safety and infection prevention strategies for … dommert-breckler rn bsn quality improvement...

BA RBA RA DOM M ERT-BRECKLER RN BSN QUA LITY IM PROVEM ENT DIRECTOR

NORTHWEST RENA L NETWORK

Safety and Infection Prevention Strategies for Dialysis Patients

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May 2013

Objectives

Provide an overview of:

Dialysis Basics CDC Guidance Vascular Access and Infection Control Medications and Vaccinations Coordination of Care Emergency Considerations

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Dialysis Basics

The kidneys are bean shaped, multifunctional organs. Kidney Functions include:

• Removing waste products and excess water

• Produces erythropoietin which stimulates the bone marrow to produce red blood cells

• Produces renin which regulates blood pressure

• Produces calcitriol, the active form of vitamin D, which helps maintain calcium balance in the body for both bones and for normal chemical balance

Dialysis Basics cont

There are 489,000 patients on dialysis according to the USDR report 2012

Chronic Kidney Disease (CKD) is a progressive degeneration of kidney function with 5 stages Causes of CKD include:

• Hypertension 30% • Diabetes 35% • Kidney Diseases i.e. polycystic kidney disease • Medications: NSAIDS, antibiotics


When CKD reaches stage 5 or End Stage Renal Disease (ESRD) then dialysis is required. It varies by individual, but dialysis is normally needed by the time the kidneys are functioning at 20% of normal capacity.


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Traditional in-center hemodialysis, treatments run anywhere from 2.5 hours to 5.5 hours, usually three days a week

Nocturnal in-center hemodialysis, treatments run 6-8 hours overnight usually three days a week

Dialysis modalities include:


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Peritoneal Dialysis: specialized fluid is placed in the peritoneal cavity four to six exchanges a day with by gravity or with a cycler


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Home Hemodialysis, treatments run at home with a machine like the in-center machine 5-7 times a week, a care partner is usually required for this modality

These are two examples of at-home machines


Dietary restrictions will vary depending on the type of dialysis and of course the individual patient.

Feel free to contact and work with the dialysis facility’s registered dietician for the exact diet for your patient.

Fluid restriction is very important since the kidneys can no longer remove any excess fluid.

In center hemodialysis is the most dietarily restrictive.


Fluid restriction is the most difficult aspect for a majority of patients

The most obvious is do not allow patients to drink a lot of fluids. (That is easy, right?)

Restricting the sodium in their diets is recommended to

reduce thirst.

A good resource is a short new movie about fluid and dialysis It is available @ this website:

www.esrdnet15.org/treatmnt.htm#fluid


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Issues that result from fluid overload

• High blood pressure

• Sudden drop to low blood pressure during dialysis

• Shortness of breath

• Cardiac issues: 1. Fast pulse 2. Weakened muscles 3. Cardiomyopathy


Hyperkalemia (high potassium) symptoms include: Arrhythmias Cardiac Arrest Many times patient is symptom free

Hypokalemia (low potassium) symptoms include:

Arrhythmias Muscle spasms Fatigue

Potassium levels need to be regulated to a lab value of- 3.5 - 5.5 mg/dL


• Potatoes

• Dairy products

• Beans, nuts or seeds (including peanut butter)

• Oranges, bananas, cantaloupe, avocados, nectarines

• Salt substitutes

• Tomatoes, winter squash, spinach, artichokes

• Chocolate

Foods high in potassium include:


High phosphorous levels symptoms include: • Itching • Burning eyes • Calcium-phosphorus deposits in:

o Heart (early heart attack) o Skin, Lungs and other organs o Blood vessels- including those used for dialysis access and those needed for a transplant

Phosphorous needs to be regulated to a lab value of 3.5 - 5.5 mg/dL


• Prepared food (phosphorous is often used as a preservative)

• Fast food • Dairy Products • Dark colas • Organ meats • Whole grains

Food with high Phosphorous include:


For hemodialysis patients since 1993:

Rate of admissions for infection is now 43% greater Hospitalization rates have increased 47% for BSI and 87% for vascular access infection


One in four patients who get a BSI caused by

S.aureus can develop complications such as endocarditis or osteomyelitis Up to one in five patients with an infection die within 12 weeks USRD 2011 ADR


The Centers for Disease Control and Prevention

(CDC) has released results of its Dialysis Bloodstream Infection Prevention Collaborative showing a 32 percent decrease in overall bloodstream infections and a 54 percent decrease in vascular access-related bloodstream infections after CDC prevention guidelines were used.

