Part Three

- Standard procedures for infection control within the dialysis unit

introduction:

◾ The dialysis process is performed by two basic methods: hemodialysis and peritoneal dialysis.

◾ The dialysis process entails some risks for the patient, as penetration into his blood vessels and the introduction of foreign bodies into his body may lead to an increase in the possibility of infection. This is due to the fact that the process requires dealing with naturally sterile places, such as the vascular system or the peritoneal cavity, and infection may occur due to contamination that may occur. In the procedures of various dialysis sessions, or the reason for this is the presence of contamination in any of the components of the dialysis system.

◾ The patient may also be exposed to infection with microbes or poisoning resulting from contamination of the water used to prepare for the dialysis process. The person caring for the patient may, by virtue of his profession, be exposed to infection with microbes present in the patient’s blood, as dialysis patients have an increased prevalence of blood-transmitted diseases.

◾ Infection and side effects may result from non-compliance with infection control procedures. Transmission of infection through contact is considered one of the most important ways by which microbes are transmitted in dialysis units. The process of transmission of infection from one patient to another is determined by the hands of the health care provider, where the health care provider By dealing with patients and touching the environment around them and the surfaces of dialysis machines, then the infection can be transmitted from one patient to another. The risk of infection or the occurrence of side effects in the dialysis unit can be reduced by strictly adhering to infection control recommendations, as well as by performing maintenance on the equipment used in the units and monitoring. Details of all procedures that may lead to bacterial or chemical contamination inside dialysis units.

◾ The most common types of infections associated with the dialysis process

◾ Infection with blood-borne microbes (such as human immunodeficiency virus - hepatitis B and C viruses)

◾ Bacteremia

◾ Peritonitis

◾ Infection of the site of entry into the body (the site of entry into the organ system or into the peritoneal cavity

First: blood dialysis

◾ Hemodialysis helps in getting rid of toxins, ionized mineral salts, and fluids by circulating the patient’s blood through hemodialysis (artificial kidney). The main components of the hemodialysis process are a venous-arterial connection, a system for treating water, another for distributing it, and dialysis solution ( To purify blood and its components), washing machines, and blood passage tubes (filters and connectors).

◾ Entry ports into the patient’s vascular system

◾ Access to the vascular system is achieved through some means, such as making external arteriovenous shunts, or internal arteriovenous fistula, or arteriovenous fistula using surgical grafting of blood vessels, or other temporary devices such as using a central venous catheter through the jugular vein.

◾ (Jugular vein), or subclavian vein.

Infection control measures during hemodialysis sessions

◾ Procedures for connecting the patient to the dialysis machine via the arteriovenous fistula connection and separation procedures Infection control recommendations are followed when connecting the patient to dialysis machines or a dialysis machine, taking into account the following:

◾ Wash hands or rub them with alcohol before the procedure.

◾ Wear appropriate personal protection (clean gloves - single-use plastic apron), and other tools may be required (such as eye protection - surgical mask) according to the risk assessment before the procedure.

◾ Use sterile cotton or gauze when connecting or disconnecting.

◾ Disinfect the insertion site before connection and after separation with an appropriate antiseptic (such as povidone-iodine 10% iodophore) taking into account the contact time.

◾ Follow the anti-contamination method when connecting or disconnecting the patient to the dialysis machine.

◾ Pressure is applied to the site of the fistula after separation and it is covered with sterile gauze. Then the medical tape is placed over the sterile bandage. It is not allowed to place the tape directly over the fistula.

◾ Take off personal protective equipment after completing the procedure, then wash your hands.

◾ Procedures for connecting the patient to the dialysis machine via a central venous catheter and separation procedures

◾ Wash hands hygienically or rub them with alcohol before the procedure.

◾ Wear appropriate personal protective equipment (such as sterile gloves - single-use plastic apron) before the procedure.

◾ Use sterile cotton or gauze when connecting or disconnecting.

◾ Disinfect the insertion site of the central venous catheter using sterile gauze saturated with an alcohol solution (60-95%) before connection and after disconnection, taking into account the contact time.

