Imagine this scenario as a nephrologist.
Your patient with ESRD undergoing hemodialysis has newly diagnosed hepatitis C virus (HCV) infection. In addition to addressing the immediate medical issue, what is the next course of action? What are the reporting requirements for a new case of HCV infection? Are you required to report this case to state and federal public health agencies? How do you ensure your patient did not acquire the infection due to lapses in infection prevention and control measures at the dialysis facility?
This series of questions may not be at the forefront in the minds of nephrologists during their day-to-day clinical practice. However, reporting of HCV infections is a requirement at both state and federal levels, and it is important that nephrologists understand the importance of partnering with state health departments in preventing healthcare-associated infections in dialysis facilities.
Infections—either individual cases or clusters—are quite frequent in hemodialysis facilities and are associated with high morbidity and mortality. Infections can vary from acute HCV, to influenza outbreaks in winter, to bloodstream infections (BSIs) related to vascular access or other factors. Between 2008 and 2017, 57% of the 37 healthcare-related HCV outbreaks reported nationwide occurred in hemodialysis facilities and resulted in 102 new cases of HCV. An additional 11 single cases, confirmed as likely patient-to-patient healthcare-associated transmission, were reported in the same time period.
Bloodstream infections are usually related to vascular access, and 70% of these are related to use of central venous catheters. The Centers for Disease Control and Prevention (CDC) strongly encourages the tracking of BSIs through the National Healthcare Safety Network (NHSN) surveillance program, and the Centers for Medicare & Medicaid Services (CMS) has mandated that all ESRD facilities use the NHSN reporting system to track BSIs as a quality indicator.
In addition to the CDC, local and state level programs play a major role in promoting healthy and safe practices in a variety of healthcare settings (Figure 1). Surveillance of infections in hemodialysis facilities also falls under the purview of the state Healthcare-Associated Infection (HAI) programs. The structure and role of HAI programs vary from state to state, depending on their laws and policies. Local and state health departments monitor trends in healthcare-acquired infections, recognize emerging pathogens, and help identify unsafe medical practices. They promote implementation of known prevention strategies, use data to recognize unmet needs in infection prevention, and support and coordinate collaborative prevention activities. The Infection Control Assessment and Response (ICAR) tool created by the CDC is widely used by local and state HAI personnel to assess infection prevention practices and guide quality improvement activities (https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html) (Figure 2). In some states (e.g., Massachusetts), HAI personnel offer teaching sessions for hemodialysis staff, using didactic presentations and simulation exercises in hand hygiene, safe injection, and cannulation practices.
What are some of the lapses in infection prevention and control practices that have resulted in the transmission of infections in hemodialysis facilities?
A collaborative effort between CDC and state health departments in four different states identified potential gaps in infection prevention and control practices when new HCV cases were identified at one hemodialysis center in each of the states (1).
The investigation identified the following lapses in infection prevention and control practices at the facilities: 1) preparation of an intravenous medication from a multi-dose vial performed at the dialysis station; 2) failure to routinely clean and disinfect the dialysis station and machine surfaces and empty priming buckets between patients; 3) use of a mobile cart to take medications from station to station; and 4) administration of intravenous medication from a single-dose vial to multiple patients.
Investigations such as this one have resulted in specific infection prevention and control recommendations: 1) single use of a single-dose vial; 2) preparation of medications at a clean central area away from dialysis stations; 3) transport of syringes by hand to individual stations instead of using supply carts; and 4) careful cleaning and disinfection of chairs and stations after patients have left the dialysis treatment area. Frequent audits, and feedback of results to frontline staff, of these and other infection control practices, such as hand hygiene, are essential to prevent transmission of pathogens.
Public health officials rely on healthcare providers to report the occurrence of reportable diseases. Timely and accurate reporting of communicable diseases is important to ensure patients receive appropriate medical treatment, to detect common sources, and to prevent transmission.
There are some perceived barriers that may prevent reporting of infections and impede collaborative efforts between state health departments and nephrologists. Hemodialysis-specific reporting requirements, such as the type of reportable infections, vary by state and may be difficult to find on state health department websites. In some states, infections must be reported at the local as well as the state level.
Physicians and dialysis staff may have misconceptions that paperwork required for reporting of infections is cumbersome. The biggest barrier, however, may be the concern among nephrologists and dialysis staff that the reporting of infection will trigger a visit by state inspectors and result in citations for the hemodialysis facility. On the other side, state HAI personnel, when contacted, may not have sufficient knowledge about ESRD facilities, and infections occurring in the dialysis setting, to conduct a comprehensive investigation of the reported issue. They may find it difficult to obtain information from hemodialysis facilities. Education on both sides is required to improve the partnership between dialysis personnel and state and local HAI programs.
In addition to reporting barriers, the services provided by state HAI professionals are often unfamiliar to the dialysis staff and nephrologists. One of the major goals of the American Society of Nephrology (ASN) Nephrologists Transforming Dialysis Safety (NTDS) initiative is to improve communication and collaboration between nephrologists and dialysis professionals and their local and state HAI personnel. We should keep in mind that the best resource to determine state-specific requirements is our local and state Department of Public Health. It is important for the dialysis staff to recognize that the relationship with state HAI staff is collaborative and not punitive in nature. The survey and certification section is a separate department from the HAI prevention and education section in most state health agencies. The resources and feedback from state HAI programs can be an invaluable collaborative tool in implementing and promoting infection control practices in the dialysis facility (Figure 3).
In summary, local and state-level HAI programs serve as a major resource for healthcare facilities, including hemodialysis centers. They can provide technical assistance about HAI surveillance, expertise on topics such as antibiotic stewardship, and information on infection control breaches. Local and state HAI experts offer assistance to facilities dealing with new infections or outbreaks, such as a patient with newly diagnosed HCV infection. Nephrologists can assist HAI personnel by providing education on the complexities of dialysis, ensuring ongoing infection surveillance at their dialysis facilities, helping to identify staff educational needs, and promoting the use of CDC infection prevention tools (https://www.cdc.gov/dialysis/prevention-tools/index.html). With a collaborative relationship among nephrologists, dialysis staff, and local and state HAI programs, we can be one step closer to our goal to “target zero infections” in the hemodialysis facility.
Thompson ND, et al.. Hepatitis C virus transmission in hemodialysis units: importance of infection control practices and aseptic technique. Infect Control Hosp Epidemiol 2009; 30:900–903.