Infection Prevention in

Dialysis Settings
A Continuing Education (CE) Training Course for
Outpatient Hemodialysis Healthcare Workers

Introduction to this Course

This course is for outpatient hemodialysis healthcare
workers, including technicians and nurses.
You will learn about the following topics in this course:
Infections that patients can get from dialysis
Infection control recommendations for outpatient hemodialysis
healthcare workers
Educating your patients and their caregivers

Course Objectives by the end of this course, you

should be able to:
List three ways to prevent catheter infections in hemodialysis
patients
Describe how to safely carry medications
Describe how to effectively perform hand hygiene

If you want to receive continuing education (CE) credit

for completing this course, you must complete a
course assessment and evaluation.

Course Contents
Lesson 1: Infections that Patients Can Get from
Hemodialysis
Lesson 2: Standard Precautions for all Healthcare
Workers in all Healthcare Settings
Lesson 3: Specific Infection Control Recommendations
for Outpatient Hemodialysis Healthcare Workers
Lesson 4: Infection Control Policies and Practices for
Outpatient Hemodialysis Facilities
Lesson 5: Educating your Patients and their Caregivers
Recap: Preventing Infections in Hemodialysis Settings
Course Assessment

Lesson 1: Infections
Infections that Patients Can
Get from Hemodialysis

Photo provided by Stephanie Booth, used with permission

A Patients Story

Brian Hess
22-year old hemodialysis patient
Central venous access port became infected
Healthcare workers tried to eliminate my infection for several
weeks using antibiotics
Ultimately my central venous access port had to be removed
to clear the infection
Photo provided by Brian Hess, used with permission

Why are Dialysis Patients at Risk

for Infection?
Patients who undergo hemodialysis
have a higher risk of infection, due to
the following factors:
Frequent use of catheters or insertion of
needles to access the bloodstream
Weakened immune systems
Frequent hospital stays and surgery

Infections in Dialysis
Dialysis patientsPatients
are at risk of getting
hepatitis B and C infections and
bloodstream infections
Hepatitis B and C are bloodborne
viral infections that can cause chronic
(life-long) disease involving
inflammation (swelling) of the liver
Hepatitis B and C viruses can live on
surfaces and be spread without visible blood

A bloodstream infection is a serious infection

that can occur when bacteria or other germs get
into the blood
One way bacteria can enter the bloodstream is through a
vascular access (catheter, fistula, or graft)

Infections in Dialysis
Patients
Bloodstream infections
are a dangerous

complication of dialysis
1 in 4 patients who get a
bloodstream infection caused by
S. aureus (staph) bacteria can face
complications such as:
Endocarditis (infected heart valve)
Osteomyelitis (infected bone)

Total costs for each infection can be more than $20,000

Bloodstream infections can cause sepsis (a potentially
deadly condition)
Up to 1 in 5 patients with an infection die within 12
weeks

National Burden of Dialysis

Infections
A Cause
for Concern
In the US, there are about
370,000 people relying on
hemodialysis
About 75,000 people receive
hemodialysis through a central
line
Central lines have a higher risk of
infection than a fistula or graft
CDC estimates 37,000 central lineassociated bloodstream infections
may have occurred in U.S.
hemodialysis patients in 2008

How Do Infections Happen?

Contact

Droplet

SOURCE

Airborne

HOST

Three elements must be present for an infection to occur:

1.A source of germs (like bacteria or viruses)
2.A susceptible host, meaning a person who is at risk of getting
an infection from the germs
3.A way for the germs to move from the source to the host

There are three ways in which germs move from the source to
the host: Contact, Droplet, and Airborne Transmission

Your Role in
Contact Transmission
Contact

SOURCE
DIALYSIS
PATIENT
A

Healthcare Worker
Hands

HOST
DIALYSIS
PATIENT
B

During dialysis, infections can be spread by

Contact Transmission
Most commonly by healthcare worker hands!
Photo provided by Stephanie Booth, used with permission

Spread of Respiratory Infections

Droplet

Airborne

SOURCE

HOST

Certain infections are spread by certain routes:

Flu may be spread by Droplet Transmission
Tuberculosis is spread by Airborne Transmission