◾ Follow the anti-contamination method when dealing with the central venous catheter when connecting the patient to the dialysis machine or disconnecting it.

◾ The entry site of the central venous catheter is covered with sterile gauze, then the medical tape is placed over the sterile bandage. The tape is not allowed to be placed directly over the catheter.

◾ Take off personal protective equipment after completing the procedure and washing hands

Second: Washing using a peritoneum membrane

◾ Peritoneal dialysis removes toxic substances, mineral salts, and ions by spreading through the peritoneal membrane. Peritoneal dialysis requires placing a catheter in the abdominal area that reaches the peritoneal cavity, where the dialysis solution is inserted and then drained from that place successively.

◾ The main components of peritoneal dialysis include the following:

◾ Inserting a catheter into the peritoneal cavity, which can be placed without surgery or through a surgical cut.

◾ The solution is a solution available for commercial use, in glass containers, polyvinyl bags, or washing operations.

◾ Determine and organize the process of introducing the solution into the peritoneal cavity and dispensing it using a precise schedule and system for the number of hours of the dialysis process.

◾ Dispose of the patient’s fluid in the sewer.

Second: Washing using a peritoneum membrane

◾ The main components of peritoneal dialysis include the following:

◾ Inserting a catheter into the peritoneal cavity, which can be placed without surgery or through a surgical cut.

◾ The solution is a solution available for commercial use, in glass containers, polyvinyl bags, or washing operations.

◾ Determine and organize the process of introducing the solution into the peritoneal cavity and dispensing it using a precise schedule and system for the number of hours of the dialysis process.

◾ Dispose of the patient’s fluid in the sewer.

Notice

◾ There are three types of infections that may result from peritoneal dialysis, such as catheter site infection, subcutaneous catheter tract infection, or peritonitis.

◾ The sources of infection are the patient’s skin, the washing solution, or the health service provider.

◾ The cause of infection related to the catheter is due to the way it is installed and cared for.

Precautions that must be followed when performing peritoneal dialysis:

· An anti-contamination method must be followed during the installation and connection of the peritoneal dialysis catheter, as well as during the procedures for changing the dialysis solution.

· Sterile gloves are worn while installing the peritoneal dialysis catheter and when handling it.

· A surgical mask is used during connection and separation procedures to reduce the risk of infection with Staphylococcus bacteria (Staph. Aureus) transmitted through the nose.

· The external site of the catheter should be kept clean and dry.

· The catheter should be well secured in a way that reduces the chances of it being removed spontaneously and causing wounds to the surrounding skin area.

· The patient should be made aware of the appropriate methods for caring for the external site of the catheter in the event of continuous frequent washing outside the hospital, and patients and staff should monitor early signs of infection if they occur.

Procedures to control the transmission of infection to patients and the health team in dialysis units:

· It is necessary to wash hands, disinfect them, or rub them with alcohol if they are apparently clean, before dealing with it.

· Workers in dialysis units must wear appropriate personal protection to prevent their exposure to blood when blood spills or spray occur as a result of a cut or rupture in the dialysis connections or dialysis filter membranes, as this occurs in the event of increased pressure inside these connections.

· Clean, single-use gloves must be used before performing any procedure that does not penetrate the body’s natural defenses, and when dealing with various surfaces and tools, including the dialysis machine. These gloves can be used to connect the patient to the dialysis machine, with the need to adhere to the non-touch method.

· Sterile gloves must be used when installing a central venous device or installing a peritoneal dialysis catheter.

· A member of the health team is allocated to transfer supplies from the warehouses to a central place in the dialysis halls. This member does not deal with patients during dialysis sessions.

· The central place is not handled by the person in charge of the process of connecting or disconnecting the patient to the dialysis machine, but rather through the handling nursing staff.

· In the event that nursing staff members are not available to handle them, the nursing staff prepares the delivery or separation supplies for one patient only immediately before the procedure and does not leave any supplies on the machines during the washing sessions.

