Infection control

Chapter 10 Infection control


Infection control is used in the dialysis setting to prevent patients and staff from acquiring infections specific to the dialysis unit. Infection control incorporates policies and procedures that include surveillance and monitoring activities for water treatment, dialyzer reuse, bacterial contamination, and transmission of blood-borne and other infectious diseases.


The Centers for Disease Control and Prevention (CDC) has issued and updated blood-borne infection control strategies and precautions (including standard precautions) over the years for dialysis centers as well as for other healthcare agencies. The Centers for Medicare & Medicaid Services (CMS) new rules, which went into effect October 2008, require dialysis providers to follow the CDC documents “Recommendations for Prevention and Transmission of Infections among Chronic Hemodialysis Patients” (MMWR, 50[RR-5], 2001) and “Prevention of Intravascular Catheter-Related Infections” (MMWR, 51[RR-10], 2002).


The Occupational Safety and Health Administration (OSHA) has issued regulations that enforce the use of standard precautions and other infection control strategies for all healthcare agencies. The OSHA blood-borne pathogen regulations provide specific measures that healthcare workers and their employers can take together to substantially reduce the risk of healthcare workers contracting a blood-borne disease while on the job. The CDC has also issued recommendations for preventing the spread of drug-resistant organisms and other potentially infectious diseases such as tuberculosis.


This chapter reviews information that personnel are required to know to help prevent the spread of infectious diseases in dialysis facilities. It also includes a review of blood-borne diseases and standard precautions, as published by the CDC, as well as strategies to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and tuberculosis (TB). Questions commonly asked by dialysis personnel regarding water treatment, bacterial contamination, dialyzer reuse, and infection control issues are addressed in the specific chapters dealing with those subjects. Updated guidelines consistent with the October 14, 2008, CMS Conditions for Coverage will be addressed to reflect regulations applicable to both chronic in-center dialysis and home dialysis programs.


The CDC has issued specific recommendations for the prevention of blood-borne pathogens in dialysis facilities. Box 10-1 outlines these guidelines.



Box 10-1 Components of a Comprehensive Infection Control Program to Prevent Transmission of Infections among Chronic Hemodialysis Patients


Infection control practices for hemodialysis units:



1. Infection control precautions specifically designed to prevent the transmission of blood-borne viruses and pathogenic bacteria among patients


2. Routine serologic testing for hepatitis B virus and hepatitis C virus infections


3. Vaccination of susceptible patients against hepatitis B


4. Isolation of patients who test positive for hepatitis B surface antigen


5. All single-use injectable medications and solutions be dedicated for use on a single patient and not be punctured more than once


6. Surveillance for infections and other adverse events


7. Infection control training and education




What are standard precautions?


A recommendation that blood and body fluid precautions be used consistently for all patients, regardless of their blood-borne infection status, is the basic tenet of standard precautions. Blood-borne pathogens, such as the human immunodeficiency virus (HIV) and hepatitis B virus (HBV), infect people of all ages, of all socioeconomic classes, and from all geographic areas. Healthcare workers may not be able to identify patients who harbor a virus or who may transmit infection. The application of “standard precautions” assumes all patients are infectious.


Reducing exposure to and transmission of blood-borne pathogens through the use of standard precautions involves appropriate work practices, such as the use of barrier precautions. Appropriate barrier precautions are to be used to prevent skin and mucous membrane exposure in contact with blood or any other body fluid of any patient. Healthcare workers should wear the personal protective equipment that is most appropriate to the anticipated potential exposure. Barrier precautions, also known as personal protective equipment (PPE), include the use of the following:



• Gloves


• Face shields or masks and goggles


• Gowns or aprons


Gloves are to be worn for touching blood and body fluids, mucous membranes, or nonintact skin of all patients; for handling items or surfaces soiled with blood or body fluids; and for performing vascular access procedures where blood spill is likely. Gloves should also be worn when touching the patient’s equipment or other environmental surfaces. Disposable gloves are for single use only and come in a variety of materials such as vinyl, latex, and nitrile. Gloves are to be changed and hands washed after contact with each patient, whenever the gloves are bloodstained, and after handling infectious waste containers. Hand hygiene should be performed using soap and water or alcohol-based antiseptic hand rubs.


