Hand hygiene is the most vital step in infection prevention in all settings, especially in outpatient hemodialysis facilities. Hand hygiene must be performed:

• Before touching a patient
• Prior to performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
• Before moving from a contaminated body site to a clean body site on the same patient
• Following a procedure involving exposure risk to body fluids
• After patient contact and glove removal
• After contact with patient surroundings including touching any object, furniture, or patient belongings

 

There are two different methods of hand hygiene that can be performed

Alcohol-based hand rub (ABHR):

• Are recognized as the most effective products for reducing the number of germs on the hands of healthcare providers.
• Are the preferred method for cleaning your hands in routine patient care
• To ensure that hand hygiene with ABHR is done correctly, ensure that all surfaces of the hands and wrists make contact with ABHR and rub until hands are completely dry.
• A sufficient amount of ABHR typically takes about 15-20 seconds to completely dry.  

Soap and Water

• Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom
• This method of hand hygiene typically includes rubbing hands for about 20 seconds, ensuring that all surfaces of the hands and wrists are covered.
• Hand hygiene with soap and water must be used after caring for patients with C. diff.

Click here for hand hygiene educational materials.

Understanding the importance of properly observing disinfectant contact and wet times help ensure that patients’ skin is properly disinfected prior to dialysis access cannulation and decannulation. Ensure that staff are properly trained on the specific products utilized within the facility prior to implementation and use on patients.

Some common active ingredients found skin disinfectant solutions used in dialysis centers include:

• Alcohol
• Chlorhexidine
• Iodine
• Sodium hypochlorite skin solutions

It is important to understand that not all products are the same. Due to differences in production and ingredients, manufacturer instructions for use (IFUs) must be followed consistently in order to use these products correctly.

A central venous catheter (CVC) is required to establish dialysis access in new hemodialysis patients. However, current hemodialysis patients may also require a CVC if their graft or fistula fails and/or they are waiting for their new graft or fistula to mature prior to use.

CVCs may be located on the neck, chest or groin. During placement, a thin tube is inserted into the patient’s vein and guided until it sits above the superior vena cava. Healthcare Workers (HCWs) and patients should be aware that this dialysis access type carries the highest risk of infection for patients.

The Centers for Disease Control and Prevention’s (CDC) Hemodialysis Central Venous Catheter Scrub the Hub Protocol provides guidance on the proper connection, disinfection, and maintenance of dialysis CVCs.

The use of intravenous and injectable medications is common in the dialysis setting. To keep patients safe, HCW must practice safe injection practices and proper medication preparation.

Medication Preparation

• Should begin with the HCW performing proper hand hygiene
• Must be done in a designated and clean medication preparation area, away from patients and patient care activities

Injectable and Intravenous Medications

• Access medication vials with a new syringe and a new needle each time.
• Vial septum must be scrubbed with an alcohol swab prior to entry.
• Multi-dose vials may be entered aseptically more than once, but single dose vials should not be accessed more than once.
• Medication should be prepared and drawn as close as possible to the time of administration. Avoid predrawing medications in order to avoid contamination
• Never leave a needle inserted in the septum of a medication vial.

Medication Administration

Injectable and Intravenous medication administration must follow proper infection control protocol. Click here for LAC DPH’s injection safety website.

Proper environmental and station disinfection is vital to any outpatient dialysis facility’s infection control program. While conducting its Infection Control and Response Project in 2022, the LAC DPH Dialysis Team found that many dialysis centers faced similar issues when it comes to station disinfection, including:

• Improper storage of disinfectants
• Improper disinfectant types
• Insufficient use of disinfectant
• Improper sequence of disinfection

In order to practice proper infection control, it is important for facilities and HCW to implement appropriate disinfection practices. Recommendations for proper station disinfection include:

• Disinfectant Type and Storage:
  • Ensure that the facility is using an EPA-approved disinfectant for the correct setting/organism(s) being targeted
  • Follow manufacturer's instructions for use (IFUs) for proper disinfectant storage
  • Ensure that disinfectants are diluted properly. In dialysis settings, bleach solutions are typically diluted to a 1:10 and/or 1:100 ratio with each dilution used for specific purposes, such as general cleaning or blood spills.
  • Ensure that diluted disinfectant solutions are stored in covered containers when not in use. Avoid placing containers near water sources, such as sinks, unless there is a solid barrier between them in order to prevent contamination
• Disinfection process
  • Ensure that wipes are sufficiently saturated with disinfectant in order to meet the contact/wet time indicated in the disinfectant manufacturer’s IFUs.
  • Follow a top-down approach to disinfection and ensure that cleaned items do not come into contact with dirty items in order to prevent contamination.
• For administrators:
  • Ensure that staff are provided with proper education regarding station disinfection, and that staff receive updated training when new materials are introduced to the facility.

 

Appropriate PPE use is an integral part of infection control in the dialysis setting. Staff should know what PPE is required during procedures, when to replace PPE, and how to don/doff PPE correctly.

Routine PPE (required for all dialysis patient care) include:

• Gloves
• Gown
• Face shield
• Face mask

Proper donning and doffing of PPE are necessary for infection prevention, and therefore must be put on (donned) and taken off (doffed) properly.

