Dialysis-Associated Infections

 
Infection Control: New Challenges Under the New Conditions slide presentation is also available for download. PDF (1.15 MB / 60 slides)

Slide 1
Infection Control: New Challenges Under the New Conditions
Priti R. Patel, MD, MPH
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
October 21, 2008
The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Slide 2
New Conditions

  • April 2008 – CMS released new conditions for coverage for ESRD facilities
  • First update since 1976
  • Incorporates CDC infection control recommendations:
    • 2001 Dialysis Recommendations
    • 2002 Catheter Guidelines
  • CDC had input into the interpretive guidance

Slide 3
What’s New in ESRD: CMS Process

  • Conditions for Coverage
  • Interpretive Guidance

New conditions in effect as of October 14, 2008

Slide 4
Outline

  • Medical Director Role
  • What’s new – items to be aware of
  • Building an Infection Control Program

Slide 5
Role of the Medical Director

  • Responsible for receiving all reports of infection control issues
  • Familiar with the infection control program, be able to provide specifics
  • Participate in QAPI meetings
  • Review infection control issues (“continuously reported and discussed”), surveillance reports, identify problems
  • Document action taken in response
  • Report infections and adverse event clusters to public health -- Transparency

Slide 6 & 7
New Items

  • Hepatitis B isolation
  • Medication handling & use
  • Environmental cleaning & disinfection
  • Hand hygiene & glove use
  • Routine serologic testing
  • Immunizations
  • Training & education
  • Surveillance

Slide 8
Hepatitis B

Slide 9
HBV Infection among Hemodialysis Patients

  • Prevalence has declined dramatically due to:
    • Infection control & isolation practices
    • Vaccination
  • Extra precautions
    • Infected persons can have high viral concentrations in blood
    • HBV can survive at room temperature on surfaces for at least 7 days
    • Hepatitis B surface antigen detected on clamps, scissors, machine control knobs
    • Can be transferred to patients via contaminated hands (gloved or ungloved), medications, equipment, and supplies

Slide 10
Prevention of HBV Transmission in Dialysis Setting
Recommendations

  • Isolate HBsAg positive patients in separate room
    • Dedicated staff
    • Dedicated equipment
    • Dialyzers should not be re-used
  • Conduct surveillance for HBV infection
  • Separate supplies for each patient (regardless of status)
  • Cleaning/disinfection of non-disposable items
  • Glove use
  • Routine cleaning/disinfection of equipment and surfaces

Slide 11
New in the Conditions

  • Hepatitis B isolation
    • New facilities must have a room
    • Existing facilities may have an area: must be separated by at least width of 1 dialysis station from adjacent stations
  • No patient “buffer”
  • Patients that require a booster dose of Hep B vaccine not eligible to be cared for by HCW treating HBsAg+ patient

Slide 12
Modified Contact Precautions

Slide 13
Criteria for Additional Precautions

  • Additional precautions for patients at increased risk of transmitting pathogenic bacteria
  • Criteria:
    • Infected skin wound with drainage not contained by dressings
    • Fecal incontinence or diarrhea uncontrolled with personal hygiene measures
    • Regardless of pathogen (need not be drug resistant)

Slide 14
Precautions to Prevent Bacterial Transmission

  • Additional precautions for patients at increased risk of transmitting pathogenic bacteria
  • Precautions:
    • Wear a separate gown over clothing and remove gown when finished caring for the patient
    • Dialyze the patient at a station with as few adjacent stations as possible (e.g., at end or corner of unit)

Slide 15
Precautions in Outpatient Dialysis
Separate gown anytime likely to come in contact with patient or equipment at their station
Contain drainage or use additional precautions

Slide 16
Hand Hygiene

  • Process
    • Hand hygiene should be performed frequently
    • Prior to contact with vascular access
    • Glove change in between tasks at the HD station
      • dialysate is not a sterile fluid
  • Structure
    • Designate hand hygiene sinks distinct from utility sinks

Slide 17
Environmental Cleaning & Disinfection of the Station

  • Separated from patient care processes
  • Must be performed for adequate amount of time and with no patient at the station
  • Process:
    • Patient# 1 completes treatment, leaves station
    • Station is cleaned & disinfected (no patient present)
    • Patient# 2 enters station
  • Proper cleaning / disinfection of surfaces, priming buckets, etc.

Slide 18
Why?