Masks and goggles or full face shields shall be worn during any procedure likely to generate droplets, blood splashes, or body fluids near the face. Masks should fully cover the nose and mouth. Goggles should fit snugly over and around the eyes. Personal eyewear, such as prescription glasses, are not a substitute for protective eyewear. Face shields should cover the forehead, extend below the chin, and wrap around the side of the face when worn properly. Initiating and terminating dialysis and troubleshooting the vascular access are examples of procedures that may increase a healthcare worker’s risk of exposure to blood-borne pathogens if barrier precautions, such as gloves, face shield, and impervious gowns or aprons, are not used.


Cover garments, such as impervious gowns or aprons, are to be worn during procedures likely to generate droplets, blood splashes, body fluids, potentially contaminated substances, or chemicals near the body. The protective garment should provide full protection to the arms and torso from the area of the neck to the thigh or knee. The use of protective aprons is appropriate only if they have incorporated sleeves. Before leaving the work area, all PPE should be removed and placed in a designated area or container for washing, decontamination, or disposal. Hands should be thoroughly washed after the removal of PPE and before leaving the work area. In addition to barrier precautions, employee work practices, such as diligent handwashing, are essential in order to reduce risk of exposure to and transmission of blood-borne pathogens.


Employee work practices include precautions that healthcare workers should take to prevent injuries caused by needles, scalpels, and other sharp instruments that may be responsible for the transmission of blood-borne diseases.


Precautions should be taken in the following situations: when cleaning used instruments, during disposal of used needles, and when handling sharp instruments after procedures. Needles should not be recapped, purposely bent, or broken by hand; removed from disposable syringes; or otherwise manipulated by hand. After use, disposable syringes and needles, scalpel blades, and other sharp items must be placed in puncture-resistant containers located as close as practical to the use area.


Sharps containers should not be mounted too high, but should be easily accessible. They also should not be allowed to overfill.


To minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, pocket masks, resuscitation bags, or other ventilation devices should be available for use in areas where the need for resuscitation is predictable.


Healthcare workers with exudative lesions or weeping dermatitis should refrain from direct patient care and from handling patient equipment until the condition resolves. All skin defects (cuts, abrasions, ulcers, etc.) must be covered with an occlusive bandage.


Pregnant healthcare workers are not known to be at greater risk of contracting HBV or HIV infection than healthcare workers who are not pregnant; however, if a healthcare worker develops HBV or HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Therefore, pregnant healthcare workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HBV or HIV transmission.



Why is handwashing so important?


The most common method of transferring pathogen from patient to patient or staff to patient is by the hands. Handwashing reduces the risk of transferring contamination from hands to other individuals, to other areas of the body, or to the other surfaces the healthcare worker may later contact. Hands should be washed when entering or leaving patient care areas, before gloving and immediately after removal of gloves or other personal protective equipment, in between patient contacts, and after touching an environmental surface such as the dialysis machine without having gloved first. Dialysis facilities must identify and dedicate “clean” sinks used for handwashing purposes only. Care must be taken not to use the “clean” sink for draining fluids or for placing items that have been used in the course of the patient treatment. Sinks must also be made available to patients to wash their access sites and hands before treatment.


It is important to remember that gloves should never be used as a replacement for handwashing.


Adherence to handwashing guidelines is essential to provide safe patient care. Handwashing should always be performed after gloves are removed. The CDC has issued guidelines on the use of alcohol-based hand rubs as an alternative to using traditional soap and water when providing patient care: before patient contact; after contact with a patient’s intact skin, body fluids or excretions, nonintact skin, or wound dressings; and after removing gloves. The traditional method of handwashing with soap and water is indicated when hands are visibly dirty, contaminated, or soiled.


When handwashing with soap and water, the hands should be rubbed together for at least 15 seconds followed by a rinse. When decontaminating with an alcohol-based hand rub, the product should be applied to the palm of the hand and the hands rubbed together until dry. Some dispensers can be set to deliver the exact amount of soap or hand rub recommended by the manufacturer.


The length of fingernails should be considered because studies have documented that long fingernails (>¼ inch) may harbor high concentrations of bacteria. Even after careful washing, long fingernails may harbor significant numbers of pathogens—such as gram-negative rods, corynebacteria, and yeasts—in the subungual space. Artificial fingernails also contribute to the spread of certain gram-negative pathogens and should not be worn when providing care to patients who have compromised immune systems. This is extremely important to keep in mind when caring for those with a high risk of developing infections.