· All tools used in dialysis that were handled once or were taken to a specific patient’s station must be disposed of immediately after use. (If it is intended for use again) or clean, disinfect or sterilize it before reusing it again or before storing it (if it is multi-use).

· A separate place must be allocated to install central venous catheters for patients outside the dialysis room.

· A set of sterile supplies and tools must be prepared for each patient when connecting via central venous catheters.

· Heparin must be prepared immediately before using it for the patient, and an anti-contamination method must be followed when giving it to the patient during a dialysis session.

· Patients should be instructed on the correct way to care for the insertion site of dialysis catheters.

Kidney dialysis machines

· Blood pump: The blood pump consists of two or more cylinders, and the patient’s blood is pumped through a group of tubes and a dialysis machine at constant and accurate flow rates.

· Liquid passages inside the washing machine:

There are three types of dialysis machines, which are as follows:

· Recycling machines

· These machines recycle the washing solution continuously through the washing machine during the dialysis process.

· Single-pass recycling machines:

· These machines continuously recycle the solution through the washing machine during the dialysis process, and with a continuous flow of new solution, the washing solution is partially replaced.

· Single-pass machines

· Single-pass machines produce a continuous flow of washing solution, which passes through the machine and is then disposed of without being recycled.

Recommendations

· It is preferable to use single-pass machines, as the internal fluid passages of these machines are not exposed to blood contamination unless a blood leak occurs in the single-pass machine. Contamination of single-pass machines is usually due to how well the water or other components of the solution used in washing are treated.

· Blood tubes:

To avoid blood contamination with bacteria and contamination of blood tubes, the following procedures should be followed:

· Keep intravenous tubes away from the waste container during the process of preparing the dialysis machine.

· Hands should always be washed after handling waste.

· Disinfect containers designated for disposal of waste resulting from the filtration process daily.

· Cleaning and disinfecting the outside of dialysis machines.

· Disinfecting the internal and external pipes for the washing solution.

Cleaning and disinfecting dialysis machines

· The external surfaces of the machine must be cleaned and disinfected after each patient.

· The internal and external pipes for the washing solution must be disinfected.

· The manufacturer’s instructions must be followed, provided that they are written.

· Carry out rinsing and disinfection procedures for the single-pass machine at the beginning and end of the day or according to the manufacturer’s instructions.

· For recycling machines (currently rarely used), rinsing and disinfection procedures are carried out between one patient and another.

· The same cleaning and disinfection methods are followed if blood leakage does not occur, regardless of the type of dialysis machine used.

· You must follow the instructions of the manufacturer of the disinfectant used to disinfect the dialysis machine.

· Cleanliness of the environment in the dialysis unit

· Policies and protocols must be written for cleaning and disinfecting surfaces and equipment in the dialysis unit, including careful cleaning before carrying out any disinfection process.

· The patient’s station must be cleaned and disinfected after the dialysis session, including the dialysis bed, various nearby surfaces, dialysis solution containers, and waste containers.

· Covers and bedsheets must be changed between each patient.

· The hazardous waste bag should be disposed of immediately at each session.

· Spills of blood and other fluids should be dealt with immediately when they occur.

· The rest of the standard infection control procedures regarding environmental cleanliness are followed.

· Monitoring the quality of water used in the dialysis process

· A work crew must be appointed to be responsible for the initial and routine control of the water used to perform the dialysis process. The members of this crew must be fully aware of the various aspects related to water treatment and distribution systems, and they must have the authority to investigate problems related to the quality of the water used in The dialysis process and working to solve these problems.

· The specifications of the water used in the dialysis machine must conform to the standards of the Ministry of Health stipulated in Ministerial Resolution No. 63 of 1996 and its amendments. Microbiological and chemical monitoring of the water must be carried out at least once a month in accordance with this ministerial decision.

Microbiological monitoring:

· Microbiological monitoring of treated water must be carried out at least once a month, and the number of times may increase if any problems are proven.

· Samples of water used in dialysis must be collected at the point where the water reaches the machine.

· Water samples used in dialysis must be collected during or after the end of the dialysis process.

