Dialysis Guidelines for APIC Houston …apichouston.org/images/meeting/021913/presentation_feb...Objectives • The group will understand the reporting requirement for dialysis centers

Dialysis Guidelines

Donna Robertson, RN,BSN,CIC

HCA Mainland Medical Center

APIC Houston President-elect

• NHSN Reporting Requirements for Dialysis

• Guidelines and Recommendations forInfection Prevention for dialysis in

inpatient and outpatient Settings

• Infection Prevention Checklist

• AAMI guidelines and Water Cultures

• IP surveillance in the Dialysis area

Topics

Objectives

• The group will understand the reporting requirement fordialysis centers for NHSN

• The group will understand 5 the general IC guidelines andrecommendations for IP for dialysis inpatient and outpatientsettings

• The group will be able to remember at least 5 items includedon the IP checklist for dialysis reviews

• The group will be able to list the two basic AAMI guidelinesfor water culture requirements for dialysis

• The group will be able to name 3 important functions of theICP in the dialysis area

NHSN Reporting Requirements

• Outpatient dialysis centers are required toregister for NHSN reporting.

• The registration process is like the registrationprocess acute care hospitals were required todo.

• Critical access hospitals are not required toparticipate in the hospital inpatient QualityReporting Program. They may voluntarilyreport data for publication.

Guidelines and Recommendations forIP in Inpatient and Outpatient Settings

• Standard Precautions – all healthcare settings(hand hygiene, personal protectiveequipment, injection practices)

• Policies and Procedures – tailored to thefacility and reviewed on regular basis

• IC professional must be employed or readilyavailable – (outpatient)

• Employee Health – vaccinations andexposures

Guidelines (continued

• Healthcare worker education and training – job and task specificpatient and employee safety

new hire and annuallycompetencies on new hire and repeated as appropriate (usually annually

and with new tasks)Use and selection of proper personal protective equipmentinjection safety – safe injection practicescleaning and disinfection of environmental surfacesre-usble medical equipmentTransmission-based precautions and Respiratory Hygiene and CoughEtiquette (generally outpatient settings are not able to handle AIRBORNE)

• Reportable disease and outbreak reporting requirements for local, stateand federal – Inpatient and outpatient

• Perform regular audits and staff evaluations to be sure staff is adhering toinfection prevention practices.

Infection Prevention Checklist forDialysis Reviews

• Infection Prevention policies and proceduresare available, current and evidence-based. P/Pare evaluated at least annually or as requiredby state or federal requirements.

• At least 1 trained IC person is employed orregularly available for the facility.

• Supplies necessary for Standard precautionsare available.

IC Checklist for Dialysis

• The Infection Control Staff or Consultant forthe facility can use a checklist to review keypoints to be sure the facility is meetingnecessary components of the infection controlprogram.

• The infection control program encompassesblood borne pathogens, isolation, handhygiene, employee health, safe injectionpractices, disinfection and sterilization, etc…

IC Checklist for Dialysis (continued)

• EH - Healthcare workers receive job specifictraining on IC P/P on new hire & at least annually.Competency and compliance with P/P for IC aredocumented on new hire and annually.

HCW’s are trained on OSHA bloodbornepathogen standard upon new hire & at leastannually.

Facility log on exposure events, post-exposureevaluation and follow-up, including prophylaxis.


HEP B Vaccine – post- vaccine antibodyscreening – no cost

Annual influenza vaccination – no cost

Those with potential for TB exposure – TBscreen at new hire and annually if negative –outpatient

Respiratory protection program – respirator userequirements – fit testing


Management and prevention of job-related andcommunity-acquired infections or exposures.

• Report - disease reportable conditions andoutbreaks to the appropriate public healthauthority. The facility shows they have done this.

• Hand hygiene supplies are available to adhere tohand hygiene practices. HCW’s are educated onhand hygiene practices. Show adherence to handhygiene practices. Facility shows monitoring.


• PPE – enough and appropriate PPE, readilyaccessible, HCW’s trained on proper use andselection.

• Injection Safety – vial size fit procedure needsof facility, limit need for sharing multi-dosevials. Aseptic technique is used in preparinginjections in clean area free of contamination.Facility has P/P to track HCW access to controlsubstances.


• Respiratory Hygiene – P/P for cough etiquette &respiratory protection. Signs at entry areas.Providing tissues, masks, and hand hygiene.Spacing patients in waiting areas to preventtransmission. Education to HCW’s on respiratoryhygiene.

• Environmental Cleaning – P/P on routine cleaningand disinfection of environmental areas and ID ofpersonnel responsible for cleaning.


