By Megan M. Krischke, contributor
June 26, 2012 - Health care workers are endeavoring to reduce health care acquired infections, including those that occur in the nephrology specialty, where patients suffering from kidney failure are already immunocompromised and more susceptible to infection. The process of receiving dialysis necessarily breaks the body’s skin barrier, thus further increasing a patient’s risk of acquiring an infection.
“Those patients who must have catheters undergo a constant breach of their skin barrier. Those with central venous catheters are at greatest risk for infection because they have a pathway from the outside world straight to their hearts,” explained Glenda Payne, MS, RN, CNN, president of the American Nephrology Nurses Association (ANNA). “Infection is the second leading cause of death in dialysis patients, after cardiovascular problems.”
The Centers for Disease Control (CDC) recently collaborated with the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) on a project to raise awareness for the need for infection prevention in dialysis treatment. Checklists have been created to serve as easy tools to evaluate the consistency and effectiveness of infection prevention techniques.
Among the tools available from the CDC is a list of six Core Interventions for Dialysis Blood Stream Infection Prevention. These core interventions, proven effective by pilot programs, include:
- Surveillance and feedback using the National Healthcare Safety Network;
- Hand hygiene surveillance;
- Catheter care/vascular access observations;
- Patient education/engagement;
- Staff education and competency; and
- Catheter reduction.
“One of the most important things I think we need to focus on from the nursing perspective is that we don’t want to think ‘infection control’ anymore--we want to think prevention. This includes not only bloodstream infections, but diseases that can be prevented through vaccination, such as Hepatitis B, flu and pneumonia,” stated Kerri Holloway, RN, CNN, clinical quality manager and infection control specialist for Fresenius Medical Care, the largest dialysis provider in the United States, and ANNA representative to the CDC.
“Along those lines,” added Payne, “it isn’t just the patients who should be vaccinated, but all the health care workers interacting with them.”
Glenda Payne, MS, RN, CNN, ANNA president, notes that preventing infections isn't difficult but it takes time and requires understanding.
“One of the keys to infection prevention is patient education. They need to understand that they are at increased risk and that they need to do all they can as well as help monitor what others do,” Payne said. “I have always told my patients, ‘You are the only person who is always here.’ The patient should be educated regarding what they should expect from their caregivers. Then, if they experience a variation in their treatment, they should politely but firmly question the actions of the person working with them.”
In addition to making the patient an active partner by knowing what to expect and ensuring that their caregivers are following protocol, the patient needs to wash the skin surrounding their access before they sit down in the dialysis chair. They also need to know not to manipulate their catheter and to bring up any concerns they have about their access with their nurse or medical care provider.
“It is the responsibility of the nurse to be certain that all of the care team follows good infection control techniques. Nurses should ensure that their hands are as clean as possible before approaching the patient and wear gloves. All caregivers should change gloves and use hand hygiene between patients,” noted Payne.
“While this isn’t complicated, the busy environment in the dialysis unit presents a challenge. As soon as one patient leaves, another is coming in to occupy the vacant chair.” Payne pointed out that, in the rush, staff could potentially skip steps such as ensuring the chair is completely clean and the machine sanitized. “If health care workers aren’t educated about the risks involved, they are more likely to skip steps as they hurry to get to the next patient.”
Patients who use a catheter are at the greatest risk of infection. Those patients with a central line are twice as likely to die and seven times as likely to acquire an infection. There is, therefore, an initiative to avoid the use of catheters when possible and quickly remove catheters when they must be used.
Kerri Holloway, RN, CNN, suggests that the checklists and audits provided by the CDC can help dialysis providers reduce infections.
“At our facilities, if a patient comes in with a catheter, we immediately start the process of getting them to a surgeon for an evaluation to see if they can get a fistula or a graft instead. We have vascular access coordinators whose main focus is to get catheters removed as quickly as possible. Ideally, the catheter can be removed within the first 90 days of treatment,” stated Holloway.
There is also a push for early placement of fistulas in patients who are at risk for needing dialysis.
“Sometimes renal failure patients have another health crisis that causes an urgent need for dialysis and the only option at that point is a catheter. There has been some push-back about placing fistulas before dialysis is required because of the potential waste of resources, but a study done in Canada showed that 80 percent of fistulas placed before needed were eventually used. Early placement of fistulas can be an important move to protect our patients from future infections,” remarked Payne.
For nurses and other dialysis staff who wish to learn more about how they can actively prevent infections in their patients, the CDC has created a free continuing education course entitled Infection Prevention in Dialysis Settings. The one-hour, self-guided training covers infections that patients can get from dialysis, infection control recommendations for outpatient hemodialysis health care workers, and educating patients and their caregivers.
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