Download Session 2 Training Slides - Fistula First

National Healthcare Associated Infections (HAIs)
Learning and Action Network Event
Standard Precautions, Your First Line of Defense.
December 11th, 2014
Meeting Host
Vicky Cash,
NCC Assistant Director of Quality Improvement
Meeting Objectives
 Understand disease transmission differences of
infectious diseases in ESRD
 List 5 key elements of standard precautions
 Identify correct procedures to adhere to standard
precautions
 Verbalize the importance of adherence to these
precautions in caring for ESRD patients
 Identify violations in standard precaution compliance
 Learn about tools that can help to improve correct use of
standard precautions in your setting
Review of Disease Infectious Disease Process
Brian S. Koll, MD, FACP, FIDSA
Executive Director, Infection Prevention
Mount Sinai Health System
4
Infections in ESRD Patients
 2nd most common cause of death accounting for nearly
14% of deaths
 Risk for infection increased
 Immunosuppression
 Need for routine access of bloodstream for treatment
 Risk for antimicrobial resistant organisms
 Exposure to antimicrobials
 Frequent hospitalization
 7.7 – 34.7/100 patient months
Klevens RM, Edwards JR, Andrus ML, et al. Seminars in Dialysis 2008; 21: 24 – 28
Infections in ESRD Patients
Tokars JI, Miller ER, Stein G. Am J Infect Control 2002;30:288-295
Blood Stream Infections
Klevens RM, Edwards JR, Andrus ML, et al. Seminars in Dialysis 2008; 21: 24 – 28
Transmission of Pathogens
in Dialysis
 Susceptible person
 Source of pathogens
 Transmission
 Contact transmission
 Healthcare worker hands or environment
 Medications
 Bacteria, hepatitis
 Droplet transmission
 Healthcare worker hands or environment
 Influenza
 Airborne transmission
 TB, varicella
8
Infection Prevention

Hand hygiene

Personal Protective Equipment

Safe Injection Practices

Safe Handling of Medications

Separation of Clean from Contaminated Areas

Aseptic Technique for Vascular Access Care
9
Transmission pathways
 Colonized/infected patient contaminates the
environment
 Organism able to survive in the environment anywhere
from hours to days
 Organism remains virulent after environmental
exposure on surfaces frequently touched by healthcare
workers
 Transmission directly or via the contaminated hands of
healthcare workers
 Ability to colonize patients newly admitted to an area
inadequately cleaned
Survival of Pathogens on
Environmental Surfaces
Staphylococci • 6 months
C. difficile
VRE
• > 5 Months
• 4 months
Acinetobacter • 4 months
Rotavirus
• 3 months
Norovirus
• 3 weeks
Adenovirus
• 3 weeks
Influenza
• 3 days
Environmental Cleaning
Infection Prevention –
Bacterial and Viral Infections
 ESRD patients at increased risk for spreading bacteria
or viral pathogens to other patients
 Open or infected skin wound with drainage that is not
contained by dressings
 Fecal incontinence or uncontrolled diarrhea
 In addition to PPE, dialyze at a station with as few
adjacent stations as possible near the end or corner of
the room
 Respiratory illness and a fever
 Offer surgical mask
 Dialyze at least 6 feet away from other patient stations
or any shared supplies
Infection Prevention –
Vaccinate
 Influenza Vaccine
 Protects against two types of influenza A and influenza
B
 Reduced severity of H3N2 if infected
 Pneumococcal Vaccine
 PCV13 followed by PPSV23
 If already vaccinated with PCV13, give PPSV23
 Hepatitis B
15
17
Standard Precautions
Minimum infection prevention expectations for safe care in ALL healthcare
settings
Sally Hess, BS, MPH, CIC
UVM Medical Center
[email protected]
December 11, 2014
Slides based on CDC Dialysis Online CE Course
PPE photo provided by Rosetta Jackson, used with permission
Standard Precautions
for all Healthcare Workers
Five Key Elements
1. Hand hygiene
2. Personal protective
equipment (PPE), gloves,
gowns & masks
3. Safe injection practices
4. Safe handling of potentially
contaminated equipment or
surfaces in the patient
environment
5. Respiratory hygiene/cough
etiquette
Universal or Standard
Precautions?
 Universal Precautions: Prevention of blood-borne
pathogen transmission (1985 – 1987)
 Standard Precautions: Foundation for preventing
transmission of infectious agents in all healthcare
settings.
 1996 Guideline for Isolation Precautions in Hospitals
 2001 CDC Hemodialysis recommendations
 2007 HICPAC Isolation Precaution Guideline
 Respiratory hygiene/cough etiquette,
 Safe injection practices,
 2008 CMS Conditions for Coverage
WHO needs to know about
hand hygiene?
 Any health-care worker,
caregiver or person involved in
direct or indirect patient care
needs to be concerned about
hand hygiene and should be
able to perform it correctly and
at the right time
 This includes patients, family
members and visitors
When Should Hand Hygiene best
practices be performed?

