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Infection Control in CKD A Culture of Safety Leona Dinnan, RN, CDN Slide 2 Objectives Identify Infection Control Practices Required in the dialysis environment Introduction of the ESRD Condition for Coverage (CfC): Infection Control Identify 5 major routes of infection transmission in dialysis Understand NHSN: Definition of Dialysis Event Slide 3 Functions of the Normal Kidney The 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 Slide 4 KDOQI Stages of Kidney Disease StageGFRDescriptionTreatment1 190+Normal kidney function findings point to kidney disease Observation, control of blood pressure 260-89Mildly reduced kidney function Observation, control of blood pressure and risk factors 3A 3B 45-59 30-44 Moderately reduced kidney function Observation control of blood pressure and risk factors 415-29Severely reduced kidney function Planning for End stage renal failure 5 Why Hand Hygiene & Surface Disinfection Are Vital Organisms remain viable on surfaces for prolonged periods Hepatitis B>1 week Influenza1-2 days MRSA7 days to 7 months VRE5 days to 4 months C. difficile spore5 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, 2011 Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006 Slide 17 Providing a Culture of Safety Education Self Assessment & Surveillance Regulatory Reviews Slide 18 ESRD Regulation Timeline 1976: First ESRD regulations published 70s-90s: Technical updates 1994: Community Forum Meeting to begin complete rewrite of ESRD regulations April 2008: New ESRD regulations published September 2008: New ESRD Interpretive Guidelines Slide 19 Infection Control From two tags to a separate Condition (29 tags) Adopts CDCs 2001 Recommendations for Prevention of Infections in Hemodialysis CDCs 2002 Guidelines for the Prevention of Catheter-Related Infections Slide 20 Conditions for Coverage 494.30 V111-V148 The 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 Slide 21 Potential Infection Transmission Route #1: On the Hands of the Staff Wear gloves, perform hand hygiene (HH) (V113) Sufficient number of sinks w/warm H 2 O & soap (V114) Locations listed in IG PPE appropriate to task (V115) 21 Slide 22 Route #2: Ineffectively Disinfected Equipment & Surfaces Cleaning & disinfecting contaminated surfaces & equipment (V122) HD machine transducer protectors changed when wet (V120) 22 Slide 23 Route #3: Contaminated Supplies & Medications Clean and dirty areas designated and (V117)-for supplies and medications Supply carts (V119) Kept sufficient distance from dialysis stations Not moved between stations Staff do not keep supplies in pockets Items taken to dialysis station are disposed, dedicated, or disinfected before use on another patient (V116) 23 Slide 24 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 Slide 25 Route #4: Inadequate Vascular Access Care CVC access and care to prevent contamination (V147) Monitor CVC-related blood stream infections (CLABSIs) (V148) 25 Slide 26 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+ patients Isolation room/area or waiver (V128-129)-use your tan laminate! Dedicate ALL equipment to isolation (V130) Staffing-protect susceptible patients (V131) 26 Slide 27 NHSN Outpatient dialysis facilities report "Dialysis Events" to the CDC through NHSN. Slide 28 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 Slide 29 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 Slide 30 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 Slide 31 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. Slide 32 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 Slide 33 Thank You