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Antiseptic Use in HemodialysisManitoba Renal Program

November 2016

Kathy McGhie RN, BScN, CIC



Centre for Disease Control (CDC) Dialysis Collaborative17 Facilities reporting to National Healthcare Safety Network (NHSN)

Core Interventions1

1.Surveillance & feedback using NHSN;

2.Hand hygiene observations;

3.Catheter/vascular access care observations;

4.Staff education & competency;

5.Patient education/engagement;

6.Catheter reduction –Identified & addressed barriers to permanent access;

7.Chlorhexidine for skin antisepsis;

8.Catheter hub disinfection;

9.Antimicrobial ointment to catheter exit sites with dressing change.

54%54%54%54% Reduction

in access related bloodstream infections2

37,000Bloodstream

infections every year2

1.CDC.Dialysis Bloodstream Infection (BSI) Prevention Collaborative. http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html2.Patel PR, Yi SH, Booth S, et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis. 2013;62:322-330


© 3M 2015. All Rights Reserved 3

Hemodialysis Patients

Why are they at high risk?• Presence and frequent manipulation of devices for

venous/arterial access

• Weakened immune systems

• Proximity to other patients in dialysis centres

• Frequent contact with healthcare workers

• Increased incidence of diabetes

• Colonization with Staphylococcus aureus

Are receiving hemodialysis and

are at risk for developing

bloodstream infections*

23,188CANADIANS*

* http://www.kidney.ca/document.doc?id=1376

CDC.Dialysis Bloodstream Infection (BSI) Prevention Collaborative. http://www.cdc.gov/dialysis/collaborative/



Why are we here?

Reports of skin irritation

Practice review

requested to ensure

products were being used correctly

Goals: Review appropriate skin

antiseptics for access sites

Decrease incidence of irritation

Provide refresher on the use of skin antiseptics



Observations of 3M antiseptic useSt. Boniface, Health Sciences Centre, Seven Oaks – May 2016

Total Observations: Total Observations: Total Observations: Total Observations: 15 patients with chlorhexidine gluconate skin antisepticProcedures Observed: Procedures Observed: Procedures Observed: Procedures Observed: Central Line dressing change, Fistula cannulation

Key Observations related to the use of 3M antiseptic:1. Multiple swabs used for dressing change (range 2-7)2. Multiple layers of antiseptic applied3. Excessive friction used4. Antiseptic not allowed to dry before procedure begins or dressing applied

Additional Observations related to irritation:1. Patients experiencing irritation are Non-Caucasian2. Patients reported no other known skin sensitivities3. Program policy & procedures not followed re 2nd, 3rd choice of product4. Perceptions of “allergy to CHG” and discontinuation of use

Povidone Iodine was the antiseptic of choice



Intolerance of chlorhexidine in Patients Undergoing Hemodialysis

Surveyed facilities participating in CDC Dialysis Collaborative

• Facility demographics

• Chlorhexidine use practices

• Prevalence of chlorhexidine-intolerant patients

Intolerance – “a patient who was unable to use chlorhexidine because of perceived adverse

reaction”

17% intolerant (12% central lines, 21% Fistula, 23% Grafts)

Data suggests variations in practice may explain some intolerance – recommend standardized

practices for antiseptics and better defining what constitutes an adverse reaction

Preliminary work suggests ↑ drying, ↓ friction will ↓ adverse reactions

Kallen, et.al., Intolerance of chlorhexidine as a skin antiseptic in patients undergoing hemodialysis. 2011, Infection Control and Hospital Epidemiology, 32:11, 1144-1146



What is it?

• Non-allergic irritation resulting from chemical irritant: redness, swelling, blistering usually in area exposed to adhesive

• May look similar to allergic dermatitis

Non-allergic irritant contact dermatitis

What is it?

• Rare, cell-mediated immunological response to a particular component of antiseptic, tape adhesive, or backing

• Erythema, edema, itching, wheals, vesicles

• Similar appearance to non-allergic dermatitis

Allergic dermatitis



Isopropyl Alcohol1,2

• Most rapid

• Greatest reductions

• Rapid drying

• No persistence

• Flammable

• Least expensive

Chlorhexidine2,4,5

• Greatest persistence & residual action

• Low skin irritancy

• Good broad spectrum coverage

• No absorption

• Incompatible with anions (soaps, dyes)

• Not inactivated by blood, serum proteins

Povidone Iodine2,3

• Minimal persistence

• Good broad spectrum coverage

• ~ 1-5 min. contact

• Skin irritation & absorption

• Neutralized by organic material

• Documented contamination 8

Combination Products: Alcohol & Chlorhexidine Gluconate, Alcohol & Povidone Iodine

(shown to be superior in several comparison studies) 1. Ali, Y., Fendler, J., Larson, E., (2001). Alcohols, in Block, SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins2. Larson, E., (1988). Guideline for use of topical antimicrobial agents. American Journal of Infection Control, 16(6), 253-266.3.Gottardi, W., (2001). Iodine and iodine compounds, in Block, SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins4.Denton, G., (2001). Chlorhexidine, in Block SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins5.Edwards, PS., Lipp, A., Holmes, A., (2004). Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews. DOI.10.1002/14651858.CD003949.pub2 8Weber JD, Rutala WA Sickbert-Bennett EE Outbreaks associated with contaminated antiseptics and disinfectants. Antimicrobial Agents and Chemotherapy 2007;51:4217-4224.



