysis initiation (weeks)

Mortality by access at dialysis initiation

catheter (n=200,978)

graft (n=29,103)

PD (n=16,520)

fistula (n=40,916)

Day 90

Impact of a Type of Vascular Access

CJASN 2011, Chan

CDC Approach to BSI Prevention in Dialysis Facilities

• Cholhexidine for skin antisepsis

• Catheter hub disinfection

• Antimicrobial ointment

Through improper injection or handling

Through catheter exit site

Bacteria Entry Points

Mechanisms of HD Central Line Infection: Study Methods

• Tunneled catheters removed from 76 HD patients were collected over a 3 year period

– 26 patients had bacteremia, 50 had catheters

– Removed for non-infectious reasons • Excluded patients with exit site infection

– Cultured and measured biofilm on several surfaces of the catheter:

Ramanathan V. et al. AJKD 2012 Jul 13 [Epub]

Extravascular segment

intravascular segment

skin

Mechanisms of Infection: Results

• Culture-positive catheters – In 62% bacteremic patients; 30% uninfected patients

• Most common site of bacterial growth:

– Outer surface, extravascular segment

• Significantly thicker catheter biofilm

– In bacteremic patients (all surfaces) – Outer vs. luminal surfaces (both patient groups, both segments) – Extravascular vs. intravascular segments (both surfaces, both patient groups)

Catheter duration had no impact on rate or location of bacterial growth

Ramanathan V. et al. AJKD 2012 Jul 13 [Epub]

Poor catheter care is the primary cause of

catheter related infections.

Pictured used with permission of Dr. Lefler

Vascular Access Technique Observation

• Critical component of care opportunity

for improvement

• Use aseptic technique

• Audit and share results

with staff

• Standardize practice

Chlorhexidine vs. Sodium Hypochlorite vs. Povidone-Iodine

• Assessed and compared antiseptic efficacy and “substantive” effect of 2% CHG w/alcohol, 10% sodium hypochlorite solution, 10% povidone-iodine

• Applied to skin of 31 healthy volunteers

• Outcomes: bacterial colony counts at 1 minute, ability to inhibit newly introduced bacteria at 2 hours

• Concluded: – The 3 agents have essentially same effect at 1 minute – Only CHG has a substantive effect

Macias JH. American Journal of Infection Control 2013

Chlorhexidine: Basics

• Cleansing the skin decreases colonization

• Chlorhexidine has rapid (~30 sec) and persistent (up to 48 hours) antimicrobial activity

• Part of the central line bundle

• Recommended by HICPAC, KDOQI

• • Reduces catheter-related BSI

CDC Approach to BSI Prevention in Dialysis Facilities

Dialysis Station Routine Disinfection

No Visible Blood Pre-luminal

Bergervoet P. J Hosp Infect 2008; 68:323-333

…Presto!

And now for a little magic

Common Themes of Infections Paths from CDC Investigations of Hepatitis C

Outbreaks in Dialysis Facilities

• Patient overlaps in space and time (i.e., transmission from): – One patient to the next at same station – One patient to another at adjacent stations

• Breaches in environmental cleaning and

disinfection practices – Surfaces wiped down with patient still at station – Rushed turnover processes

http://www.cdc.gov/hepatitis/Statistics/HealthcareOutbreakTable.htm

Disinfecting the Dialysis Station

• All equipment and surfaces are considered contaminated after a dialysis session and therefore must be disinfected

• After the patient leaves the station, disinfect the dialysis station (include 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

Safe Handling of Dialyzers and Blood Tubing

• Cap ports and clamp tubing prior to removing or transporting used dialyzers and blood tubing

• Place used dialyzers and tubing in leak-proof containers for transport to reprocessing or disposal area

• If dialyzers are reused, follow published methods

(e.g., AAMI standards) for reprocessing

AAMI-Association for the Advancement of Medical Instrumentation

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/store medications or clean supplies in the same area where used equipment or blood samples are handled

• Remember: Treatment stations are contaminated areas!

clean area

CDC Resources

• The CDC Dialysis Team would like to share some new infection prevention resources. Dialysis facility staff now have access to a new, bilingual version of the Provider Training Video: Preventing Bloodstream Infections in Outpatient Hemodialysis Patients: Best Practices for Dialysis Staff, available with Spanish captions (use the video player buttons to turn captions on). This 11-minute video focuses on best practices for preventing infections in hemodialysis patients. (http://www.cdc.gov/dialysis/prevention-tools/training-video.html)

• Please also take a look at our continuing education course, “Infection Prevention in Dialysis Settings” for outpatient hemodialysis healthcare workers, including technicians and nurses: Continuing Education Course: Infection Prevention in Dialysis Settings. This 1-hour, self-guided training course focuses on educating patients and healthcare personnel about infections and infection control practices applicable in a dialysis setting. Staff can earn free Continuing Education Credits after completing the course assessment and evaluation. (http://www.cdc.gov/dialysis/clinician/CE/infection-prevent-outpatient-hemo.html)

CDC Resources

• Also take a look at the updated NHSN Dialysis Event Surveillance Training, which was posted in April 2014! Dialysis users are required to take this training annually so they stay updated on the Dialysis Event training. The training is self-paced and users are able to earn free Continuing Education Credits as well! (http://nhsn.cdc.gov/nhsntraining/courses/C18/)

• Just added to our website is the Hemodialysis Catheter Compatibility Chart, which helps to connect providers to information about using compatible skin antiseptics and antimicrobial ointments with different chronic hemodialysis catheters. (http://www.cdc.gov/dialysis/prevention-tools/catheter-compatibility-

information.html)

“Never doubt that a small group of thoughtful, committed people can change the world.

Indeed, it is the only thing that ever has.”

- Margaret Mead

Questions?

Barbara Dommert- Breckler [email protected]

206.923.0714

HealthInsight

HealthInsight is a private, non-profit, community-based organization dedicated to improving health and health

care, operating in nine western states: California, Alaska, Idaho, Montana, Oregon Washington, Nevada,

New Mexico and Utah. The HealthInsight ESRD Alliance was formed in 2015 to bring together the strengths of all partners to further integrate quality efforts across

the care continuum for patients at risk for kidney disease, those with chronic kidney disease, those on

dialysis or receiving kidney transplant care.

References

• Garcia-Houchins, Sylvia, (2009). Dialysis. APIC Text of Infection Control and Epidemiology, 3rd ed. pp: 48.1-48.17.

• CDC, 2012. Infection Prevention in Dialysis Settings. Continuing Education Course. http://www.cdc.gov/dialysis/clinician/CE/infection-prevent-outpatient-hemo.html

• CDC, 2001, Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm

• National Kidney Foundation, Inc. 2006. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI). 2006 Updates Clinical Practice Guidelines and Recommendations. http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_iii.html

• Paintsil, Elijah, et. al. Hepatitis C Virus Maintains Infectivity for Weeks after Drying on Inanimate Surfaces at Room Temperature: Implications for Risks of Transmission Journal of Infectious Disease. First Published online November 23, 2013

• Chan KE, Maddux FW, Tolkoff-Rubin N, Karumanchi SA, Thadhani R, Hakim RM: Early Outcomes among Those Initiating Chronic Dialysis in the United States. Clin J Am Soc Nephrol. Vol 6, Sept, 2011