Kidney Research and Clinical Practice 2018 Mar; 37(1): 1-3  https://doi.org/10.23876/j.krcp.2018.37.1.1
Infection control guidelines in hemodialysis facilities
Ayman Karkar
Department of Nephrology, Kanoo Kidney Center, Dammam, Saudi Arabia
Correspondence to: Ayman Karkar, Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, PO Box 11825, Dammam 31463, Kingdom of Saudi Arabia. E-mail: han94dan97@gmail.com. ORCID: http://orcid.org/0000-0002-7343-1296
Received: January 29, 2018; Revised: January 31, 2018; Accepted: January 31, 2018; Published online: March 31, 2018.
© The Korean Society of Nephrology. All rights reserved.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Healthcare-associated infections are a major risk to patient and staff safety. Hemodialysis (HD) patients, as well as dialysis staff, are vulnerable to healthcare-associated infections due to frequent and prolonged exposures to many possible contaminants in the HD environment. The increased risk is mainly due to 1) the immune-compromised status of dialysis patients, 2) frequent and prolonged blood exposure during HD treatments through vascular access (mainly catheters) and extracorporeal circuit (with many ports and connections), 3) close proximity to other patients during treatment in the HD facility, 4) frequent contact with healthcare workers, who frequently move between patients and between machines, 5) frequent hospitalization and surgery, and, most importantly 6) non-adherence or breaks in implementation of recommended practices.

Infection is the first cause of hospitalization and the second most common cause of mortality among HD patients. Infection control in dialysis units remains the most important measure to maintain a healthy environment and to prevent and avoid dissemination of infection among immunocompromised patients. HD patients are exposed to different types of infections including bloodstream infections and localized infections of vascular access; blood-borne infections with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus; and airborne infections. Sources of infections include contaminated water, equipment, environmental surfaces, and infected patients. Contaminated healthcare worker hands are among the most common modes of transmission of healthcare-associated infections [1]. In fact, hand hygiene is singled out as the most important intervention to prevent infections (Table 1). The evident increased potential for transmission of infections in the HD setting led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions [2].

Different international organizations have generated guidelines and recommendations on infection prevention and control for implementation in the HD setting. These include the Centers for Disease Control and Prevention (CDC), the Association of Professionals in Infection Control (APIC), the Kidney Disease Outcomes Quality Initiative (K/DOQI), the European Best Practice Guidelines/ European Renal Best Practice (EBPG/ERBP), and the Kidney Disease: Improving Global Outcomes (KDIGO) [3]. In this issue of Kidney Research and Clinical Practice, Park et al [4] established the “Korean clinical practice guidelines for preventing the transmission of infections in hemodialysis facilities.” These key recommendations were focused on adult end-stage renal disease patients over 18 years old who receive hemodialysis therapy in dialysis units. These guidelines were based on an expert group composed of nephrologists and infection control specialists and covered different important aspects of infection control, including standard precautions, isolation strategy, vascular access, water treatment, procedures of cleaning, disinfection and sterilization, waste management, environmental control, and vaccination. Each recommendation is categorized as either Category I (strong recommendation) or Category II (weak recommendation) based on evidence levels (high, moderate, low, and very low), benefits and risks, and clinical applicability in the medical field. The categorized recommendations were adjusted when the performance level of the recommendation was expected to be low even though the level of evidence was high. In addition, some recommendations that have not fully reflected the domestic medical situation and have caused conflicts of interest have not been graded and have been classified as unresolved issues.

The established Korean infection control guidelines are evidence-based, well-designed, concise, and with clear instructions. These guidelines/recommendations should not only support all practicing national dialysis units, but should help to standardize and unify the implemented policies and procedures of infection control. This should be supported by quality improvement projects to ensure reliable, consistent, and strict implementation of infection control policies and procedures. A specialized committee or at least one designated person with training in infection control and epidemiology should be responsible for oversight of the program as well as the education of staff and patients on infection prevention and control. These measures should help patients be dialyzed safely in any national dialysis unit when moving and/or travelling between different parts of the country.

