Tackling the high risk of infection in dialysis patients

Infection control standards in a dialysis facility

Statement on nephrologists, other physicians, surgeons, and advanced practitioners with regard to compliance with infection control standards

Infection in the most frequent reason for hospitalization in the end-stage renal disease patient, according to the U.S. Renal Data System’s 2013 report. It accounts for the largest number of hospitalization days, and infection remains the second leading cause of death for patients with ESRD.

Chronic hemodialysis patients are particularly at risk for infection because direct vascular access is needed to successfully complete the dialysis process. In the typical dialysis facility where multiple patients receive dialysis concurrently, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel.

In this statement we have focused on the hands and outerwear of the nephrologist. We believe that the medical director and attending nephrologist should lead by example in the effort of infection control and should not have behavior or hygiene standards that differ from other clinical staff.

It is our collective opinion that this Guide for the Physicians and Physician Extenders in the Dialysis Setting should be implemented as follows:

Hand hygiene basics

Hand hygiene includes either the use of anti-microbial soap and water or an alcohol-based hand rub.

Alcohol-based hand rubs may be used before gloving and after glove removalifthe gloves had not been exposed to blood or other potentially infectious materials.

Use anti-microbial soap and water (not hand gels) after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus).

It is recommended that all clinicians (physicians, NPs, PAs, physician extenders) providing services in the facilities do not wear artificial fingernails.

When entering treatment area

Perform hand hygiene

Put on a disposable impermeable gown(buttoned, impermeable and long sleeved), as a preference

As a compromise, a clean and fresh unsoiled non-disposable, buttoned, long sleeve lab coats may be worn if they are impermeable and have not been in other clinical environments. When the risk of exposure is low, and there will be no patient or equipment contact, a clean fresh white gown that does not leave the premises may be worn as an alternative. Disposable gowns may not be re-used, while clean white gowns must be cleaned (or substituted for) should they become soiled. The physician and advanced practitioners should follow the guidelines for all other clinical personnel who are in that specific facility. If the facility policy is to wear disposable impermeable gowns for patient care technicians and nurses, then the physician should do the same.

During rounds

Perform hand hygiene between each patient

Gloves are not required for routine examination of patients; however, gloves should be wornwhile performing procedures that have the potential for exposure to blood, dialysate and other potentially infectious substances. This would include when physically examining the patient's access or touching any patient equipment at the dialysis station.

Change gloves and complete hand hygiene:

between dialysis patients

if gloves are soiled with blood or other body fluids

when moving from a “dirty” task to a “clean” task

Clean stethoscope between dialysis patients with an alcohol prep pad

Stethoscopes that are visibly contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution. Furthermore, they should be cleaned between patients

Do not perform a dressing change except for vascular access care

Change gown after caring for an infectious patient (e.g. C Diff or HBV)

When leaving treatment area

Remove gown and dispose

Complete hand hygiene

Commentary

It was our collected opinion that the treating physician should not only follow the above guidelines but should be a model of compliance with infection control practices for the staff of the facility. In addition, failure of a physician to follow these guidelines in the dialysis facility should be noted by either the Facility Administrator or the Charge Nurse and pointed out to the physician in a private setting. There should not be any retribution or negative consequences for these staff members from the physician as a result of their communication on this issue. Any breach of this by the physician should be reported to the Governing Body to be dealt with appropriately. -by Don Williamson, MD and Stan Lindenfeld, MD

About this series

Three years ago, the Chief Medical Officers from 13 dialysis providers met to share common issues about patient outcomes: successes and area for improvement. A commitment to share clinical and facility level approaches to issues, protocols, and policies, even data, grew out of this initial meeting. Since that time there have been two national meetings attended by the CMOs and their operational teams and enormous collaboration has taken place to improve patient satisfaction and quality of dialysis. We have had monthly calls, including separate calls by operations teams, to enhance the experience of the patient undergoing dialytic therapy. This is not about the business of the dialysis provider. It is about the quality of patient care.

There is a commitment to address issues such as the catheter rate, hospitalizations and rehospitalizations, the quality of the intradialytic experience, infection prevention, morbidity and mortality, and which quality measures and processes really make a difference in the welfare of patients.

Additionally, the CMO group has had several meetings with various agencies within the Centers for Medicare & Medicaid Services, and has acted as a resource to the advocacy groups Kidney Care Council and Kidney Care Partners. But the primary purpose has been to have an informal discussion and sharing of ideas among colleagues who have agreed that acting together can have a unique impact on patient outcomes through collaboration.

The three documents published in the January, February and now in this issue of Nephrology News & Issues represent agreements by the undersigned CMOs and their providers to address change that will impact key clinical conditions of patients within their respective dialysis facilities. We believe that we cannot necessarily always await to act for an evidence-based process. When the preponderance of evidence suggests that action must be taken, then we are prepared to respond. Improving hand hygiene, this month’s topic, follows our first paper published in January on the risks of the buttonhole access technique.

Working together, we believe that we can make a change in our patients’ dialysis experience and, most importantly, their survival.

Tom Parker, III, MD

Find more CMO Intititave articles

Resources

U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013.

Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001;50(No. RR-5):1-41.

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR- 16):1-45.

What to do about C. difficile, MRSA, and other MDROs Page 2 of 14 Infection Control and Prevention for Outpatient Clinics/Offices June 2012

ESRD basic Technical Surveyor Training, ESRD FAQs Version 1.3; Centers for Medicare & Medicaid Services Version 1.2 Pages 2-4.

ESRD Surveyor Training Interpretive Guidance, Interim Final Version 1.1 October 3, 2008:5-32