Thank you Michelle for allowing me to present on infection control issues identified in CMS surveys. I will be reviewing some of the most frequent infection control citations that are cited as deficiency level or condition levels in surveys from across the division. All of these citations are easy to avoid if the appropriate policy and procedures are followed. More importantly by following policy and procedure we can prevent infections in our patients that can be life threatening.
To start with today's objectives are, Review the infection control conditions for coverage. Review the infection control issues that have been cited and To understand each individuals responsibility in meeting these infection control requirements.
What is the impact of infections in our patient population? Approximately 15% of all patient deaths are infection related, and 57% of these are due to vascular access infections. For patients with vascular catheters the risk for bacteremia is 7 times higher. There are several factors that impact the potential risk some of these are: They have multiple and frequent exposure to Healthcare environment (3x a week) – which increases the r isk of exposure to infections They require a method of vascular access such as central line catheters or AV fistula – which provides o pportunities to acquire infections . The extracorporeal nature of Hemodialysis devices - provides more opportunities for transmission of infections And dialysis patients are immunocompromised – making them more s usceptible to infections Associated with the high infection rate is the increased MRSA rate. Our patients are 100 times more likely to be infected with MRSA.
During the past year there have been many initiatives across the country to investigate and develop prevention actions for the prevention of healthcare acquired infections. Many of these HAI projects have been facilitated thru ESRD networks in collaboration with the CDC. During a recent meeting of advisory committee members this slide was presented. This is a compilation of the most frequently cited CMS V-tags in Network 1 region. This is all dialysis facilities, not just Fresenius. As you can see V113 - Hand washing, gloves is ranked #1 for the US and is in the top 5 for most of the facilities located in Network1. In addition CMS is working jointly with AHRQ and CDC to conduct a new ESRD Infection Control Initiative to reduce healthcare associated infections in ESRD facilities. AHRQ has contracted with the Health Research & Educational Trust to assist in implementing this project. The goal of the project is to improve adherence to infection control practices in ESRD facilities and to reduce preventable infections
To review, the CMS conditions for coverage that were released in 2008 changed the previous 1976 conditions of coverage from 2 infection control tags to 26. Subsection 494.30 includes V tags 111-148, the first statement includes the requirements for a sanitary environment. “sanitary environment” is an environment that meets the “Standard Precautions” for an inpatient hospital setting plus the more stringent precautions which are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. The more stringent precautions dialysis units follow are found in the CDC’s “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients” published in the Morbidity and Mortality Weekly Report, April 2000, pages 18-28.
Specific CDC recommendations are incorporated into the Conditions for Coverage. One of the most important documents is the infection control practices recommended by CDC for hemodialysis units which will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly through contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel. These practices should be carried out routinely for all patients in the chronic hemodialysis setting because of the increased potential for blood contamination during hemodialysis and because many patients are colonized or infected with pathogenic bacteria.
In addition to the 2001 recommendations the CDC develop the “Guidelines for the Prevention of Intravascular Catheter Related Infections. This guideline was incorporated into the conditions for coverage infection control requirements. The guideline was released in 2002. Last year the recommendations were updated in collaboration with the Association for Professional in Infection Control and Epidemiology and the CDC. Our updated catheter care policies and procedures are based on these updates.
There are frequent citations related to V-tag 111, as you can see this tag really covers any infection control issue that may be identified in the facility. It is really the overarching tag.
The most important statement from that tag is included here. This is the one that incorporates all of our infection control policies and procedures.
The most important recommendation is hand hygiene. Hand hygiene includes using either soap and water, or alcohol based sanitizer. Studies indicate that the frequency of handwashing or antiseptic handwashing by personnel is affected by the accessibility of hand-hygiene facilities. Easy access to hand-hygiene supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand-hygiene recommendations. One of the most frequent citations regarding hand hyiene is: the staff member did not perform hand hygiene after removing gloves. Gloves do not count as hand hygiene. Anytime a staff touches the machine, the computer, the patient or any patient equipment hand hygiene must be performed. You should have sanitizer placed at all machines, at door ways, near the scale and anywhere else you feel necessary. There can not be enough sanitizer in the facility.
CDC has recommended that HCWs wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another. Before the emergence of the acquired immunodeficiency syndrome (AIDS) epidemic, gloves were worn primarily by personnel caring for patients colonized or infected with certain pathogens or by personnel exposed to patients with a high risk of hepatitis B. Since 1987, a dramatic increase in glove use has occurred in an effort to prevent transmission of HIV and other bloodborne pathogens from patients to HCWs . The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood. Glove use has to be the next most frequently cited issue. Staff must have gloves on when touching the patient equipment. We are seeing citations for touching the machine without gloves even when it is considered clean. There is no exception for not using gloves on a presumed clean machine. This includes first thing in the morning at start up gloves must be used. Gloves must be worn appropriately, frequent citations are seen for just wrapping a glove around the finger to mute an alarm. Along with this finger cots are not considered appropriate for use.
