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

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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

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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

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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+

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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

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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)

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“Route” #2: Ineffectively Disinfected Equipment & Surfaces

Cleaning & disinfecting contaminated surfaces & equipment (V122)

HD machine transducer protectors changed when wet (V120)

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“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)

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“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)

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“Route” #4: Inadequate Vascular Access Care

CVC access and care to prevent contamination (V147)

Monitor CVC-related blood stream infections (CLABSIs) (V148)

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“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)

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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