Infection (Out of) Control

Dialysis staff, including physicians, are not consistently following universal infection control precautions—washing hands between patients and changing gloves as needed.

When we were young, we all remember our mother telling us to wash our hands when we got back from the playground, or the petting zoo, or just from hanging around with our friends.

In the typical dialysis clinic and physician practice today, it seems that lesson has gone the way of home delivery of milk.

When dialysis clinics go through a Medicare review, surveyors under the new Core Survey  process look at the clinic’s past record of non-compliance and focus on whether those infractions have been addressed. But consistently, the number one “tag” on the checklist that surveyors use to identify areas of noncompliance is related to hand hygiene.

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Dialysis staff, including physicians, are not consistently following universal precautions—washing hands between patients and changing gloves as needed. That tag has remained the #1 citation for years.

The second highest infraction in the Core Survey reviews is similar—machine maintenance related to infection control protocols. In essence, staff are not disinfecting dialysis machines and patient chairs between sessions. And more infection control infractions are in the top 10 list that surveyors noted in 2014 surveys (see charts of the 2014 survey data below).

Core Survey data shows dialysis clinics are not following basic infection control guidelines

Core Survey data shows dialysis clinics are not following basic infection control guidelines

2014 survey data from the presentation, “CMS surveys and QIP measures,” by Glenda M. Payne, RN, MS, CNN, Director of Clinical Services, Nephrology Clinical Solutions. Presented at the Florida Renal Administrators Annual Meeting, July 17, 2015, Naples, Fla.

Time for a refresh

What makes these infractions more dangerous for patient care is:

  • The number of these citations is increasing. The top two tags show an increase in citations of 35% (hand hygiene) and 15% (disinfecting surface equipment) when comparing the newer Core Survey with the traditional survey process (pre-2014). And citations for tag V147, which involves using careful infection control techniques for central venous catheter care, is up 83%.
  •  Sepsis is the #2 killer, behind cardiovascular events, of dialysis patients. That should put the practice of following infection control protocols at a higher priority.
  • Poor infection control not only places dialysis patients at risk during a therapy that involves blood exchange over a sustained period of time, but also places the health care worker at risk.

Physicians, clean up your act!
Nephrologists are not immune to negligent behavior related to hand washing. Earlier this year, NN&I published an article by the CMO Initiative on the need for physicians to practice basic hand hygiene. The CMO group reflects views from chief medical officers representing the large and medium-sized dialysis organizations in the U.S.

Read also: CDC provides new infection prevention resources for dialysis providers

“In the typical dialysis facility where multiple patients receive dialysis concurrently, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel,” authors Don Williamson, MD and Stan Lindenfeld, MD wrote. “…We believe that the medical director and attending nephrologist should lead by example in the effort of infection control and should not have behavior or hygiene standards that differ from (the expectations of) other clinical staff.”

The article details when a physician needs to practice infection control, before, during, and after a treatment. “It was our collected opinion that the treating physician … should be a model of compliance with infection control practices for the staff of the facility. In addition, failure of a physician to follow these guidelines in the dialysis facility should be noted by either the facility administrator or the charge nurse and pointed out to the physician in a private setting. There should not be any retribution or negative consequences for these staff members from the physician as a result of their communication on this issue. Any breach of this by the physician should be reported to the governing body to be dealt with appropriately.”

There is plenty of incentive to do the right thing here for patient care: treat the dialysis clinic as an infection incubator—and use the tools and established protocols to make and maintain a safe environment for both staff and patients.