Frequent citations related to these requirements are: The staff member assigned patients in the isolation area are assigned patients that have not been vaccinated or have not responded to vaccination. This includes the staff member assigned to administer medications and in cases where only licensed staff may initiate catheter treatments. It’s important to ensure that strict infection control practices are followed. If necessary you may need to schedule the meds or initation of catheter patients be done last after all others have been done. Other areas that have been cited related to hepatitis b include no geographic buffer zone, it is important to identify which patients are protected and can be assigned to stations nearest the isolation. Many times this is cited because a patient is rescheduled and placed in the buffer zone without verifying appropriateness. Ensure when staff are rescheduling, calling patients in to an empty seat that patient has antibodies if being placed in the buffer zone. Frequently we see citations for staff caring for patients that have been vaccinated, responded and then the titer drops and that staff member is caring for positive patients. As you can see hep b status requires continued vigilance to ensure some of these patients get missed when revaccination or booster is required. There is no requirement that staff must be antibody positive to care for isolation patients, but the preference and the better practice is if you have staff that are immune they should be assigned to the isolation patients before someone that did not respond to vaccine or someone that has not been vaccinated.
Other areas that continue to be cited are the clean areas. Staff should be able to clearly identify those areas that are designated as clean areas and should use them as designated. Some of the more frequent citations seen are dirty items just dropped into a clean sink. Some of these items are dirty clamps, or normal saline bags allowed to drain in the sink. If the equipment or saline bag was placed on the patient machine it is considered contaminated. The phoenix meter or myron L meter should be placed at the dirty sink. The lab area is considered a contaminated area, the blood glucose monitor and centrifuge should be kept in this area. Lab tubes, plastic bags, vaccutainers etc. can not be kept in this area. They are considered clean until used. It is also important to remember that when blood samples are drawn they can not be placed in a clean area, this includes the nurses desk. They should be immediately taken to the lab area. Finally nothing should be stored under the sinks.
The cleaning and disinfection of machines, other equipment and chairs continue to be cited. All equipment must be cleaned according to manufacturers recommendations. This means appropriate disinfectant and recommended time for cleaning. A big issue seen in citations is the cleaning of chairs, they must be put in trendelenburg position and completely cleaned. Surveyors are inspecting chairs and finding many different things. One surveyor found $10 on the rail beneath the chair. The surveyors know how to put the chairs in trendelenburg and open the sides of chairs that swing out. Any blood on equipment or chairs should be immediately cleaned up with the appropriate bleach solution. Our policy is that anything greater than 10cc requires 1:10 solution. Cleaning equipment appropriately includes, thermometer, blood glucose monitor or any other equipment that is used for patient care.
Frequently cited is the routine testing for hepatitis b. Before 2008 we would see this citation occasionally, since 2008 it has become more frequent. It is important to follow the FMS policy that is written per the CDC recommendation. All patients new to dialysis must be tested for hepatitis b. This should be done at least 30 days prior to admission. In addition they must be tested for hepatitis b antibody, and hepatitis B core antibody. If the patient is susceptible to hepatitis they must be tested monthly.
Finally vaccination of patients. All susceptible patients must be offered the vaccination. The issue of susceptible patients is where many citations are seen. Many times the patient was vaccinated and responded to vaccination meaning the antibody level was equal to or greater than 10mIU/mL. Later the titer drops and no further vaccination or booster is offered, and many times this patient is left in the buffer zone. The antibody of patients that respond to vaccine should be drawn annually. If the titer drops the patient must be offered a second series of vaccination or if the patient received the second series a booster should be offered. If the patient does not respond with a level of equal to or greater than the 10mIU/ml they are no longer considered protected. There is the misconception that even if the titer drops below 10 they are still protected, this is only for immunocommpetent persons. Another frequent issue is because the titer dropped the monthly testing was not reinstituted. As you can see monitoring hepatitis status is critical to prevent citations in this area. It is possible to get an immediate jeopardy based on these citations. The status of hepatitis vaccination is included in the QAI program, this should keep you focused on these results.
I appreciate your time and if you have any questions I’ll be glad to answer them.