  • Lack of patient-free period between shifts associated with HCV outbreaks
  • KDIGO: “Unit should ensure that there is enough time between shifts for effective decontamination of the exterior of the machine and other shared surfaces”1
  • Patient privacy concerns
  • Patient should not be exposed to bleach or other disinfectant solution

Slide 19
One-way Flow of Supplies

  • No return of supplies
  • No transfer of supplies from one station to another
  • No mobile carts

Slide 20
Supplies
Items taken into a station:

  • Dedicated for use on only a single patient at that station
  • Disposed of
  • Cleaned and disinfected before taken to a common area or used on another patient

Slide 21
Medication Vials

  • Multidose vials
    • Have preservative to prevent bacterial growth (preservative has no impact on HBV, HCV)
  • Single dose vials
    • No preservative
    • Pooling of medications caused outbreak of Serratia bloodstream infections

Slide 22
What’s New When it Comes to Single Dose Medication Vials?

  • “Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed.”
  • Multidose vials should be dedicated for one patient whenever possible
  • No pooling meds
  • Medications should be drawn at the time of use

BEST PRACTICE
one vial, one patient; no re-entry or re-use

Slide 23
Where is this Documented?
MMWR August 15, 2008 / 57(32);875-876
Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials

Slide 24
Options

  • Medications in prepackaged, pre-filled syringes
  • Single dose vial for single patient
  • Multidose vial for single patient
  • Multidose vial for > 1 patient

Slide 25 & 26
Safety of Medication Strategies

  • Less opportunity for contamination
    • Prefilled syringes
    • Single vial for single patient
  • Greater caution required
    • Multidose vial for >1 patient
All medications must be prepared in a separate clean area to ensure they do not become contaminated

Slide 27 & 28
Safety of Medication Strategies

  • Engineering controls
    • Separate medication clean room
  • Greater caution required
    • Medication preparation performed in patient treatment area
Nothing else stored or handled in or near the area; no contaminated items

Slide 29 & 30
Image of news headlines

Slide 31 & 32
Private Medical Practice: New York City, 2001
Image of Injection Preparation and Disposal site
Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded

Slide 33
Injection Preparation Table, Pakistan
image of medical prep area

Slide 34
What else can be done to make medication administration safer?

  • Reduce frequency of medication administration
  • Utilize a standard dose, or standard set of patient doses
  • Rational dose packaging
  • Align cost structure / incentives with best practice

Slide 35
The Facility Must

  • Implement a comprehensive infection control program:
    • Routine serologic testing
    • Immunization
    • Training & education Surveillance

Slide 36
Hepatitis C Virus Infections in Dialysis

  • Prevalence: 8-10%
    • (1.6% in general popn)
  • Majority of infections are asymptomatic; majority develop chronic infection
  • Isolation is not recommended, no vaccine
  • Prevention requires strict attention to infection control practices

Slide 37
Schedule for Routine HBV & HCV Testing

  On admission Monthly Semi-annual Annual
All patients HBsAg
Anti-HBs
Total-anti-HBc
Anti-HCV
ALT		      
HBV-susceptible   HBsAg    
Anti-HBs = 10, anti-HBc (-)       Anti-HBs
Anti-HBs (+), anti-HBc (+)   No additional HBV testing needed
HCV-susceptible   ALT Anti-HCV  

Slide 38
HBV / HCV Testing

  • HBV Testing
    • Required by CMS
    • Check total anti-HBc on admission
  • HCV Testing
    • Not required or reimbursed by CMS
    • Only realistic way to identify transmission and rectify incorrect practices
    • Consider testing on admission, and annually (or with some regular frequency)
Must review and act upon results in a timely manner

Slide 39
HCV Outbreaks, 1998-2006

  % of patients with chronic HCV infection % of susceptible patients that became newly infected
Maryland, 1998 22% 17.5%
Ohio, 2000 36% 8.2%
Wisconsin, 2000 4% 13%
Virginia, 2006 19% 13%

Slide 40
Immunization: Administration and Tracking

  • Hepatitis B
    • All patients, all staff
  • Influenza yearly
    • All patients, all staff
  • Pneumococcal
    • All patients

Slide 41
Catheter Care Training & Education

  • Study of catheter care practices and policies in dialysis facilities
    • compared those facilities with low vs. high BSI rate
  • Most facilities (78%) required training only one time for staff who perform catheter care
  • Facilities with low BSI rate required more weeks of training compared to facilities with high BSI rate (median: 9.7 vs. 6.2 weeks)
Patel P. Evaluation of Catheter Care Practices in Hemodialysis Centers. SHEA Annual Conference, April 2008. Orlando, FL.

