Anyone who has had to manage or provide oversight for a hemodialysis unit knows it can be a complex department to stay on top of. Providing dialysis services to your inpatient population is a high-risk service line that requires close monitoring of devices, staff, and processes. Today we are going to give you a few pointers for making your hemodialysis processes run smoothly and safely with a focus on infection prevention. The Center for Disease Control (CDC) recognizes that hemodialysis patients are at high risk for infection just by nature of the procedure. Sources of infection can be from vascular access, external surface contaminants, as well as internal pathway contaminants. Blood stream infections are far too common. Bacterial infections specifically involving vascular access, are the most frequent infectious complication of hemodialysis and a major cause of morbidity and mortality among hemodialysis patients. Accessing the venous catheter (e.g., fistula, grafts) requires a focus on standard precautions including appropriate hand hygiene and meticulous handling of devices utilized to access the venous port. Surveillance activities by the organization should include standard precautions compliance and hand hygiene practices by the dialysis unit staff.
Patients must be routinely monitored for blood borne pathogens such as Human Immunodeficiency Virus (HIV) and Hepatitis B and Hepatitis C. Doing so reduces the chance of transmitting infections between chronic dialysis patients. CDC recommends segregating these patients to a separate room and designated machine to help mitigate the possibility of transmission. Bleach should still be used to rinse internal pathways of the unit between each use, with this vulnerable population.
The hemodialysis machine and its external components can also transmit bloodborne viruses and pathogenic bacteria. The CDC reports that external surfaces of the machine are the most likely sources for contamination and surfaces should be cleaned after each patient use with an Environmental Protection Agency (EPA) category disinfectant. High touch surfaces cleaned between use include the control panel and attached waste containers used during the priming of the dialyzers, blood tubing draped or clipped to waste containers, and items placed on tops of machines for staff convenience. Venous pressure transducer protectors should be used to cover pressure monitors and should be changed between patients, not reused.
Water is necessary for all hemodialysis treatments. However, drinking water contains a range of substances that are toxic to patients on hemodialysis. Thus, all dialysis facilities are equipped with a water treatment system that removes those substances from the water before it is used to prepare dialysate. The Association for the Advancement of Medical Instrumentation (AAMI) has published standards and recommended practices that address monitoring of both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients. Both water systems and dialyzers should be checked for contaminant levels; for example, water cultures and endotoxin levels should be monitored monthly. Wall boxes and drains pose a particular challenge as that area is considered contaminated. Wall box drains should be cleaned and disinfected routinely.
Internal fluid pathways should undergo intermediate level disinfection. The type of disinfection selected (heat, chemical or heat/descaling combination) will depend on the type of machine and the manu-facturer’s recommendations for disinfection. Microbial contaminants in dialysate contribute to long-term morbidity and has led to more stringent microbiological quality standards for dialysate, and a consequent need to control biofilm formation in the fluid pathways involved in dialysate preparation.
Evidence shows healthcare organizations can reduce the risk of nosocomial infection in dialysis patients by utilizing proper infection control techniques for initiation, care, and maintenance of access sites. Infections caused by contaminated water and equipment can be prevented by a well-designed water-treatment system, routine cleaning, disinfection of system components, and routine bacteriologic monitoring of dialysis water and dialysis fluid. Manufacturers recommendations provide guidance on how to disinfect the internal circuits of the dialysis machine, as well as to reprocess dialyzers for reuse. These methods are designed to control bacterial contamination but will also eliminate bloodborne viruses. CDC recommends following the above guidelines to assure these immune compromised patients are safe while in our care.
References
ANSI/AAMI. (2004). ANSI/AAMI RD52:2004, Dialysate for hemodialysis, · PDF file American National Standard RD52:2004 dialysate for Hemodialysis developed by Association for the Advancement of - [PDF document]. ANSIAAMI RD522004. Retrieved May 2022, from https://documents.pub/document/ansiaami-rd522004-dialysate-for-hemodialysis-american-national-standard.html?page=1
ANSI/AAMI. (2004). ANSI/AAMI RD52:2004, Dialysate for hemodialysis, · PDF file American National Standard RD52:2004 dialysate for Hemodialysis developed by Association for the Advancement of - [PDF document]. ANSIAAMI RD522004. Retrieved May 2022, from https://documents.pub/document/ansiaami-rd522004-dialysate-for-hemodialysis-american-national-standard.html?page=1
Centers for Disease Control and Prevention. (2016). Recommendations for preventing transmission of infections among chronic dialysis patients. MMWR. Retrieved May 2022, from https://www.cdc.gov/mmwr/pdf/rr/rr5005.pdf
Centers for Disease Control and Prevention. (2020, October 15). Water use in dialysis. Centers for Disease Control and Prevention. Retrieved May 2022, from https://www.cdc.gov/dialysis/guidelines/water-use.html
Centers for Medicare & Medicaid Services. (2008). Dialysis. CMS. Retrieved May 28, 2022, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis
MJ; C. A. D. A. (2013). Hemodialysis and water quality. Seminars in dialysis. Retrieved May 28, 2022, from https://pubmed.ncbi.nlm.nih.gov/23859187/