Bloodstream infections (BSI) among hemodialysis patients are among the most challenging problems in dialysis units, and are associated with significant morbidity and mortality (1).
Approximately 37,000 vascular access–related BSIs are estimated to have occurred among US hemodialysis patients with a central venous catheter in 2008, with an average cost per hospitalization of $23,000 (2,3). A number of factors appear to have contributed to these high rates, and they apply to both dialysis staff and patients; proper gowning and gloving, hand sanitation, high catheter rate, and appropriate skin antisepsis are examples. An overlooked and perhaps the most important modifiable risk factor in this equation is patients’ personal hand hygiene. Despite recommendations by the Centers for Disease Control and Prevention (CDC) that all hemodialysis patients should wash their hands pre- and post-hemodialysis, this is not always the case. The potential for cross-contamination between dialysis equipment and vascular access from unclean hands is both real and preventable.
Infection control efforts to date
In 2009, the CDC sponsored a collaborative project to prevent BSIs in 17 outpatient hemodialysis facilities by implementing a set of core interventions (4). Among these interventions, dialysis units were required to perform monthly hand hygiene audits with feedback of findings to clinical staff. After 15 months of intervention, there was a sustained 32% decrease in overall BSIs and a 54% decrease in vascular access–related BSIs (6). Based on these results, the CDC now recommends a set of bundled interventions to be implemented in all outpatient hemodialysis facilities (Table 1).
Hand hygiene in dialysis facilities
One of the challenges I see in our dialysis facility is that hand washing is perceived as a mundane and repetitive exercise, with no stimulation and little feedback on the quality of the hand washing technique. This often contributes to patients going through the motions, or wholeheartedly skipping the practice altogether.
The reality is that patients are just like everyone else in the workplace: They want to be “patted on the back” for the good job they are doing, and they want acknowledgment from the provider that they are making improvements in their own healthcare decision-making. Only through a cycle of repetitive positive reinforcement can we expect a significant change in behavior that will lead to better healthcare outcomes. There is also evidence to support educational activities along with feedback of observed hand washing sessions to improve hand hygiene compliance in dialysis units (6).
Quality improvement project
Imagine my surprise when I came across a product known as Glo-germ, which is marketed as a fun and effective way of training hand cleanliness in the workplace. Glo-germ comes in a liquid or powder form that is applied to the hand and glows under ultraviolet (UV) light (simulates germs). The idea is to have patients apply the liquid uniformly on both hands, and then ask them to wash their hands as they normally would along with soap and water. Poor handwashing technique will leave residual stains on the hand, often unseen by the naked eye, but will illuminate under UV light and this illumination can be used as a surrogate measure for quality of the hand wash (Figure 1). As a pilot quality improvement project, I enrolled 20 hemodialysis patients from our dialysis facility and scored them on a scale of 0 to 4 based on the amount of residual illumination that remained after the initial hand wash. In addition, I recorded the total time spent on each hand washing session. This was followed by a five-minute session of patient education on proper hand washing techniques, demonstrating thoroughness in using soap, deep hand rubbing, and coverage of finger wedges. Many patients were surprised at how poorly they performed on the initial hand wash. A second observation of the same patients occurred one week later with measurement of the same performance indices.
Demonstration of successful hand washing technique using Glo-germ
Citation: Kidney News 9, 5
I was not surprised that at one week follow-up, patients were more engaged with the process and displayed better hand washing technique. Many of the patients enjoyed playing with Glo-germ product and were eager to show what they had learned from their previous sloppiness. There was a statistically significant improvement in both hand stain score (i.e., cleaner hands) and time spent with hand washing (Figure 2). Obviously, the project was limited by the small sample size, and larger studies with longer intervention periods are needed to demonstrate a decrease in infection rates in dialysis units. However, I believe that at the very least, the project has raised awareness of the inadequacy of personal hand hygiene among our dialysis patients, and that more time and energy needs to be devoted to this simple task.
Effectiveness of educational intervention on hand washing adequacy
Citation: Kidney News 9, 5
Dr. Chu was invited to share this research as a part of the Nephrologists Transforming Dialysis Safety (NTDS) initiative. Created through a partnership of the CDC and the American Society of Nephrology, NTDS aims to engage nephrologists as dialysis facility team leaders to target zero infections by actively pursuing the elimination of preventable infections in dialysis facilities through adherence to recommended infection prevention practices, appropriate screening and detection of infections, implementation of clinical protocols, and collaboration with state and federal healthcare-associated infection programs.
References
- 1.↑
Collins AJ, Foley RN, Herzog C, et al.. US Renal Data System 2012 annual data report. Am J Kidney Dis 2013; 61(1)(suppl 1):e1–e480.
- 2.↑
CDC. Vital signs: central line–associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011; 60:243–248.
- 3.↑
Ramanathan V, et al.. Healthcare costs associated with hemodialysis catheter-related infections: a single-center experience. Infect Control Hosp Epidemiol 2007; 28:606–609.
- 4.↑
Centers for Disease Control and Prevention: core interventions to reduce dialysis bloodstream infections. http://www.cdc.gov/dialysis/prevention-tools/index.htmlaccessed on March 10, 2017.
- 5.
Priti Patel, et al.. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013; 62:322–30.
- 6.↑
Sánchez-Carrillo LA, et al.. Enhancement of hand hygiene compliance among healthcare workers from a hemodialysis unit using video-monitoring feedback. Am J Infect Control 2016; 44:868–72.
