An Infection Preventionist’s Approach to Hemodialysis

An Infection Preventionist’s Approach to Hemodialysis

According to the 2018 U.S. Renal Data System Annual Data Report, 28,831 hemodialysis patients receive dialysis in a hospital setting. Hemodialysis patients are at high-risk for acquiring a healthcare-associated infection in the hospital setting that can lead to lengthy hospitalizations, readmissions, and fatal outcomes. Some of the causes are attributed to:

  • Non-adherence to hemodialysis evidence-based practice or manufacturer instructions for use (examples: hand hygiene, use of personal protective equipment, and cleaning/disinfection of equipment and patient dialysis stations)
  • Hemodialysis treatment involves repeated and prolonged patient blood exposure from graft, fistula, or central venous catheter access, and dialysis machine circuit ports and connections
  • Patient immune-compromised status
  • Recurrent healthcare worker contact between multiple patients and hemodialysis machines

Infection Prevention and Control

An Infection Prevention and Control Program that is driven by a comprehensive risk assessment includes the Dialysis Program under its surveillance (whether it is a contracted service or not) to ensure both a safe environment and prevent patient harm from infection. Infection Control Committee (ICC) meetings should have dialysis program representation. As a best practice, the ICC meeting minutes should include documentation of the dialysis endotoxin, bacterial, and water testing report results. This reporting submission structure does not replace contacting Infection Prevention and Control and the Dialysis Program Medical Director in real time when testing results exceed normal limits and remediation activities are warranted.

A Partnership Focused on Patient Safety

The relationship between Infection Prevention and Control and the Dialysis Program is a partnership focused on patient safety. A multidisciplinary approach is critical to the successful implementation, sustainability, and intended patient outcomes associated with hemodialysis. Leadership, Environment of Care/Facilities/Engineering, Infection Prevention and Control, medical and nursing staff, and contracted agencies (if appropriate) are all key stakeholders. At minimum, your programs should include:

  • A review of environmental cleaning and disinfection of the dialysis machines, dialysis stations, endotoxin, bacterial, and water reports
  • The process for caring for Hepatitis B surface antigen positive (HBsAg) and unknown Hepatitis B status patients
  • Routine review of hand hygiene
  • Appropriate use of personal protective equipment (PPE)
  • Accessing and de-accessing the fistula, graft, or central venous catheter

Key Knowledge Points

While not all activities fall entirely under the Infection Preventionist’s realm, it is worth noting and understanding any items that ultimately relate to providing safe dialysis practices and preventing patient harm. Below are some of the key Dialysis Program components for the Infection Preventionist to focus on with associated CMS Conditions of Participation and Joint Commission Standards/EPs.

1. Hemodialysis Program inclusion in infection prevention and control risk assessment
Include as part of the infection prevention and control risk assessment, which is performed annually (at minimum) and when a significant change occurs with the organizations’ Dialysis Program (for example if your organization recently acquired contracted dialysis services). Prioritize this service’s risk based on a comprehensive multidisciplinary approach.

CMS Condition of Participation: §482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
Joint Commission Standard/EP: IC.01.03.01 EPs 1,2,3


2. Adhering to hemodialysis evidence-based guidelines
Examples of hemodialysis evidence-based guidelines for consideration are:

CDC Guidelines for Dialysis Safety
CDC Guidelines for Environmental Infection Control
CDC Guidelines for Water Use in Hemodialysis
ANSI/AAMI Dialysis Standards

CMS Condition of Participation: §494.30 | Subpart B Patient Safety | Condition of Participation: Infection Control
Joint Commission Standard/EP: IC.01.05.01 EP1

3. Hepatitis B surface antigen positive (HBsAg) or unknown Hepatitis B patient status is identified and documented with evidence-based interventions performed
Results of Hepatitis B testing should be known before patient dialysis is initiated. Separation of HBsAg-positive patients (a separate room is the safer and preferred method of separation) and their equipment, supplies, and medication from HBV-susceptible patients.

CDC Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients

CMS Condition of Participation: §494.30 | Subpart B Patient Safety| Condition of Participation: Infection Control
Joint Commission Standard/EP: IC.02.01.01 EP3

4. Appropriate frequency and documentation of dialysis machine cleaning and disinfection 
Observe and validate adherence to Dialysis Program established procedures, manufacturer instructions for use, and selected guidelines for dialysis machine interior and exterior cleaning and disinfection. Find a checklist here.

CMS Condition of Participation: §494.30 | Subpart B Patient Safety | Condition of Participation: Infection Control
Joint Commission Standard/EP: IC.02.02.01 EP2

5. Cleaning and disinfection of the dialysis station environment
Observe and validate adherence to Dialysis Program established procedures, manufacturer instructions for use, and selected guidelines for dialysis station environmental cleaning and disinfection.

CMS Condition of Participation: §494.30 | Subpart B Patient Safety | Condition of Participation: Infection Control
Joint Commission Standard/EP: IC.02.02.01 EPs1,2

6. Water testing results include chemical, microbial, and endotoxin levels which are supported by selected evidence-based guidelines

ANSI/AAMI Dialysis Standards

CMS Condition of Participation: §494.40 |Subpart B Patient Safety |Condition of Participation: Water and dialysate quality
Joint Commission Standard/EP: EC.02.04.03 EP5

7. Central-line associated blood-stream infections (CLABSI) in hemodialysis patients.
Observe and validate adherence to Dialysis Program policy, procedures, and selected guidelines for central line use. Incorporate Infection Prevention and Control surveillance to include hemodialysis catheter-related infections.

CDC Guidelines for Intervascular Catheter Related Infections
CDC Guidelines for Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol

CMS Condition of Participation: §494.30 |Subpart B Patient Safety |Condition of Participation: Infection Control
Joint Commission Standard/EP: NPSG.07.04.01 EPs 1-9,11-13

8. Infection Prevention and Control training and education for the dialysis setting.
Initial and ongoing education and competency may include:

    • Hand Hygiene
    • Use of personal protective equipment (PPE)
    • Safe handling and administration of patient medications
    • Separating HBsAg-positive patients with a separate room, dialysis machine, supplies, medications, and staff
    • Infection control practices for initiation, care, and maintenance of graft, fistula, and central venous catheter access sites
    • Methods to clean and disinfect equipment and environmental surfaces
    • Record keeping that includes routine serologic testing results for HBV and HCV, Hepatitis B vaccine status, and surveillance for water and dialysate quality.

CMS Condition of Participation: §494.30 | Subpart B Patient Safety |Condition of Participation: Infection Control
Joint Commission Standard/EP: HR.01.04.01 EPs 1,3 |HR.01.05.03 |EP1 |HR.01.06.01 |EPs 5,6

HOW TiER1 HEALTHCARE CAN HELP

If your organization needs help with assessing your Hemodialysis Program, please call our office at (800) 241-0142 or send us an email at: info@tier1performance.com