What are specific examples of standard precautions in a dialysis unit?


Standard precautions in a dialysis unit can be summarized into four main categories:



• Barrier precautions and PPE, such as gloves, face shields, masks, protective eyewear, gowns, and aprons


• Protection against penetration caused by sharps


• Good personal hygiene


• Good environmental control and avoidance of environmental contamination


During initiation and termination of dialysis, or any time there is a risk of exposure to blood-borne pathogens, a mask, protective eyewear (goggles or face shield), and gloves must be worn. An impervious gown or plastic apron should be worn if there is likely to be blood splashed. A sharps container should be positioned within reach of the patient caregiver so that the needle can be disposed of immediately without it having to be placed down and picked up a second time. Hands must be washed after removing gloves and before touching any environmental surfaces, such as machine knobs, charts, phones, or other equipment. Eating, smoking, applying cosmetics, or handling contact lenses in the treatment room must be prohibited. Good environmental controls include maintaining separate areas for clean and soiled areas, as well as adequately cleaning and disinfecting the treatment area and equipment in contact with the patient, such as chair and blood pressure cuff.



What is the needlestick safety and prevention act?


The Needlestick Safety and Prevention Act went into effect on April 18, 2001, with a goal of protecting healthcare workers from accidental exposure to blood-borne diseases. The CDC estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital personnel. This does not include needlesticks sustained in other settings such as long-term or home healthcare locations or private offices.


This law applies to any facility that is bound by federal OSHA regulations where an employee may be exposed to blood or other potentially infectious material. This Act requires healthcare employers to provide their employees with safety-engineered sharp devices. Employers must also maintain a log of injuries from contaminated needlesticks. Information to be collected must solicit exposure information on type and brand of device causing the injury, department where the injury occurred, and how the injury was sustained. Employers are required to obtain employee input when choosing safer needle devices, and staff must be properly trained in the appropriate use of safe needle devices used in their facility.



What are the most significant blood-borne pathogens?


A blood-borne pathogen simply means a microorganism (usually a virus) transmitted in the blood or body fluids that can cause disease in humans. The most significant blood-borne pathogens are HBV, hepatitis C virus (HCV), and HIV. Efficiency of transmission varies among the viruses because of the number of viruses present in the blood. The risk of infection will vary and is dependent on the pathogen involved, the type of exposure, the amount of blood involved, and the amount of virus in the patient’s blood at the time of the exposure.



What is hepatitis?


Hepatitis is an inflammation of the liver caused by infectious agents, medications, or toxins. There are several types of infectious hepatitis but the most common types are hepatitis A (HAV), HBV, and HCV. The CDC estimated that 12,000 HBV infections occurred in healthcare personnel in 1985. The number declined to an estimated 500 in 1997, largely because of the widespread immunization of healthcare workers and the use of standard precautions. The three hepatitis viruses are transmitted through different routes. Vaccines are available for both HBV and HAV. No vaccine exists at this time for HCV.



How infectious is hepatitis B?


HBV is a highly transmissible virus because of the high concentration of the virus in the blood of infected people (1 mL of HBsAg-positive blood may contain 100 million infectious doses of virus) and the ability of the virus to survive for several days on environmental surfaces at room temperature. The CDC estimated 46,000 new infections in 2006 and an estimated 800,000 to 1.4 million people with chronic HBV infection (CDC, 2009).



How is hepatitis B transmitted?


In the dialysis unit, exposure to blood with the possibility of HBV transmission can be either direct or indirect. Direct exposure consists primarily of penetration of the skin (percutaneous) by sharp objects, such as needles, scalpels, and broken capillary tubes, or blood on broken skin and on mucous membranes of the eyes, mouth, or nose.


Indirect exposure involves transmission from environmental surfaces, such as clamps, control knobs on dialysis machines, and doorknobs.


The most common ways that HBV is spread in dialysis units are by penetration of the skin by sharps and by contact of blood with broken skin or mucous membranes.

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Jul 24, 2016 | Posted by in NURSING | Comments Off on Infection control

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