· The total numbers of live bacteria present in the water used for dialysis must not exceed 200 bacterial colony units per milliliter. The total numbers of live bacteria present in the dialysis solution must not exceed 200 bacterial colony units per milliliter.

· The presence of coliforms and Escherichia coli (E. Coli) is not allowed in the water of dialysis units.

· The presence of Pseudomonas bacteria, Enterococcus 'Streptococcus' faecalis, and Anaerobic Sulfur Reducing Bacteria is not permitted in the water of dialysis units.

Kidney dialysis machines

· Blood pump: The blood pump consists of two or more cylinders, and the patient’s blood is pumped through a group of tubes and a dialysis machine at constant and accurate flow rates.

· Liquid passages inside the washing machine:

There are three types of dialysis machines, which are as follows:

· Recycling machines

· These machines recycle the washing solution continuously through the washing machine during the dialysis process.

· Single-pass recycling machines:

· These machines continuously recycle the solution through the washing machine during the dialysis process, and with a continuous flow of new solution, the washing solution is partially replaced.

· Single-pass machines

· Single-pass machines produce a continuous flow of washing solution, which passes through the machine and is then disposed of without being recycled.

Recommendations

· Blood tubes:

To avoid blood contamination with bacteria and contamination of blood tubes, the following procedures should be followed:

· Keep intravenous tubes away from the waste container during the process of preparing the dialysis machine.

· Hands should always be washed after handling waste.

· Disinfect containers designated for disposal of waste resulting from the filtration process daily.

· Cleaning and disinfecting the outside of dialysis machines.

· Disinfecting the internal and external pipes for the washing solution.

Cleaning and disinfecting dialysis machines

· The external surfaces of the machine must be cleaned and disinfected after each patient.

· The internal and external pipes for the washing solution must be disinfected.

· The manufacturer’s instructions must be followed, provided that they are written.

· Carry out rinsing and disinfection procedures for the single-pass machine at the beginning and end of the day or according to the manufacturer’s instructions.

· For recycling machines (currently rarely used), rinsing and disinfection procedures are carried out between one patient and another.

· The same cleaning and disinfection methods are followed if blood leakage does not occur, regardless of the type of dialysis machine used.

· You must follow the instructions of the manufacturer of the disinfectant used to disinfect the dialysis machine.

· Cleanliness of the environment in the dialysis unit

· Policies and protocols must be written for cleaning and disinfecting surfaces and equipment in the dialysis unit, including careful cleaning before carrying out any disinfection process.

· The patient’s station must be cleaned and disinfected after the dialysis session, including the dialysis bed, various nearby surfaces, dialysis solution containers, and waste containers.

· Covers and bedsheets must be changed between each patient.

· The hazardous waste bag should be disposed of immediately at each session.

· Spills of blood and other fluids should be dealt with immediately when they occur.

· The rest of the standard infection control procedures regarding environmental cleanliness are followed.

· Monitoring the quality of water used in the dialysis process

Microbiological monitoring:

· Microbiological monitoring of treated water must be carried out at least once a month, and the number of times may increase if any problems are proven.

· Samples of water used in dialysis must be collected at the point where the water reaches the machine.

· Water samples used in dialysis must be collected during or after the end of the dialysis process.

· The presence of coliforms and Escherichia coli (E. Coli) is not allowed in the water of dialysis units.

· The presence of Pseudomonas bacteria, Enterococcus 'Streptococcus' faecalis, and Anaerobic Sulfur Reducing Bacteria is not permitted in the water of dialysis units.

Note:

· Immediate corrective action must be initiated to reduce bacterial contaminants if the total numbers of live bacteria present in the water used in the dialysis solution or in the dialysis solution exceed 0.5 bacterial colony units per milliliter.

· Treating the water used in the dialysis process

· The water used in the dialysis unit must be treated in order to get rid of chemical compounds, pollutants and bacterial toxins so as not to harm the patient. When water is purified from chlorine during the water treatment process to be used in the dialysis process, it is more likely to grow in bacteria. Therefore, care and care must be taken at every stage of the water treatment process to reduce the risk of bacteria penetrating the system or allowing the treated water to remain stagnant.