1. Right Product



Guideline & Standards Recommendations

• CDC, INSCDC, INSCDC, INSCDC, INS:

• use alcohol-based chlorhexidine (>0.5%) solution

for insertion and during dressing changes.1, 2

• KDOQIKDOQIKDOQIKDOQI:

• 2%CHG/70%IPA preferred for long-term catheter

sites3

• Sensitivities to 2%CHG/70%IPA → use 2%

Aqueous CHG, → use PI3

• AV Access- Wash site with antibacterial soap &

water, use 2% CHG/70% IPA or 70% IPA3

1. O’Grady et al.Guidelines for the Prevention of Intravascular Catheter-related Infections. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). American Journal of Infection Control 2011; 39:4 (1 Suppl): S1- 34. 2. Infusion Nurses Society. Infusion Nurses Standards of Practice. Journal of Infusion Nursing 2016; Suppl to Jan/Feb 2016V39, Number 1S3. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1).



Manitoba Renal ProgramPolicies & Procedures

Central Venous Catheter, Dressing Change, 2015

Antiseptic of Choice: 1 package

antiseptic swab stick (2% CHG

70% IPA)

If there are documented allergies to

2%CHG/70%IPA use Aqueous

CHG

If there are documented

allergies to CHG, use Povidone

Iodine

Skin prep/barrier as needed

When using CHG apply using back & forth motion

Begin at exit site, in circular motion extending to the area outside the dressing X 2

Do not blot

Allow to dry completely, at least 2 minutes

Excessive adhesive residue may be removed using adhesive remover followed by a sterile 0.9% NaCl rinse

Drying time is important for antiseptic effect and to minimize skin reaction when adhesive

from dressing comes in contact with antiseptic



Manitoba Renal ProgramPolicies & Procedures

Venipuncture of Arteriovenous Fistula/Graft, 2015

Antiseptic of Choice: 2

packages of 2% CHG.70% IPA)

If there are documented allergies to

2%CHG/70%IPA use Aqueous

CHG

If there are documented

allergies to CHG, use Povidone

Iodine

Wash or have patient wash access site with CHG soap and water. Dry with single-use paper towel

Apply antiseptic using back & forth rubbing motion

CHG/IPA cleansing is at least 30 seconds

Allow to dry completely prior to access



Manitoba Renal Program 3M SoluPrepTM Formats

Small Swab• 2%CHG/70%IPA• 2%CHG Aqueous

Wipe• 2%CHG/70%IPA• 2%CHG Aqueous



2. Right Volume for Treatment Area



Treatment Area

Assess size of area to be preppedAssess size of area to be prepped

Choose product format that will deliver the

surface coverage required

Choose product format that will deliver the

surface coverage required

• What is the stated coverage area?

• Coverage is more important than volume

Too much product increases the risk of irritation and increases the length of time required for the antiseptic to dry



3. Right Application Time

4. Right Application Technique



Swabs and Wipes

* 3M 1301-00230B 2_70 Instructions for Use.© 2013

Demonstrated persistence for up to 7 days on dry skin under semi-occlusive dressing

*

*

*

*



Swabs and Wipes

Demonstrated persistence for up to 72 hours on dry skin under semi-occlusive dressing

* 3M 1211-03381B Instructions for Use.© 2013

*

*

*

2% CHG

SoluPrep™Brand Products

Please note: Application time must be increased to 4 minutes for use pre-surgery or on a moist body site.

Large Wipe (5cm x 5cm)Small Swab (5cm x 6cm)



Modified application ‘option’ (around a catheter or device)

Side 1 – back & forth vertical strokes around catheter (15 seconds)

Flip Swab

Side 2 – back & forth horizontal strokes around catheter (15 seconds)



5. Let it Air Dry! (no blowing, fanning, wiping)



“Dry time Varies!”Influencing Factors:HostDry or moist body site?Presence of hairSkin type

EnvironmentAmbient humidityVolume of product used, size of treatment area, prepping technique

FormulationAlcohol or not?

Importance of drying:

Efficacy

Minimizing irritation

Safety (flammability)

Lack of thorough drying before applying dressing, increases the risk of skin irritation



1. Right Product

2. Right Volume

3. Right Time

4. Right Technique

5. Let it Dry!



Thank you

[email protected]

The materials are provided as general information for the healthcare professional. The materials contain statements, technical information, and guidance which are based on current literature and clinical information at the time the materials were produced, and which we believe were reliable when the materials were created. These materials should be used as a guide only. In all cases, professional clinical judgment must be used for assessment, intervention, and evaluation in each clinical situation. 3M Canada shall not be liable or responsible for the consequences of any actions taken on the basis of the information provided in, or errors or omissions from , these materials. These materials may not be copied or used in part or full without the express permission from 3M Canada. ©2015, 3M. All rights reserved.

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