The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
In 2007, there were 368,544 U.S. residents with end-stage renal disease (ESRD) that received hemodialysis. A majority of these patients (338,265) are served in the ambulatory hemodialysis setting. According to the Centers for Disease Control and Prevention (CDC), there were 37,000 central line-associated bloodstream infections (CLABSIs) in 2008 and more than thirty outbreaks of hepatitis B and hepatitis C in dialysis centers, outpatient clinics, and long-term care facilities. Patients with ESRD who receive maintenance hemodialysis are at higher risk of infection due to their compromised immune systems and frequent healthcare procedures, including directly accessing the bloodstream to perform dialysis treatments. These patients experience frequent hospitalizations for bloodstream infections that require extended antibiotic treatment, and sometimes necessitate the removal of their vascular access devices. Due to frequent healthcare contact and the invasiveness of hemodialysis, infection prevention becomes extremely important for hemodialysis settings. Pathogens of importance in this environment include MRSA, non-resistant Staphylococcus aureus, bloodborne pathogens including hepatitis B (HBV), and others, such as, Clostridium difficile and influenza.
As the person responsible for infection prevention in the hemodialysis setting, your understanding of infection prevention is critical to your patient's safety. It's vital to understand the actions and procedures in hemodialysis settings that put patients at greatest risk for acquiring infections. Infection risks specific to dialysis settings include the common unit design in which patients are treated in close proximity to one another by the same shared staff. Additional dialysis-specific infection risk factors include, multiple patient co-morbidities, invasiveness of the procedures performed, and complex equipment used. All infection risk factors must be considered when performing site assessments, planning and providing staff education, and executing prevention strategies to safeguard the patient and staff.
Key infection prevention principles and practices designed to reduce the risk of healthcare-associated infections in the dialysis setting include adherence to standard and transmission-based precautions; hand hygiene; environmental and equipment cleaning and disinfection; aseptic technique during insertion, access and care of vascular access devices; and safe injection practices. Transmission-based precautions for this specialized setting must include HBV isolation precautions. Other key components of infection prevention programs in this setting include appropriate water treatment and testing, patient and employee immunizations and TB screening, pre-surgical infection prevention, and surveillance of dialysis-related infections.
Environmental Cleaning and Disinfection
Many organisms can survive on contaminated environmental surfaces for days or months including: multidrug-resistant organisms such as MRSA, Clostridium difficile, Acinetobacter baumannii, and HBV. Contaminated healthcare worker hands can also be involved in transmission of these organisms. Similarly soiled equipment can transmit organisms from patient to patient. Using an Environmental Protection Agency (EPA) registered healthcare disinfectant with friction to the surface will remove the soil (clean) and kill the organisms (disinfection). If there is no visible soil on the surface, a one-step (wiping surface with cleaner/disinfectant) process is adequate to both clean and disinfect the surface. If soil is visible, then a two-step method is recommended (clean first, discard wipe, wipe surface again with fresh wipe and let air dry). In all situations, immediately clean any visibly soiled surfaces, and always clean the entire patient zone between patients (any surface touched by dialysis staff and/or patient).
Equipment Cleaning and Disinfection
Use the same principles for cleaning and disinfecting equipment as you would for environmental surfaces. Blood pressure cuffs, stethoscopes, scissors, clamps and other equipment used during the patient visit should be cleaned/disinfected before use on another patient.
Non-disposable equipment (blood pressure cuffs, stethoscopes) should be wiped down with a disinfectant wipe and allowed to dry before use on another patient. Blood pressure cuffs should be cleaned first with detergent and water when soiled.
Non-disposable instruments (scissors, clamps) that have no contact with blood, sterile tissue, or mucous membranes should be submerged in an enzymatic detergent, thoroughly cleaned, and rinsed. After cleaning these instruments, disinfect them according to the manufacturer's instructions. They can also be sent to a Sterile Processing Department, if available.
Hemodialysis equipment such as hemodialysis machines, dialyzers, water supply/treatment/distribution systems, and other components need to be cleaned/disinfected between patient uses or discarded if "disposable/single use" (per manufacturer's instructions and facility policy).
Hand hygiene is essential in preventing contamination of the patient and equipment, and the acquisition of healthcare-associated infections. Alcohol-based hand sanitizers (60 percent or greater of alcohol) should be used preferentially for all hand hygiene except when hands are visibly soiled. Soap and water must be used when hands are soiled or visibly dirty. The most critical time for hand hygiene is before and after touching the patient. It is also important to clean hands before putting on gloves, after glove removal, and before touching clean and sterile supplies. Artificial nails can harbor microorganisms that can contaminate whatever is touched, even if hand hygiene is performed. Intact nail polish is acceptable, but natural nails should be no longer than ¼ inch long. If the nails can be seen over the top of the fingertips, they are too long.
Personal Protective Equipment
Gloves must be worn whenever caring for a patient, touching the hemodialysis equipment, cleaning the environment or equipment and handling specimens. Gloves should be changed between patients and between clean and dirty functions to prevent cross contamination. Sterile disposable gloves are used for procedures requiring aseptic technique. Gloves must be changed after cannulation.
Masks prevent transmission of respiratory droplets between patients and staff. They also protect staff from exposure of staff to blood splash or spray during the dialysis procedure. Masks must be worn by coughing patients/staff. Masks with eye protection (goggles/face shield) must be worn by staff during initiation and discontinuation of dialysis; during reprocessing of re-usable dialyzers; cleaning equipment in a sink; and by staff who are within 6 feet of an unmasked coughing patient.
Fluid-resistant lab coats are worn as per facility policy for patient care and equipment cleaning. Fluid-resistant long sleeved gowns are used during care of a patient in isolation (HBV, draining wound, diarrhea).
Immunizations to communicable diseases, including flu and HBV, protect staff and patients and should be current. It is important to have both staff and patient immunization records to identify follow up procedures when a communicable disease exposure occurs.
Aseptic technique during cannulation/decannulation and the use of an antimicrobial ointment at the dialysis catheter insertion site helps minimize the risk of bloodstream infections. Prevention of infection always requires a bundle of strategies consistently and appropriately performed at key times to prevent the indirect and direct transmission of organisms. Dialysis settings offer many opportunities to protect the patient and staff from exposure to contamination and acquisition of microorganisms that could cause infection. The consistent application of infection prevention principles and practices in the dialysis setting helps assure the protection of the patient and staff.
1. USRDS 2009 Annual Data Report. United States Renal Data System Website. www.usrds.org/adr.htm. Accessed November 10, 2009. (The USRDS End-Stage Renal Disease Incident and Prevalent Quarterly Update is available at www.usrds.org/qtr/qrt_report_table_c_ Q1_09.html.)
2. APIC Elimination Guide: Guide to the Elimination of Infections in Hemodialysis. 2010 http://www.apic.org/AM/Template.cfm?Section=APIC_Elimination_Guides&Template=/CM/HTMLDisplay.cfm&ContentID=17590.
3. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001;50(RR-5):1–43.