The processing units used consist of several stages

1) Carbon filters:

◾ It works to get rid of chlorine, chloramines, and organic materials present in drinking water, as it allows residual free chlorine in the unit’s water up to (2.0) and chloramine up to (1.0).

◾ These filters are exposed to bacterial contamination.

◾ Two carbon filters must be placed in succession to increase their effectiveness and to avoid system malfunction.

◾ When carbon filters break down, they must be replaced and not repaired to avoid the risk of pollution.

2) Molecular filters:

◾ Molecular filters are used to purify water from sediments. Bacteria may grow in these filters, causing harm to the patient and leading to fever. Therefore, these filters must be changed and disinfected in accordance with the manufacturer’s recommendations.

3) Reverse osmosis filter:

◾ Osmotic difference (reverse osmosis) and hydrostatic pressure difference on both sides of the semi-permeable membrane are used to eliminate organic and ionic compounds.

◾ Reverse osmosis filters are capable of eliminating 90% - 99% of bacteria, viruses, toxins, metals and ions.

4) Ion removal devices:

◾ These devices contain surfaces to remove ions from water, as they work to get rid of positively charged ions and negatively charged ions by attaching them to those surfaces and releasing hydrogen and hydroxide ions.

◾ Deionizing devices do not eliminate bacteria and toxins, and may contribute to significant bacterial growth.

5) Regular filters, ultra filters and ultraviolet rays:

◾ These filters work to reduce bacterial or toxic pollution to the maximum extent possible. Ultraviolet rays may be ineffective in eliminating some types of bacteria, and they do not work to get rid of toxins.

Note

◾ All filters must be changed and disinfected according to the manufacturer’s recommendations.

◾ Take into account the follow-up of the results of the analyzes of the departmental water unit and their conformity with Ministerial Resolution No. 3 6 of 1996 and its amendments regarding the percentages allowed for

◾Bacteriological examination of the water of dialysis units.

Water distribution and storage

◾ Water is distributed after treatment in plastic pipes, as pipes made of metal lead to contamination of the treated water with chemicals such as copper, lead, and zinc.

◾ Use the least possible number of curved connections (angles).

◾ The outlets must be at the highest point in the system to allow sufficient contact of all parts of the system with disinfectants.

◾ It is preferable not to use tanks to store water as much as possible because stored water is susceptible to bacterial contamination, and when using a tank take care of the following:

◾ Make the tank as small as possible.

◾ It must be designed to accommodate continuous flow without any places allowing water to stagnate.

◾ Use a tightly closed lid.

◾ To be cleaned, disinfected, and rinsed easily.

◾ All tanks and all pipes must be disinfected, including the water lines connecting to the washing machines (to prevent bacterial growth).

Note

◾ Problems that arise from the lack of microbiological conformity of water samples in dialysis units:

◾ 1- The presence of Gram-negative bacteria:

◾ Bacteria in the blood and reactions occur that lead to shivering - fever - low blood pressure - headache - muscle weakness - nausea - vomiting.

◾ 2- The presence of bacterial toxins:

◾ Fever - chills - multi-organ injury that may lead to death.

Dealing with waste from dialysis units

◾ All disposable items should be placed in bags thick enough to prevent leakage. It is possible that the waste resulting from the dialysis unit may be contaminated with blood, so it should be dealt with accordingly.

◾ Room cleaning staff members in the dialysis unit should remove waste after each session.

◾ Sharp tools are disposed of immediately after use in their safety containers. There must be a container near each patient service area

◾ Workers in dialysis units

◾ The necessary training and guidance must be provided to people who are exposed to infection by virtue of their work on a regular basis. The necessary training and guidance must also be provided to new employees before they take up work in dialysis units.

◾ All workers in dialysis units must be vaccinated against hepatitis B.

◾ Employees must wear appropriate personal protective equipment.