Infection Control Requirements and survey activity
North Division Condition Level CitationsCondition Citation 59 Conditions 57 Conditions 45 Conditions 2009 2010 2011 – YTD AugV110 Infection Control 7 15 4V175 Water/Dialysate 7 3 3V 400 Physical Environment 4 1 5V450 Patient Rights 0 0 1V500 Patient Assessment 10 11 10V540 Patient Plan of Care 10 12 11V580 Care at Home 2 2 0V625 QAPI 2 4 3V675 Laboratory Services 1 0 0V680 Personnel Qualification 1 1 1V710 Responsibilities of 8 6 3 Medical DirectorV725 Medical Record 1 0 0V750 Governance 5 2 4V 760 Grievance 1 0 0
North Division - Standard Level Citations HD Standard Level Citations 2009 - 988 2010 - 1281 2011- Aug YTD - 933V100 Compliance /Fed, State, Local Laws 4 9 2V110 Infection Control 247 370 200V175 Water and Dialysate 105 134 76V400 Physical Environment 146 158 108V450 Patient Rights 37 33 30V500 Patient Assessment 142 186 162V540 Patient Plan of Care 151 187 162V580 Patient Care at Home 22 16 5V625 QAPI 22 42 56V675 Laboratory Services 3 0 1V680 Personnel Qualifications 15 22 27V710 Responsibilities of Medical Director 44 54 58V725 Medical Records 23 48 25V750 Governance 27 22 21
ObjectivesReview the Conditions for Coverage Infection Control requirementsReview related survey citationsUnderstand individual infection control responsibilities
2nd Leading Cause of Death• Infection accounts for 15% of all deaths• 57% due to Vascular Access infections• Risk for bacteremia is seven fold the risk in patients with catheters• MRSA is 100 times higher
Rank US NE CT MA NH VT ME RI1 V113 V 113 V 520 V541 117 515 V751 1122 V 122 V 541 V 113 V113 114 143 1223 V 403 V 520 V 101 V111 184 1224 V 715 V 501 V 541 V114 122 1135 V 541 V 122 V 684 V544 113 7146 V 543 V 114 V 501 V143 115 6277 V 767 V 101 V 504 V542 755 4048 V 401 V 117 V 323 V501 110 3209 V 402 V 115 V 715 V634 250 31810 V 116 V 542 V 726 V191 143
Conditions for Coverage494.30 V111-V148The dialysis facility must provide andmonitor a sanitary environment tominimize the transmission ofinfectious agents within and betweenthe unit and any adjacent hospital orother public areas
CDC’s Components of a comprehensive infection control program• Infection control practices for hemodialysis units Infection control precautions specifically designed to prevent transmission of bloodborne viruses and pathogenic bacteria among patients Routine serologic testing for hepatitis B virus infections Vaccination of susceptible patients against hepatitis B Isolation of patients who test positive for hepatitis B surface antigen• Surveillance for infections and other adverse events• Infection control training and educationhttp://www.cdc.gov/mmwR/preview/mmwrhtml/rr5005a1.htm
CDC’s Central Venous Catheter Guidelines• Incorporated into the Conditions for Coverage• CDC’s “ Guidelines for the Prevention of Intravascular Catheter-Related Infections”• Recently updated• Guidelines for the Prevention of Intravascular Catheter-Related Infections
Frequent Citations Related to V111• Infection control precautions specifically designed to prevent transmission of bloodborne viruses and pathogenic bacteria among patients• Routine serologic testing for hepatitis B virus infections• Vaccination of susceptible patients against hepatitis B
Infection control precautions specifically designedto prevent transmission of bloodborne viruses and pathogenic bacteria among patients• Hand Hygiene• Glove Use• Caring for one or more HBV+ patients and one or more immune patients at the same time, but may not simultaneously care for Hepatitis B susceptible patients.• Clearly designated clean areas• Cleaning and disinfection of contaminated surfaces, medical devices, and equipment
Hand Hygiene• Single MOST important procedure• Hand washing uses soap and water• Hand hygiene uses waterless alcohol based
Gloves• Wear Gloves – When doing patient care – When administering medications – When handling equipment• Change Gloves – When working between patients or machines – When going between clean and dirty tasks – Whenever contaminated
Caring for HBsAg positive patients.• Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another.• Hepatitis B status should be considered when patients are assigned to stations nearest the isolation area. (immune)• Patients who require a booster dose of the HBV vaccine should not be assigned to a staff member concurrently caring for HBV+ positive patients.• When possible, only HBV immune staff should be assigned to care for HBV+ patients
Clearly Designated Clean Areas• Areas designated for preparation, handling and storage or medications.• Clean areas clearly separated from contaminated areas where used supplies and equipment are stored• Medications or clean supplies are not stored in or adjacent to the area where used equipment or blood samples are handled.
Cleaning and disinfection of contaminated surfaces, medical devices, and equipment• Follow manufactures guidelines for disinfection• Appropriate dilution and contact time of disinfectant• Correct cleaning and disinfection of environmental surfaces• Prompt cleaning of blood spills
Routine serologic testing for hepatitis B virus infections• Routinely test all patients for Hepatitis B virus• Test HBV susceptible, including nonresponders to vaccine: – HBsAg monthly – Anti-HBs is <10mIU/mL, patient is considered susceptible
Vaccination of susceptible patients against hepatitis B• Vaccinate all susceptible patients and staff members against hepatitis B.• Test for anti-HBs 1-2 months after last primary vaccine dose – If anti-HBs is <10mIU/mL, consider susceptible, revaccinate with an additional three doses and retest for anti_HBs – If anti-HBs ≥ 10mIU/mL, consider immune, and retest patients annually – Give booster dose of vaccine to patients if anti-HBs declines to <10mIU/mL and continue to retest patients annually.
References• Centers for Disease control and Prevention. (2001). Recommendations for preventing transmission of infections among chronic hemodialysis patients. Morbidity and Mortality Weekly Report, 50 (RR-5).• Centers for Medicare & Medicaid Services. (2008) Conditions for coverage for end stage renal disease facilities: Final rule, Federal Register. Retrieved from http://www.cms.gov/cfsandcops/downloads/esrdfinal rule0415.pdf• Gomez, N. (Ed.). (2011). Nephrology Nursing Scope and Standards of Practice (7th ed.) . Pitman, NJ: American Nephrology Nurses’ Association.