What Can You do to Prevent the

Spread of Infections?
Understand and Follow the
Basics of Infection Control
All healthcare workers are expected to follow
Standard Precautions for infection control.
Standard Precautions are reviewed in Lesson
2

In addition, CDC has developed specific

recommendations tailored for hemodialysis
healthcare workers, recognizing the
increased risks for infection.
These dialysis-specific recommendations are
reviewed in Lesson 3

Lesson 2: Standard
Precautions
Standard Precautions for all Healthcare
Workers
in All Healthcare Settings

PPE photo provided by Rosetta Jackson, used with permission

Standard Precautions
for all Healthcare Workers

Perform hand hygiene

Use personal protective equipment (PPE)
Follow safe injection practices

Perform Hand Hygiene

:

How to perform hand hygiene

When hands are visibly soiled
with blood or other body fluids,
wash hands with soap and
water
If hands are not visibly soiled,
use an alcohol-based hand
rub

Remember: hand hygiene is one of the

most important ways for you to prevent
the spread
of infections

At least 15
seconds

Perform Hand Hygiene

When you should perform hand hygiene
Before you touch a patient
Before you inject or infuse
a medication
Before you cannulate a
fistula/graft or access a catheter
After you touch a patient
After you touch blood, body fluids, mucous membranes,
wound dressings, or dialysis fluids (e.g., spent
dialysate)
After you touch medical equipment or other items at
the dialysis station
After you remove gloves
Remember: perform hand hygiene between
each patient or station

Use Personal Protective Equipment (PPE)

Correctly
For your own protection
and to protect patients
Wear gloves, a gown, and/or face
protection when you think you
may come into contact with blood
or other potentially infectious
materials
Change gloves during patient care if
the hands will move from a
contaminated body-site to a clean
body-site
Remove gloves after contact with a
patient and/or the surrounding
environment (including medical
equipment)
Do not wear the same pair of gloves
for the care of more than one
patient

Follow Safe Injection Practices

Medications are injected
directly or indirectly into the
patients bloodstream
Any germs that have entered
the medication vial or syringe
can cause serious infections in
the patient
Germs also can be introduced
at the time of injection (e.g.
contaminated injection port)

Follow Safe Injection Practices

Three things you need to know:
1. Needles and syringes are single
use devices. They should not be
used for more than one patient.
2. Do not administer medications
from a single-dose vial or IV bag
to multiple patients.
3. Perform hand hygiene and
cleanse the access port before
injecting into it.

Saline bags are

always single
patient use

Lesson 3: Recommendations
Specific Infection Control Recommendations
for Outpatient Hemodialysis Healthcare
Workers

Specific Infection Control

Precautions
forgloves
Hemodialysis
Healthcare
Wear
and other personal
protective
equipment (PPE) for
all patient care
Workers

Promote vascular access safety

Separate clean areas from contaminated areas
Use medication vials safely
Clean and disinfect the dialysis station between
patients
Perform safe handling of dialyzers

Wear Gloves During Patient Care

For your own protection

Wear disposable gloves when caring for the patient or

touching equipment at the dialysis station
Wear gloves when cleaning surfaces in the environment or
medical equipment
Remember to remove gloves and perform hand hygiene
between each patient or station, and if moving from a
contaminated to clean area of the same patient or within
the same dialysis station

Use Personal Protective Equipment

For your (PPE)
own protection
In addition to gloves, you
should wear gowns and face
protection to protect yourself
as needed:
During initiation and
termination of dialysis
When cleaning dialyzers
When handling lab samples
PPE should be changed if it
becomes dirty

Photo provided by Rosetta Jackson, used with permission

Basic Steps in Fistula/Graft Care

Cannulation Procedure:
1.Wash the site
2.Perform hand hygiene
3.Put on a new, clean pair of
gloves
4.Wear proper face protection
5.Apply skin antiseptic and
allow it to dry
6.Insert needle using aseptic
technique
7.Remove gloves and perform
hand hygiene
Aseptic technique means taking great care to not contaminate
the fistula or graft site before or during the cannulation or
decannulation procedure
Photo provided by Stephanie Booth, used with permission