• EVS staff receive job-specific training on hireand when tasks change. Techs and Nursingreceive this training as well.

• Training & equipment for PPE to preventexposure to chemicals and infectious agents.

• Cleaning procedures and monitored to be surethey are being done correctly.

• P/P for decontamination of blood spills.


• Reprocessing of Re-usable Instruments – P/Pto ensure re-usable medical devices arecleaned and reprocessed appropriately priorto use. That these are available in re-processing area if this is done at the facility.That personnel are properly trained andcompetencies are regularly documented (atleast annually and as new equipment isbrought in). Proper PPE is worn. This isaudited.


• Sterilization of Re-usable instruments – all re-usable critical devices are sterilized prior to re-use. Routine maintenance of sterilizationequipment is performed and records arepresent. P/P are in place.

• High-level disinfection of Re-usableInstruments and Devices – All re-usable semi-critical devices have at least high-leveldisinfection prior to re-use.


• Log to document instrument used – tied topatient for each procedure.

• Maintenance records are kept and availablefor high-level disinfection.

AAMI Guidelines and WaterCultures

• The Association for the Advancement of Medical Instrumentation (AAMI) has standards for the water usedto prepare dialysate, reprocessing of hemodialyzers, or substitution fluid for renal replacement therapy.

• These standards cover processes and equipment used to purify water for the preparation of dialysates,concentrations, reprocessing of dialyzers, and for the devices used to store and distribute this water.

• Microbiological limits for hemodialysis fluids:

Dialysate colony counts are tested according to SM18 9215C. New AAMI guidelines ANSI/AAMI:RD 52: 2004 2004 and

ANSI/AAMI RD 52: 2004/A1:2007,a2:2007, a3:2009, and , A4:2009 effective 3/25/2010

colony count dialysate 50 -199 CFU/mL: AAMI action level; begin to evaluate , corrective action PRN. Greater than 200CFU/mL.

Water colony counts are tested according to SM18 9215C. New AAMI guidelines for water:

colony count for water 50-199 CFU/mL; AAMI action level; begin to evaluate , corrective action PRN. Greater than 200CFU/mL.

Endotoxin water: New AAMI guideline for water treatment equipment for hemodialysis applicationANSI/AAMIRD62:2006 and ANSI/AAMSI RD 62: 2006/A1 2009 effective 1/26/20110.00-0.99: negative,1:00- 1.99 EU/mL: AAMI action level , begin to evaluate, corrective action PRN, >= toto 2.0 EU/mL, criticallevel exceeds AAMI standards. If these action levels are observed, prompt actions are required to reducelevels.

Infection Prevention Surveillance InDialysis

• IP presence in the dialysis suite is one of themost important ways to make sure IP&Cprocedures are being carried out.

• Monitoring hand hygiene opportunities,proper use of PPE, isolation, andenvironmental cleaning and disinfection.

• Monitoring for care of lines and barrierprecautions.

References

• http://www.cdc.gov/nhsn/FAQ_CMS_HAI.html

Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333 USA

• http://www.cdc.gov/dialysis/collaborative/interventions/index.html

Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333 USA

• http://www.cdc.gov/hicpac/pubshtml

• 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities

http://www.cdcgov/hicpac/Disinfection_Sterilization/1_sumIntroMethTermshtml

Guideline for Environmental Infection Control In Healthcare Facilities

http://.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

Guideline for Hand Hygiene in Healthcare Settings

http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

2007 Guideline for Isolation Precautions

Preventing Transmission of Infectious Agents in Healthcare Settings

http://www.cdc.gov/hicpac/2007IP/2007ip_ExecSummary.html

• Guideline for Prevention of Surgical Site Infection, 1999

http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf

• Guideline for Prevention of Intravascular Catheter-Related Infections, 2011

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Management of Multi-Drug Resistant Organisms in Healthcare Settings 2003

http://www.cdc.gov/hicpac/mdro/mdro_toc.html

Influenza Vaccination of Healthcare Personnel2006

http://www.cdc.gov.mmwr/preview/mmwrhtml/rr5502a1.htm

Guideline for Infection Control In Healthcare Personnel 1998

http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

References (continued)

• Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm

CDC Website on Injection Safety

www.cdc.gov/injectionsafety

Recommendations for Dialysis Water Quality and Dialysate

http://www.cdc.gov/healthywater/other/medical/hemodialysis.html

Documents

Dialysis Guidelines for APIC Houston …apichouston.org/images/meeting/021913/presentation_feb...Objectives • The group will understand the reporting requirement for dialysis centers