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Infection Control in CKD. A Culture of Safety Leona Dinnan , RN, CDN. Objectives. Identify Infection Control Practices Required in the dialysis environment Introduction of the ESRD Condition for Coverage ( CfC ): Infection Control - PowerPoint PPT Presentation
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Infection Control in CKD
A Culture of Safety
Leona Dinnan, RN, CDN
ObjectivesIdentify Infection Control Practices
Required in the dialysis environmentIntroduction of the ESRD Condition for
Coverage (CfC): Infection ControlIdentify 5 major routes of infection
transmission in dialysisUnderstand NHSN: Definition of
Dialysis Event
Functions of the Normal KidneyThe kidney's◦Regulate body chemistry◦Regulate body water (BP)◦Remove the end products of metabolism◦Remove products not utilized by the body◦Aides in the production of Red Blood Cells
KDOQI Stages of Kidney DiseaseStage GFR Description Treatment11 90+ Normal kidney function
findings point to kidney disease
Observation, control of blood pressure
2 60-89 Mildly reduced kidney function
Observation, control of blood pressure and risk factors
3A3B
45-5930-44
Moderately reduced kidney function
Observation control of blood pressure and risk factors
4 15-29 Severely reduced kidney function
Planning for End stage renal failure
5 <15 or on dialysis
Very severe or end stage kidney failure
Treatment choices
Population with CKD The incidence of recognized CKD in people ages 65 and older
more than doubled between 2000 and 2008.
One in 10 American adults, more than 20 million, have some level of CKD.
At the end of 2009, more than 871,000 people were being treated for ESRD.
Between 1980 and 2009, the prevalent rate for ESRD increased nearly 600 percent, from 290 to 1,738 cases per million.
United States Renal Data System’s 2010 Annual Data Report and 2011 Annual Data Report.
FactsIncreased risk of infection related
hospitalization found in individuals with early stages of Kidney disease
Stage 3 & 4 patients had an 80 percent more at risk for pulmonary infection like pneumonia compared to participants with normal renal function
March American journal of Kidney Diseases
DialysisDialysis is a Greek word meaning
"loosing from something"
Hemo:Blood
Peritoneum: The serous membrane that lines the walls of the abdominal cavity and folds inward to enclose the viscera
Dialysis
Access for DialysisWith hemodialysis we access the blood
through an A/V Fistula, Graft, or Catheter
Peritoneal dialysis we access the blood vessels through the peritoneal cavity using a Tenckhoff catheter.
National Burden of Dialysis Infections
In the US, there are about370,000 people relying on hemodialysis
About 75,000 people receive hemodialysis through a central line
Central lines have a higher risk of infection than a fistula or graft
CDC estimates 37,000 central line-associated bloodstream infections may have occurred in U.S. hemodialysis patients in 2008
A Cause for Concern
Infections in Dialysis PatientsBloodstream infections are a dangerous complication
of dialysis1 in 4 patients who get a
bloodstream infection caused byS. aureus (staph) bacteria can facecomplications such as:◦ Endocarditis (infected heart valve)◦ Osteomyelitis (infected bone)
Total costs for each infection can be more than $20,000Bloodstream infections can cause sepsis (a potentially
deadly condition)Up to 1 in 5 patients with an infection die within 12
weeks
Infections: A Major Patient Safety Problem in Dialysis – 2nd Leading
Cause Of Death
12
UM-KECC, 2009
Approximately 15,000 dialysis patients die annually due to infections
The “Perfect Storm” in Hemodialysis
High risk for spread of blood-borne and
other pathogens
Staff caring for multiple
patients
Short “changeover”
times
Lots of potential
blood exposure
13
ESRD patients are immunosuppressed
How Are Infections Spread in Dialysis?