Basic Steps in Fistula/Graft Care

Decannulation Procedure:
1.Perform hand hygiene
2.Put on a new, clean pair of gloves
3.Wear proper face protection
4.Remove needles using aseptic technique
5.Apply clean gauze/bandage to site
6.Compress the site with clean gloves
7.Remove gloves and perform hand hygiene

Basic Steps in Catheter Care

Catheter Connection Procedure:
1.Perform hand hygiene
2.Put on a new, clean pair of gloves
3.Wear proper face protection
4.Apply antiseptic to catheter hub and allow it to dry
5.Connect the catheter to blood lines using aseptic
technique
6.Unclamp the catheter
7.Remove gloves and perform hand hygiene

Basic Steps in Catheter Care

Catheter Disconnection Procedure:
1.Perform hand hygiene
2.Put on a new, clean pair of gloves
3.Wear proper face protection
4.Disconnect the catheter from blood lines using
aseptic technique
5.Apply antiseptic to catheter hub and allow it to
dry
6.Replace caps using aseptic technique
7.Make sure the catheter remains clamped
8.Remove gloves and perform hand hygiene

Catheter Exit Site Care

1. Perform hand hygiene
2. Put on a new, clean pair of
gloves
3. Wear a face mask if required
4. Apply antiseptic to catheter
exit site and allow it to dry
5. Apply antimicrobial ointment
6. Apply clean dressing to exit
site
7. Remove gloves and perform
hand hygiene

Photo provided by Stephanie Booth, used with permission

Separate Clean Areas from

Contaminated Areas
Clean areas should be used for the
preparation, handling and storage
of medications and unused supplies
and equipment
Your center should have clean
medication and clean supply areas

Contaminated areas are where used

supplies and equipment are handled
Do not handle or store medications or
clean supplies in the same area as
where used equipment or blood
samples are handled

Clean area

Remember: Treatment stations are

contaminated areas!
Photo provided by Stephanie Booth, used with permission

Dedicate Supplies to a Single Patient

Any item taken to a patients
dialysis station could become
contaminated
Items taken into the dialysis station
should either be:
Disposed of, or
Cleaned and disinfected before being
taken to a common clean area or used
on another patient

Unused medications or supplies

taken to the patients station should
not be returned to a common clean
area (e.g., medication vials,
syringes, alcohol swabs)
Photo provided by Marshia Coe and Teresa Hoosier, used with permission

Safe Use of Medication Vials

Prepare all individual patient doses
in a clean area away from dialysis
stations
Prepare doses as close as possible
to the time of use
Do not carry medications from
station to station
Do not prepare or store
medications at patient stations
CDC recommends that dialysis
facilities:
Use single-dose vials whenever possible
and dispose of them immediately after use

Guidelines for Carrying

Medications

Do not use the same medication cart to deliver

medications to multiple patients
Do not carry medication vials, syringes, alcohol
swabs, or supplies in pockets
Be sure to prepare the medication in a clean
area away from the patient station and bring it
to the patient station for that patient only at
the time of use

Cleaning and Disinfecting the

Dialysis Station
Cleaning and disinfection reduce the risk of
spreading an infection
Cleaning is done using cleaning detergent,
water and friction, and is intended to
remove blood, body fluids, and other
contaminants from objects and surfaces
Disinfection is a process that kills many
or all remaining infection-causing
germs on clean objects and surfaces
Use an EPA-registered hospital disinfectant
Follow label instructions for proper dilution

Wear gloves during the cleaning/disinfection

process

Disinfecting the Dialysis Station

All equipment and surfaces are considered to be
contaminated after a dialysis session and therefore
must be disinfected
After the patient leaves the station,
disinfect the dialysis station
(including chairs, trays, countertops,
and machines) after each patient
treatment
Wipe all surfaces
Surfaces should be wet with disinfectant and allowed to air dry
Give special attention to cleaning control panels on the dialysis
machines and other commonly touched surfaces
Empty and disinfect all surfaces of prime waste containers

Photo provided by Stephanie Booth, used with permission

Safe Handling of Dialyzers and

Blood Tubing
Before removing or transporting
used dialyzers and blood tubing,
cap dialyzer ports and clamp
tubing
Place all used dialyzers and tubing
in leak-proof containers for
transport from station to
reprocessing or disposal area
If dialyzers are reused, follow
published methods (e.g., AAMI
standards) for reprocessing
AAMI is the Association for the Advancement of
Medical Instrumentation
Photo provided by Stephanie Booth, used with permission