Before touching a patient

Before you inject or infuse
a medication

Before you cannulate a
fistula/graft or access a catheter

After you touch a patient

After you touch blood, body fluids,
mucous membranes, wound
dressings, or dialysis fluids
(e.g., spent dialysate)

When moving from a contaminated body site to a
clean body site during patient care

After touching medical equipment or other items at the
dialysis station

After gloves removal
Remember: perform hand
hygiene between each
patient or station
Hand Hygiene Choices
 Wash your hands with soap and water
 When hands are visibly dirty or visibly soiled with blood or other body
fluids
 When caring for a patient with C. difficile
 or after using the toilet.
 Clean your hands with an alcohol-based hand rub
 Preferred method for routine hygienic hand antisepsis if hands are not
visibly soiled.
 It is faster, more effective, and better tolerated by your hands than
washing with soap and water.
Hand care
• Take care of your hands by
regularly using a protective hand
cream or lotion, at least daily
• Do not routinely wash hands with
soap and water immediately
before or after using an alcoholbased handrub
• Do not use hot water to rinse your
hands
• After handrubbing or handwashing,
let your hands dry completely before
putting on gloves
Please remember
• Do not wear artificial fingernails
or extenders when in direct
contact with patients.
• Keep natural nails short.
Use Personal Protective Equipment
(PPE) Correctly: For your own protection
and to protect patients




Wear gloves, a gown, and/or face
protection when you think you
may come into contact with blood
or other potentially infectious
materials
Change gloves during patient care
if the hands will move from a
contaminated body-site to a clean
body-site
Remove gloves after contact with
a patient and/or the surrounding
environment (including medical
equipment)
Do not wear the same pair of
gloves for the care of more than
one patient
Wear Gloves During Patient Care:
For Your Own Protection
 Wear disposable gloves when caring for the patient or touching
equipment at the dialysis station
 Wear gloves when cleaning surfaces in the environment or medical
equipment
 Remember to remove gloves and perform hand hygiene between
each patient or station, and if moving from a contaminated to clean
area of the same patient or within the same dialysis station
Use Personal Protective Equipment
(PPE): For Your Protection
In addition to gloves, you should
wear gowns and face protection to
protect yourself as needed:
 During initiation and termination of
dialysis
 When cleaning dialyzers
 When handling lab samples
 PPE should be changed if it
becomes dirty
Photo provided by Rosetta Jackson,
used with permission
Safe Injection Practices

Medications are injected directly or
indirectly into the patient’s bloodstream

Any germs that have entered the
medication vial or syringe can cause
serious infections in the patient

Germs also can be introduced at the time
of injection (e.g. contaminated injection
port)
Safe Injection Practices
Three things you need to know:
1. Needles and syringes are single use
devices. They should not be used for
more than one patient.
2. Do not administer medications from a
single-dose vial or IV bag to multiple
patients.
3. Perform hand hygiene and disinfect the
access port before injecting into it.
Saline bags are
always single
patient use
Safe Use of Medication Vials
 Prepare all individual patient doses in
a clean area away from dialysis
stations
 Prepare doses as close as possible to
the time of use
 Do not carry medications from station
to station
 Do not prepare or store medications at
patient stations
 CDC recommends that dialysis
facilities:
 Use single-dose vials whenever
possible and dispose of them
immediately after use
Separate Clean Areas from
Contaminated Areas
 Clean areas should be used for
the preparation, handling and
storage of medications and
unused supplies and equipment
 Your center should have clean
medication and clean supply
areas
Clean area
 Contaminated areas are where
used supplies and equipment are Photo provided by Stephanie Booth, used with permission
handled
 Do not handle or store
Remember:
medications or clean supplies in
Treatment stations are
the same area as where used
contaminated areas!
equipment or blood samples are
handled
Dedicate Supplies to a
Single Patient
 Any item taken to a patient’s
dialysis station could become
contaminated
 Items taken into the dialysis station
should either be:
 Disposed of, or
 Cleaned and disinfected before
being taken to a common clean
area or used on another patient
 Unused medications or supplies
taken to the patient’s station should
not be returned to a common clean
area (e.g., medication vials,
syringes, alcohol swabs)
Photo provided by Marshia Coe and Teresa Hoosier, used with permission
Guidelines for Carrying
Medications
 Do not use the same medication cart to deliver
medications to multiple patients
 Do not carry medication vials, syringes, alcohol
swabs, or supplies in pockets
 Be sure to prepare the medication in a clean area
away from the patient station and bring it to the
patient station for that patient only at the time of
use
Cleaning and Disinfecting the
Dialysis Station
 Cleaning and disinfection reduce the risk of spreading an
infection
 Cleaning is done using cleaning detergent,
water and friction, and is intended to
remove blood, body fluids, and other
contaminants from objects and surfaces
 Disinfection is a process that kills many
or all remaining infection-causing
germs on clean objects and surfaces
 Use an EPA-registered hospital disinfectant
 Follow label instructions for proper dilution
 Wear gloves during the cleaning/disinfection process
Disinfecting the Dialysis
Station
 All equipment and surfaces are considered to be
contaminated after a dialysis session and therefore
must be disinfected
 After the patient leaves the station,
disinfect the dialysis station
(including chairs, trays, counters,
and machines) after each patient
treatment
 Wipe all surfaces
 Surfaces should be wet with disinfectant and allowed to air dry
 Give special attention to cleaning control panels on the dialysis
machines and other commonly touched surfaces
 Empty and disinfect all surfaces of prime waste containers
Photo provided by Stephanie Booth, used with permission
Safe Handling of Dialyzers and
Blood Tubing
 Before removing or transporting
used dialyzers and blood tubing,
cap dialyzer ports and clamp
tubing
 Place all used dialyzers and
tubing in leak-proof containers for
transport from station to
reprocessing or disposal area
 If dialyzers are reused, follow
published methods (e.g., AAMI
standards) for reprocessing
 AAMI is the Association for the
Advancement of Medical
Instrumentation
Photo provided by Stephanie Booth, used with permission
Respiratory Hygiene/Cough Etiquette
 Visual Alerts:
 Post signs at entrances with instructions to patients with symptoms
of respiratory infection to:
 Respiratory Hygiene – educate patients & staff
 Cover their mouths/noses when coughing or sneezing
 Use and dispose of tissues
 Perform hand hygiene after hands have been in contact with
respiratory secretions
 Provide tissues and no-touch receptacles for disposal of tissues
 Provide alcohol based hand sanitizer for performing hand hygiene in
or near waiting and treatment areas
 Masking and separation of persons with respiratory symptoms
 Offer masks to coughing patients and other symptomatic persons
upon entry to the facility
 In waiting room - Provide space and encourage persons with
symptoms of respiratory infections to sit as far away from others as
possible.
Respiratory Hygiene and Cough Etiquette