CDC Guidance 19

http://www.cdc.gov/dialysis/collaborative/ Tools website: http://www.cdc.gov/dialysis/prevention-tools/index.html

CDC Guidance 20

Hand Hygiene: Use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus). Otherwise, the preferred method of hand decontamination is with an alcohol-based hand rub.

CDC Guidance 21

Environmental Cleaning: Select EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare. Focus on those surfaces in proximity to the patient and those that are frequently touched.

CDC Guidance 22

Respiratory Hygiene/ Cough Etiquette: Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the duration of the visit

Vascular Access and Infection Control

Three basic access types- (for in-center or home hemodialysis)

Arteriovenous fistula- preferred access type, requires day-surgery usually and maturation time

Arteriovenous graft- requires day-surgery usually and is

prone to replacement every couple of years Central Venous Catheter (CVC)- fastest application with immediate use, highly prone to infections, catheter end is located directly into the heart


Arteriovenous fistula- preferred access With lowest infection rates Follow hand hygiene practices before touching the sites Wash access prior to leaving for treatment Do not scratch or pick at the site

Save Their Life(line)

Aneurysms that are shiny, growing and/or have skin deterioration need immediate attention.

Vascular Access and Infection Control 26

Arteriovenous graft- requires day-surgery usually and is prone to replacement every couple of years


Moderate infection risk: due to foreign material that white blood cells cannot penetrate Follow the same precautions as the AVF For both the fistula and the graft: report signs and symptoms of infection immediately


Central Venous Catheter (CVC)- Fastest application with immediate use, highly prone to infections, catheter end is located directly into the heart


Work with the Dialysis Facility to have the access changed.


Use chlorhexidine for skin antisepsis during insertion/dressing change (allow to dry) Use antimicrobial ointment or chlorhexidine-impregnated sponge dressings 4% Sodium Citrate Lock has been shown to reduce infections and CVC replacement Antibiotic and Alcohol locks have also been shown to reduce infections


Precautions need to be taken when a patient with a CVC bathes. Bath method preferred not allowing water level to reach the CVC site. If the patient insists on showering, a protective cover is a must.


Save their Life Line

Do not use the “access arm” to take blood pressures or to draw blood. Do remove soiled bandages as needed to wash the fistula or graft site with soap and water and replace the dressing. Do not change the CVC dressings unless visibly soiled, then use sterile technique. Do report signs of infection or prolonged bleeding to the dialysis facility as soon as possible. Do protect other potential access sites for future use


Peritoneal Dialysis

Access technique is the most important item for infection prevention. Hand hygiene and clean environment also important. Besides the signs and symptoms of site infection, all cloudy effluent should be reported to the dialysis facility for culture. There are mixed theories regarding the use of mupirocin ointment due to mupirocin-resistant S. aureus.

Medications and Vaccinations

Due to the compromised kidney function, medications may not be excreted and have a dangerous build up in the blood stream.

Any changes in a patient’s medications should be communicated to the dialysis facility.

As mentioned in the renal diet slide, binders need to be taken as prescribed, which is usually with meals and snacks.

Caution needs to be taken with medications prescribed to dialysis patients.

Medications and Vaccinations

Coordination of Care

Treatments: • Many dialysis facilities run on a tight patient schedule, so

the patient needs to be on time

• Some medications (blood pressure, antibiotics) may need to be held prior to dialysis

Patient Issues: • Any bleeding or fall issues should be reported to the facility

Communication between the care facility and the dialysis facility will ensure the best care for the patient.

Emergency Considerations

During an emergency, if you must do things differently with your patients, the dialysis facility must also

Dialysis facilities must: • have their own emergency plan. • must make arrangements with a near-by facility to dialyze their patients if they cannot. • must have emergency contact numbers and provide them to you • have your facility’s numbers as well.

Emergency Considerations cont

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If your patients must be evacuated, it is most important that the receiving staff know:

• that the dialysis patient is currently receiving dialysis

• the physician’s order for the dialysis

• how long it has been since the last dialysis treatment.

Emergency Considerations cont

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There are other materials available that will assist you in caring for the extra needs of a dialysis patient during an emergency. Please feel free to contact:

Sharon Badger RN [email protected]

or @ 206-923-0714

mailto:[email protected]

Questions? 41

Barbara Dommert-Breckler [email protected]

206.923.0714

mailto:[email protected]

Northwest Renal Network

Network Mission

The mission of Northwest Renal Network is to promote optimal dialysis and transplant care for kidney patients in

Alaska, Idaho, Montana, Oregon and Washington.

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To receive 1 hour of continuing education credits, please do the following:

• Complete a course evaluation (you will

be automatically directed to the survey after the webinar)

• Your RN or Admin. license number is required for credits

• Provide this confirmation code: 34671

CE Credits

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