The Korean guidelines should help dialysis units to establish their own infection control policies and procedures and to regularly survey and update them per the local incidence and prevalence of any type of infection. However, strict implementation of these policies and procedures remains the cornerstone in infection control in dialysis units. In addition, regular education, training (especially for newly appointed staff), and monitoring are essential to ensure proper implementation. Full knowledge of infection control policies and procedures should be provided to all healthcare workers, and awareness campaigns should be regularly performed. The patient and/or caregiver should also be educated on hand hygiene and care of new vascular access (Table 2). Equally important is the continuous need of regular revision, feedback, and update of the implemented policies and procedures. Lastly, it is essential to preclude any break in these policies and procedures. The following factors, which can be avoided and prevented, will inevitably lead to a break in the implementation of recommended practices: 1) understaffing with poor nurse-to-patient ratio [5], 2) frequent turn-over of nursing staff [6], 3) lack or inadequate training and lower level of competency among HD staff, 4) inadequate or lack of patient/family education, 5) inadequate provision of necessary supplies/ equipment, 6) poor design of HD unit layout (congested and inadequate segregation/isolation) [7], and 7) urgency associated with dialysis complications (sometimes life-threatening situation) may sacrifice adherence to standard precautions [8].

In conclusion, international guidelines are of great value in supporting worldwide infection control programs in hemodialysis facilities. However, it is important for national/local dialysis facilities to establish their own guidelines and applicable recommendations. These local guidelines should be prepared in collaboration with expert nephrologists, epidemiologists, infection control specialists, and occupational health specialists, and implementation should be monitored regularly. These guidelines should be designed to meet local requirements and based on local risk assessment, survey results, and practical experience. Regular clinical audit of the recommendations in these guidelines should form an integral part of good practice and of an HD facility’s contribution to local clinical governance initiatives.

Conflicts of interest

All authors have no conflicts of interest to declare.

Tables

Estimated minimum number of times where hand hygiene is required per dialysis session per patient (regardless of glove use)

SNActivityBeforeAfterTotal
1Accessing supplies from common clean storage area11
2Preparing/setting-up the HD machine*11
3Preparing/administering medications (including for anticoagulation)112
4Pre-dialysis: measuring vital signs/weighing*11
5Preparing trolley/tray for cannulation*11
6Palpating clean cannulation sites*11
7Skin preparation & cannulation of arteriovenous access (AVF, AVG)*11
8Preparing trolley for catheter dressing*11
9Removing old dressing over catheter site11
10Catheter exit site dressing*11
11Connection for HD112
12Handling blood samples and other specimens1Minimum 1
13Checking blood pressure (every 1/2–1 hour for 4 hours)11Minimum 8
14Catheter/blood line manipulation11Minimum 2
15Adjusting machine parameters and/or attending machine alarms1Minimum 1
16Attending to patient incidents/assisting patient11Minimum 2
17Prepare trolley for dialysis disconnection11
18Disconnection of HD112
19Post-dialysis: measuring vital signs/weighing*11
20Cleaning/disinfection of dialysis equipment*11
21Leaving the dialysis unit11
Total estimated minimum number of times hand hygiene is required per dialysis per patient~30

AVF, arteriovenous fistula; AVG, arteriovenous graft; HD, hemodialysis; SN, serial number.

*Most of the time, the activity is recently preceded by hand hygiene performed at the end of one procedure/activity (between two different activities). Therefore, repetition of hand hygiene prior to an activity (wherein performance of hand hygiene is indicated per recommendation) is unnecessary.

Not included for patients with permanent arteriovenous access.

Key areas for patient education

Patients with cathetersPatients with permanent arteriovenous access
1Hand hygiene1Hand hygiene
2General access care at home (e.g., bathing with a catheter)2Washing the access site prior to treatment
3Signs and symptoms of infection3General access care at home (e.g., do not scratch or pick at the site)
4How to respond if problems with the catheter develop outside of the dialysis center4Signs and symptoms of infection
5Risks associated with catheters / importance of permanent access5How to respond if problems with access develop outside of the dialysis center
6Basic infection control practices during catheter access process (as a mean to engage patients)6Basic infection control practices during cannulation process (as a mean to engage patients)

Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP).

References
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