Lesson 4: Policies and

Practices

Infection Control Policies and Practices for

Outpatient Hemodialysis Facilities

Infection Control Policies and

Practices
for Dialysis Facilities
Vaccination of dialysis staff and patients
Preventing the spread of hepatitis B
Preventing the spread of bacterial infections

Vaccine-Preventable Infections
Influenza
Influenza or the flu is a respiratory infection
that infects the nose, throat, and lungs
The flu is spread mainly by droplets that are
made when people with flu cough, sneeze or
talk
The single best way to prevent the flu is to get
a flu vaccine each year

Hepatitis B
Hepatitis B is a serious infection that affects the
liver. It can cause acute (short-term) or chronic
(long-term) infection and liver cancer
Hepatitis B virus is easily spread through
contact with the blood or other body fluids of
an infected person
Hepatitis B vaccine can prevent hepatitis B
infection

Take Care of Yourself

Get Vaccinated
Get the flu vaccine each year
Complete the hepatitis B vaccine series

Vaccination and Routine Testing

of Hemodialysis Patients
Vaccinate all susceptible
patients against:
Hepatitis B

Recommended vaccines for

patients include:
Influenza (inactivated)
Pneumococcal

Conduct routine testing for:

Hepatitis B virus
Hepatitis C virus

Preventing the Spread of Hepatitis

B
Dialyze hepatitis B (HBsAg+) patients in a
separate room using separate machines,
equipment, instruments, and supplies
Be sure to use a separate gown when treating
these patients

Staff members caring for patients with

hepatitis B (HBsAg+) should not care for
HBV-susceptible patients at the same time
(e.g., during the same shift or during
patient changeover)
HBsAg+ means hepatitis B surface antigen (a lab test for hepatitis B virus)

was positive
HBV-susceptible means anyone who has never been infected and lacks
immunity to hepatitis B virus

Preventing the Spread of

Bacterial Infections

Hemodialysis patients who might be at increased risk for

spreading germs to other patients include those with:
An infected skin wound with drainage that is not contained by
dressings
Fecal incontinence or uncontrolled diarrhea

For these patients use the following precautions:

Wear a gown and gloves when you are caring for the patient
and remove the gown and gloves when you are finished caring
for the patient
Do not wear the same gown when caring for other patients
Dialyze the patient at a station with as few adjacent stations as
possible (e.g., at the end or corner of the room)

Patients with respiratory illness and a fever are at risk of

spreading bacterial and viral respiratory infections
These patients should be dialyzed at least 6 feet away from
other patient stations or any shared supplies

Lesson 5: Education
Educating your Patients
and their Caregivers

How to Recognize an Infection

Advise patients to inform you if they notice any of
the following possible signs of infection:
Fever
The access site is:
Swollen (bulging),
red,
warm, or
has pus
Severe pain at the access site
Remember: infections of the vascular
access site can be life threatening

Training and Education of

Patients and their Caregivers
When a new patient starts dialysis and on
an annual basis, review:
Personal hygiene and hand hygiene technique
Patient responsibility for proper care of the
access site and recognition of signs of
infection
Recommended vaccinations (including
hepatitis B, influenza, and pneumococcal)
Reasons for selecting a fistula or graft over a
catheter to lower the risk of infection

Recap
Preventing Infections in
Hemodialysis Settings

Photo provided by Stephanie Booth, used with permission

Key Infection Prevention Practices

Perform hand hygiene frequently and change
gloves
Maintain separate clean areas for supplies and
medications and separate contaminated areas
for used items
Practice proper handling and delivery of patient
supplies and medications
Perform effective cleaning and disinfection of
dialysis equipment and environmental surfaces
Carefully handle medications and the patients
vascular access to avoid contamination
Remember: Use aseptic technique every time!

Conclusion
Infections that patients can get while receiving
dialysis are serious and preventable!
Healthcare workers like you following infection
control precautions and other safe care practices
are the key to prevention
Infection prevention is everyones responsibility

Course Assessment:
Instructions