Five potential “routes” 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
14
How Are Infections Spread in Dialysis? (cont.)4. From inadequate vascular access care
Vascular access is the primary portal for dialysis patient infections Central Venous Catheters (CVC) have 7 times higher infection rates than AV fistula (AVF)
5. From virulent pathogens Hepatitis B virus remains viable and transmittable
for at least 7 days on surfaces In 1974 6.2% of hemodialysis patients acquired
hepatitis B-some facilities had as high as 30% HBV+
15
Why Hand Hygiene & Surface Disinfection Are Vital
Organisms remain viable on surfaces for prolonged periods
• Hepatitis B >1 week• Influenza 1-2 days• MRSA 7 days to 7 months• VRE 5 days to 4 months• C. difficile spore 5 months
16
Healthcare workers touch as many as 7 surfaces after touching a contaminated one!
McLaughlin AC, Walsh F. Am J Infect Control 39(6):456-463, 2011Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006
Providing a Culture of Safety
Education
Self Assessment & Surveillance
Regulatory Reviews
ESRD Regulation Timeline1976: First ESRD regulations published70’s-90’s: Technical updates1994: Community Forum Meeting to begin
complete rewrite of ESRD regulationsApril 2008: New ESRD regulations
publishedSeptember 2008: New ESRD Interpretive
Guidelines
Infection ControlFrom two tags to a separate
Condition (29 tags)Adopts ◦CDC’s 2001 Recommendations for
Prevention of Infections in Hemodialysis ◦CDC’s 2002 Guidelines for the
Prevention of Catheter-Related Infections
Conditions for Coverage494.30
V111-V148The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas
Potential Infection Transmission “Route” #1: On the Hands of the Staff
Wear gloves, perform hand hygiene (HH) (V113)
Sufficient number of sinks w/warm H2O & soap (V114) Locations listed in IG
PPE appropriate to task (V115)
21
“Route” #2: Ineffectively Disinfected Equipment & Surfaces
Cleaning & disinfecting contaminated surfaces & equipment (V122)
HD machine transducer protectors changed when wet (V120)
22
“Route” #3: Contaminated Supplies & Medications
Clean and dirty areas designated and (V117)-for supplies and medications
Supply carts (V119)Kept sufficient distance from dialysis
stationsNot moved between stationsStaff do not keep supplies in pockets
Items taken to dialysis station are disposed, dedicated, or disinfected before use on another patient (V116)
23
“Route” #3: Contaminated Supplies & Medications (cont.)
Medications prepared in clean area away from dialysis stations (V117)
Single use vials and solution bags used for one patient only (V118)
Staff adhere to aseptic techniques for medication administration (V143)
24
“Route” #4: Inadequate Vascular Access Care
CVC access and care to prevent contamination (V147)
Monitor CVC-related blood stream infections (CLABSIs) (V148)
25
“Route” #5: Virulent Pathogens
Surveillance of patients’ HBV status prior to admission and ongoing (V124)
Vaccination of all susceptible patients & staff (V126)
Isolation of HBV+ patientsIsolation room/area or waiver (V128-129)-use your tan
laminate!Dedicate ALL equipment to isolation (V130)Staffing-protect susceptible patients (V131)
26
NHSN
Outpatient dialysis facilities report "Dialysis Events" to the CDC through NHSN.
Dialysis Event Type: IV Antimicrobial Start
Report all outpatient intravenous antibiotic and antifungal starts regardless of the reason for treatment and regardless of duration of treatment Include starts unrelated to vascular access problems Report outpatient starts that are continuations of inpatient
treatment Report all IV antibiotic starts, not just vancomycin Do not report IV antiviral starts
Dialysis Event Type: Positive Blood Culture
Report all positive blood cultures collected as an outpatient or collected within 1 calendar day after a hospital admission or ER visit Even if the patient does not receive treatment Even if the infection is not related to dialysis
Dialysis Event Type: Pus, Redness or Increased Swelling at the Vascular Access Site
Report each new outpatient episode of pus, greater than expected redness or greater than expected swelling at a vascular access site Even if the patient does not receive treatment Always report pus Report redness or swelling if they are more than expected and
suspicious for infection
Additional Information: Dialysis Event Combinations A Dialysis Event report may have multiple parts,
combining: IV antimicrobial start Positive blood culture Pus, redness or increased swelling at vascular access site
For example, if a positive blood culture is the reason that a patient is treated with IV antimicrobials, this is part of the same group of events and they are reported together.
Quality
Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”
William A. Foster
Thank You