◾ Staff members should not consume food or drinks in the area designated for dialysis.

◾ It is not recommended to take any special measures or impose any restrictions on the work of health service providers infected with one of the blood-borne microbes (hepatitis B and C viruses and human immunodeficiency virus (HIV).

Environmental factors and design of dialysis units

◾ Basic principles of design

◾ Providing a suitable space away from the patient service area to store clean and sterile materials.

◾ Allocate halls or rooms for dialysis for patients infected with hepatitis B virus, away from the rest of the patients, and allocate a work team to deal with them during the dialysis period (so that they do not provide service to the rest of the patients during the same shift period), provided that the requirements for the dialysis process are These patients and all the necessary procedures for them are separate from those intended for other patients.

◾ Allocate halls or rooms for dialysis for patients infected with hepatitis C virus, away from the rest of the patients, and allocate a work team to deal with them during the dialysis period (so that they do not provide service to the rest of the patients during the same shift period), provided that the requirements for the dialysis process are For these patients, all the necessary equipment for them is separate from that for other patients.

◾ In the event that there are halls or rooms for patients positive for the human immunodeficiency virus (HIV), special machines for dialysis must be allocated for them away from the rest of the patients, with a work team allocated to deal with them during the dialysis period (so that they do not provide service to the rest of the patients during the same dialysis period). Provided that the requirements for the dialysis process for these patients and all the necessary equipment for them are separate from those designated for other patients.

◾ A warehouse is allocated for all water treatment equipment and filters.

◾ A warehouse is allocated for dialysis solution containers.

◾ A place is allocated for the temporary storage of hazardous medical waste, as well as a place for storing contaminated sheets and furnishings until transport.

◾ Records that must be available in the dialysis unit

◾ A compiled record of the number and names of all dialysis patients in the unit annually.

◾ A special record for all dialysis machines in the unit, including: their types/dates they entered service/date of maintenance/emergency events for each machine. A special record for each patient containing, medical history/date of the start of dialysis sessions in the unit, pre-serological analysis of the start of dialysis in the unit, results of special serological and chemical analyses. Patient, dialysis machine number, blood transfusions, days and duration of dialysis sessions.

◾ A comprehensive record of the results of serological tests for all patients in Oujda.

◾ A combined record of blood transfusions for all patients in the unit.

◾ A special record of the results of chemical analyzes for all patients in the unit.

◾ A special record of emergency events that occur in the unit, including machine failure/

◾ Blood leakage during dialysis sessions / malfunction of dialysis filters.

◾ A record of water sample collection as well as analysis results.

◾ A record of the unit’s water treatment plant maintenance and filter change dates.

◾ A special record of the names of the unit’s health team, along with the results of their departmental serological tests and their vaccinations.

◾ A record of patients’ vaccinations against hepatitis B.

◾ A special record to investigate outbreaks of blood-borne infections or bacterial and viral infections that occur in the unit.

◾ Guidance regarding patient care

◾ Dialysis requires awareness from the patient to reduce the risk of diseases that may be caused by infections

◾ It may also result in death, and there are steps that must be taken to educate the patient, including:

◾ Educate patients on the necessity of keeping the entry site of dialysis catheters clean and dry at all times, and the importance of personal hygiene for the patient and its relationship to entry site infection should be emphasized.

◾ Educating patients about the proper way to care for the insertion site of dialysis catheters and the need for them to be aware of the symptoms and signs of infection and to report them immediately. These symptoms include fever, feeling cold, shivering, pain, redness, or the appearance of an ooze around the site.

◾ Patients are allowed to eat meals during the dialysis procedure.

Note

◾ Problems that arise from the lack of microbiological conformity of water samples in dialysis units:

◾ 1- The presence of Gram-negative bacteria:

◾ Bacteria in the blood and reactions occur that lead to shivering - fever - low blood pressure - headache - muscle weakness - nausea - vomiting.

◾ 2- The presence of bacterial toxins:

◾ Fever - chills - multi-organ injury that may lead to death.

Dealing with waste from dialysis units