APIC IC Challenges in Dialysis Danilo B. Concepcion,CBNT, CCHT-A Operations Manager, Renal Service

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1 APIC IC Challenges in Dialysis Danilo B. Concepcion,CBNT, CCHT-A Operations Manager, Renal Service The views and opinions are those of the author and does not reflect those of St. Joseph Hospital or any other organization.

2 *Infections 2 nd Leading Cause Of Death 17.0% Infection 26.0% Cardiac 4.0% 5.0% 48.0% Cerebrovascular Disease Malignant Disease All Other UM-KECC, 2009 Approximately 15,000 dialysis patients die annually due to 2 infections

3 *Temporal and spatial issues *Water and dialysate *Staffing matrix

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9 *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.

10 Hollow fiber Fiber wall 40 microns

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13 Why Is Infection Prevention Such a Challenge in Dialysis? The in-center hemodialysis patient treatment reality: Staff caring for multiple patients w/short changeover times Lots of potential blood exposure immunosuppressed dialysis patients No physical separation of individual treatment stations High risk for spread of bloodborne and other pathogens 13 compounded by

14 Recent Studies Illustrate How the Dialysis Facility Can Become a Box of Bugs Organisms remain viable on surfaces for prolonged periods Hepatitis B Influenza >1 week 1-2 days MRSA 7 days to 7 months VRE 5 days to 4 months C. difficile spore 5 months Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006 Healthcare workers touch as many as 7 surfaces after touching a contaminated one! McLaughlin AC, Walsh F. Am J Infect Control 39(6): ,

15 How 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) 15

16 Dialysis Patient Infections Can Be Prevented by: Following good infection prevention and control practices The Centers for Disease Control and Prevention (CDC) has guidelines for these practices in dialysis facilities 16

17 The CDC Guidelines *Address 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 17

18 National Opportunity To Improve Infection Control In ESRD The NOTICE Initiative is funded by the Department of Health and Human Services to support the renal community in improving infection control 18

19 Infection Control Checklists for Dialysis *Initiation of Dialysis with CVC *CVC Exit Site Care *Discontinuation of Dialysis and Post Care of CVC *Initiation of Dialysis with AVF/G *Discontinuation of Dialysis and Post Care of AVF/G *Parenteral Medication Preparation/Administration *Cleaning & Disinfection of the Dialysis Station *Supply Management & Contamination Prevention 19

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29 Note: 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. 29

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34 The Infection Control Checklists Don t Address Everything on How to Protect Patients from HAI 34

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36 *Separate isolation room *February 9, 2009 all new facilities must have a separate isolation room (waiver) *Separate isolation area *If 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.

37 *Separate dedicated supplies and equipment, including blood glucose monitors. *Labeled isolation *Concentrate containers

38 *Staff 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

39 The more pure and endotoxin free the water and dialysate, the fewer Chronic Inflammatory Disease (CID) processes seen in patients over time

40 Fluid Water used for dialysate, reprocessing of hemodialyzers, germicide production Dialysate Bacteria (CFU/ml) 200 / 50 action level 200 / 50 action level Endotoxin (EU/ml) 2 / 1 action level 2 / 1 action level Minimum Frequency Monthly Monthly

41 Dialysate Quality for Hemodialysis Standard (AAMIRD52) Standard (EDTA- ERA BPG) Standard (Swedish Pharmocopoeia) Bacteria (cfu/ml) Allowable Level Endotoxin (EU/ml) <200 <2 <100 <0.25 <100 <0.25 Ultrapure <0.1 <0.03 Sterile 10-6 <0.03

42 *Distribution/Loop System *Central systems at least once a month *Disinfects water inlet line to hemodialysis machines *Portables *Dialysis Machines *Daily OP *Acute setting *Bicarbonate mixing systems *daily rinse *Weekly disinfect *Individual bicarbonate concentrate containers *should rinsed and inverted to drain at end of each day *disinfected weekly

43 *Culture media should be trypticase soy agar (TSA) or equivalent *No blood or chocolate agar *Incubate at o C for 48 hours *May want to go to 72 hours *Count colonies with a magnifying device *Shall not exceed 200 cfu/ml / 50 cfu action level

44 *Collected during or at the termination of dialysis at or beyond the point where the dialysate leaves the hemodialyzer. *AAMI: Two machines per month *Each machine at least once annually *The total viable bacteria count shall not exceed 200 cfu/ml.

45 *V178 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.

46 *By-products of water-borne gram negative bacteria *Reside in the cell wall *Released when the bacteria dies *Enter bloodstream *Build-up in Reprocessed Hemodialyzers *Back Diffusion* *Back Filtration* *Sense Bacteria/Endotoxin

47 *Do disinfect the ports with LAL testing *<2 EU *> 1EU action level *Current testing can be done in-center *Perform a control with each batch of tests *Outside labs usually require freezing or refrigerated specimen and have better sensitivities *Frequency *monthly *If suspected endotoxin reaction

48 *Malnutrition *Low albumin *Muscle protein wasting *Protein catabolism *Increased CRP *Atherosclerosis *Low cholesterol synthesis *Increased ferritinlevels *Resistance to EPO therapy *Bone disease, cysts, fractures *Sleep disorders *Antiendotoxinantibodies

49 *Improper water treatment system design *Loop *Holding tanks *UV/Ultrafilters *Improper maintenance of water treatment system and delivery system (dialysis machine) *Disinfection schedule *Improper disinfectant

50 A 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.