Slide 42
Infection Control Training & Education

  • Have an initial and ongoing training program
  • Frequency: upon employment and at least annually thereafter
  • Required content areas are specified
  • Consider the depth & adequacy of training
  • Periodic practice audits
  • Patient education

Slide 43
Quality Improvement: Monitoring Facility Data

  • Conduct surveillance to determine infection rates, monitor trends in those rates, and assist in identifying lapses in infection control practices
  • A log or other tracking mechanism, such as the Dialysis Module of the National Healthcare Safety Network (NHSN) should be used
  • Surveillance data
    • Bloodstream infection rates
    • Culture and susceptibility
    • Hepatitis B & C testing
    • Water testing
    • Immunization rates

Slide 44
Dialysis surveillance in the National Healthcare Safety Network (NHSN) is now open for enrollment.

Slide 45
What can surveillance do for outpatient dialysis centers?

  • Identify areas for follow-up and prevention
  • Compare data with other centers
  • Report to stakeholders
    • Data available for analysis
    • Routine and custom reports

Slide 46
Dialysis Protocol Brief

Population Chronic hemodialysis outpatients
Numerator Complete form for each dialysis event
  • Hospitalization
  • Outpatient IV antimicrobial start
  • Positive blood culture
Denominator
  • Number of dialysis outpatients on the first 2 working days of the month
  • Stratified by 5 types of vascular access

Slide 47
NHSN uses the CDC Secure Data Network
[screen capture]

Slide 48
Real-time Analyses

  • Line listings
  • Rate tables
    • Infections stratified by vascular access type
    • Hospital incidents
    • Antibiotic starts
  • Control charts
Analysis training available

Slide 49
Standard Analysis Option Screen for Dialysis Event Surveillance
[screen capture]

Slide 50
How Event (Numerator) and Denominator Come Together
Klevens, Tokars, Andrus. Nephrology News and Issues June 2005

Slide 51
Rates of Bacteremia by Access Type - Dialysis Surveillance Network, Sep 1999 - Mar 2005
Bar chart: the rate of access-associated bacteremia was 1.78 per 100 patient-months overall shown by the red line, but there was substantial variation by vascular access type: 0.3 for fistulas, 0.7 for grafts, 4.6 for cuffed catheters, and 7.3 for noncuffed catheters. That means, that on average, 7.3% of patients with a noncuffed catheter had a bloodstream infection each month.

Slide 52 & 53
UK Experience

  • Busy London dialysis unit: 112 patients
  • Implemented CDC dialysis surveillance; described their experience over 18 months
  • After initial set up, required 2 hours per month
  • Maintained compliance with surveillance
  • Outcomes: Reductions in
    • Access related bacteremia
    • Antibiotic usage
    • Hospital admissions
  • “Surveillance raised awareness and provided a cornerstone for improved infection control and line care involving all staff of the dialysis unit.”
  • “The data feedback generated unit led programmes of risk reduction and infection control.”
  • “…should be part of quality care and risk management activity for all dialysis units.”
George A, Tokars JI, Clutterbuck EJ, et al. Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study. BMJ 2006; 332:1435-1439.

Slide 54
Reducing BSI rates in ICUs
Source: MMWR 2005;54:1013-6.

Slide 55
NHSN Support

  • Online help messages within NHSN
  • Email: nhsn@cdc.gov
  • http://www.cdc.gov/ncidod/dhqp/nhsn.html

Slide 56
Safety of Medication Strategies

  • Discuss surveillance requirements
  • Address measures on the Measures Assessment Tool
    • Vascular access
    • Infection control
    • Vaccinations

Slide 57
The Medical Director Should

  • Promote a culture of patient safety and healthcare worker safety within the facility
    • Be a champion for positive change, enlist others
    • Do staff understand the importance of infection prevention?
    • Is it communicated as a facility priority?

Slide 58
The Medical Director Should

  • Consider ways to assess and improve practices & utilize available resources:
    • Partner with infection control professional (ICP) in affiliated healthcare system
    • Use the Network, engage independent consultants, and public health
    • Develop local infection control expertise: APIC meeting attendance, etc.
    • Assign a team to perform infection control audits
    • Provide feedback to the staff – surveillance data, immunization rates, audit results

Slide 59
PREVENTION IS PRIMARY!
Visit CDC DHQP website - http://www.cdc.gov/ncidod/dhqp/dpac_dialysis_pc.html
Thank you!
“The greatest challenge to any thinker is stating the problem in a way that will allow a solution”
– Bertrand Russell

 

 

Date last modified: April 20, 2009
Division of Healthcare Quality Promotion (DHQP)
National Center for Preparedness, Detection, and Control of Infectious Diseases