Ensuring consistent compliance with infection prevention policies and procedures is one of the most important aspects of a facility’s infection control infrastructure. Internal compliance audits and annual skills training should be implemented by facility administrators in order to determine areas of improvement and understand where their staff need additional support.

The CDC/National Healthcare Safety Network (NHSN) provides the following audit tools that can be utilized by facilities for their quality improvement efforts: Audit Tools and Checklists | Dialysis Safety | CDC

Facilities should also ensure that staff are properly trained on any new equipment, supplies, or procedures being introduced to the facilities prior to implementation in the facilities. Such actions support HCW, facility, and patient success and ultimately strengthen a facility’s infection control program.

Outpatient dialysis facilities must follow infection control guidelines for safe water utilization in their patient populations. Please refer to the CDC’s webpage on Water Use in Dialysis for additional information.

Proper interfacility communication ensures quality care as a patient/resident moves through the healthcare continuum. More importantly, communication of the patient’s/resident’s colonization or infection status prevents the spread of organisms- such as CRE and novel MDROs- to other facilities. LACDPH has compiled information and resources on how to ensure clear, timely, and constant communication between healthcare facilities here: LAC DPH Interfacility Transfer Resources

Isolation Rooms

• Outpatient dialysis facilities built after 2009 are required to have isolation rooms for the treatment of hepatitis B virus positive (HBV+) patients unless they are granted a waiver, per The Centers for Medicare & Medicaid Services (CMS) requirement.

Equipment

• Equipment used for the care of HBV+ patients must be separate and dedicated to this patient population. They must not be routinely removed from the isolation room/area.

Staff

• Staff must use separate gowns when providing care for HBV+ patients. These gowns must be removed and discarded prior to leaving the isolation area/room.
• Staff providing care for hepatitis B surface antigen (HBs-Ag) positive patients should not be caring for HBS susceptible patients at the same time, in the same shift, or during patient changeover.
• Staff must ensure proper adherence to hand hygiene measures and change gloves frequently.

In general, additional contact precautions are not recommended in hemodialysis units for patients infected or colonized with pathogenic bacteria. There are numerous reasons for this, such as difficulty in determining source of transmission and decreased likelihood of transmission in outpatient dialysis settings due to the amount of time patients spend there in comparison to acute hospital settings. Additionally, the routine infection control practices are more stringent than Standard Precautions, which adds an additional layer of protection.

Maintaining strict adherence to proper hand hygiene, PPE use, and environmental cleaning are paramount in the overall prevention of disease transmission in the dialysis setting. Additionally, facilities can consider more stringent precautions depending on their own capabilities. Patient cohorting may be an option for facilities that have sufficient resources.

LAC DPH has created a C. auris FAQ for dialysis centers for facilities to use as a resource: LAC_C.aurisFAQDialysisCenters.pdf.

Infections are prevalent among dialysis patients and can be potentially life-threatening. It is crucial to remember that germs can be passed from person to person through direct contact when someone is sick or by breathing in respiratory droplets after a sick person coughs or sneezes. Microorganisms may propagate within the dialysis center through the surfaces of equipment or unwashed hands.

A bloodstream infection (BSI) is a very serious infection. The majority of BSIs originate through central line catheters since they carry a higher risk of infection than fistulas or grafts. Symptoms include: :

• Fever
• Chills
• Low blood pressure

Infections caused by viruses pose concern for dialysis patients. Viruses in the bloodstream spread when an infected individual's blood enters the body of someone who is not infected. There are many potential routes for this to happen, including through surfaces and equipment in the dialysis center. Viral infections can cause many symptoms. Examples of viral infections are:

• Hepatitis B
• Hepatitis C
• HIV

Risk of Infections for Vein Access Types

Artery vein Fistula

Arteriovenous (AV) Fistulas are formed by connecting an artery and vein, usually in the arm. They last longer than a graft and are less prone to becoming infected.

Artery vein Graft

Arteriovenous (AV) Grafts are created when a doctor inserts a tube to connect a vein and an artery. These pose a higher risk of infection than an AV fistula, but a lower risk of infection than a central venous catheter (CVC).

Catheter

Central Line Catheters can be placed on the neck, chest, or groin. They are created by inserting a thin tube into a vein and guided into the superior vena cava, a large vein. They carry the highest risk of infection among all dialysis access types.

Signs of infection include:

• Fever
• Swelling, redness, pain, or purulent drainage at the access site

Patients can help prevent infections as well! The CDC recommends the following:

• Wash your hands with soap and water regularly or use alcohol-based hand sanitizer.
• Practice respiratory etiquette by covering your nose and mouth when you cough or sneeze.
• Know what to expect during your dialysis treatment by learning about the dialysis process.
• Learn about the steps that staff take to keep you safe from infections. Read the CDC Audit Tools and Checklists.
• Watch the Speak Up Video from the CDC and address questions during your dialysis treatments.
• Check your access site every day and notify staff if you see any of these infection symptoms:
  • Redness
  • Pus or unusual drainage
  • Swelling.
• Notify staff if your catheter dressing becomes dirty or wet.
• If you have a central venous catheter (CVC), inquire if a fistula or graft could be used for dialysis treatment.
• Ensure that all staff members wash their hands before and after when caring for you or your access site.
• In certain circumstances, you may be advised to take extra precautions to prevent infection. As an example, consider the COVID-19 pandemic.