Educate HCP on how to
prevent the spread of
respiratory viruses
during patient care.

Educate patients and
families

Monitor seasonal
influenza vaccination
rates of patients and
HCW’s
Summary
 Promote hand hygiene compliance
 Wear gloves, gown and other personal protective
equipment for all patient care
 Promote safe injection practices and vascular access
safety
 Use medication vials safely
 Separate clean areas from contaminated areas
 Clean and disinfect the dialysis station between
patients
 Perform safe handling of dialyzers
 Enforce respiratory hygiene/cough etiquette
Standard Precautions in Practice
Heather Weirich, BSN, RN, CNN
Education Coordinator
Independent Dialysis Foundation
Importance of Standard
Precautions
Infections:
A Major Patient
Safety Problem in
Dialysis
2nd Leading Cause
Of Death
Proceedings of “ESRD: State of the Art and Charting the Challenges for
the Future” Boston MA, April 2009, Ritz, CANS 2009
The Challenge of the “Perfect Storm”
in Hemodialysis
ESRD patients are
immunosuppressed
Why Hand Hygiene & Surface
Disinfection Are Vital
Organisms remain viable on surfaces for prolonged periods
• Hepatitis B
>1 week
• Hepatitis C
16 hours to 4 days
• Influenza
1-2 days
• MRSA
7 days to 7 months
• VRE
5 days to 4 months
• C. Difficile spores
5 months
Healthcare workers touch as many as 7 surfaces
after touching a contaminated one!
McLaughlin AC, Walsh F. Am J Infect Control 39(6):456-463, 2011
Kramer A, Schwebke I, Kampf45G. BMC Infect Dis 6:130, 2006
Putting it together
 How can dialysis patient infections be prevented?
 By adherence to good infection prevention and control practice.
 Who sets those practices?
 The Centers for Disease Control and Prevention (CDC) identifies
these practices for dialysis facilities.
 How are those practices tied to my work?
 CDC guidelines are incorporated into the ESRD CMS Conditions for
Coverage under infection control practices.
 How does CMS know we are following CDC infection control
standards?
 When the state surveyors come to your facility they watch for your
adherence to these standards.
 What do these observations tell us?
Opportunities for Improvement
Infection control ALWAYS most frequently cited –
HUGE opportunities for improvement.
PDQ Data FY 2014: 1,293 recert surveys uploaded
And They Thought It Was
Clean!
“Disinfected” Control Panel of HD Machine:
Possible Blood Visible with Luminol
Bergervoit PWM et al, Application of the forensic Luminol for blood in
infection control,* J Hosp Infection (2008), 68, 329-333
And They Thought It Was
Clean! (cont.)
“Disinfected” Side Table in HD Clinic:
Possible Blood Visible with Luminol
Bergervoit PWM et al, Application of the forensic Luminol for blood in
infection control,* J Hosp Infection (2008), 68, 329-333
And They Thought It Was
Clean! (cont.)
FOR MORE INFORMATION
Vicky Cash
Assistant Director of Quality Management
(440) 724-2054 [email protected]
Shannon Wright
NCC Project Director
(919) 463-4512 [email protected]
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