Each year, more than 75,000 hospital patients,
including patients on dialysis, become infected
with central line associated blood stream
infections.
And as many as 25 percent of those infected patients
die, according to a study conducted by the U.S.
Centers for Disease Control and Prevention.
When initiating dialysis with a fistula or graft,
medical professionals must follow recommended
infection-prevention guidelines.
Doing so can reduce the rate of central line
associated blood stream infections, decrease
hospital costs, and, most importantly, improve
clinical care.
Hand hygiene is the first vital step to initiating
dialysis with a fistula or graft and is a primary
factor in reducing infections in the dialysis
center.
Alcohol-based hand rub is the preferred method for
routine hand hygiene.
Apply the product to the palm of one hand.
Make sure to cover all surfaces of your hands and
fingers, then rub your hands together until
they're dry.
You must perform hand hygiene before touching a
patient, before beginning a clean or sterile
procedure, after being exposed to body fluid,
after touching a patient and after touching the
patient's surroundings.
You must also perform hand hygiene before you put on
new, clean gloves.
After each interaction you have with a potentially
contaminated surface, you should remove your gloves
and perform hand hygiene.
You are not required to wear gloves before
assembling supplies at the patient cubicle, but you
must perform hand hygiene to reduce the risk of
contaminating the outside of the supply packages
with microbes.
Supplies needed include: a clean barrier, antiseptic
agent, clean gloves, and two sterile dialysis
needles for cannulation of the arteriovenous or AV
access, as well as two syringes filled with
sterile saline.
These supplies are typically placed on top of
the clean barrier on the tray attached to the
dialysis chair.
Once your supplies are gathered, wash the skin
over the AV access with soap and water or an
antibacterial scrub.
In some centers, the patient may perform this
procedure on his or her own.
You must verify if the patient has done this
either by observing it or asking the patient if he
or she has washed the skin.
If the patient is unable or unwilling to do this
task, you must complete this procedure before
moving on to the next step.
Next, inspect the AV access site for both
infectious and non-infectious
abnormalities.
Be careful when you palpate the cannulation
site to identify specific sites for insertion of the
dialysis needles.
If you're not wearing sterile gloves and you
palpate over the area that was just cleaned, then you
may contaminate what was previously considered a
clean site. As a result, when the needle is inserted
bacteria can enter the blood stream.
Given this risk, please make sure that you follow
sterile procedures carefully and repeat them
as needed.
Before inserting the cannulation needle, place
a sterile or new clean barrier under the arm
containing the AV access to create a local
procedure area and reduce the risk of blood
contamination of the dialysis chair if bleeding
occurs during needle insertion.
Next, scrub the skin over the pre-identified needle
cannulation sites with antiseptic like
chlorhexidine.
Allow the antiseptic agent to dry.
Because the initiation of dialysis poses a risk for
blood contamination, you must wear personal
protective gear, including gloves, eye protection and
a mask and gown.
A mask or face shield may reduce the risk of
contamination of the catheter or site from
sneeze or cough droplets containing infectious
material.
Without contaminating the needle sites, insert the
dialysis needles into the AV access.
After the needle is successfully in place,
tape it securely.
Follow this task by performing the second
needle cannulation.
Tape the second needle securely in place.
Once you connect the dialysis lines to the
dialysis needles, dialysis is initiated.
To ensure safety, refer to the Access of AV Fistula
or Graft for Initiation of Dialysis Checklist to make
sure that you always follow proper procedure.
Every time their dialysis lines are opened and
entered, patients on dialysis are at risk of
developing blood stream infections.
For this reason, you must follow proper injection
practices when accessing the port to administer
medication to ensure safety.
Medication preparation must occur in a clean area
away from the dialysis station.
Before preparing medication, carefully
follow hand hygiene procedures.
Clean your hands with an alcohol sanitizer.
Then wipe the medication vial's opening vigorously
with an alcohol pledgete before drawing the
medication with a syringe.
Once you've prepared the syringe, clearly label the
syringe.
Include: the name of the medication, the dosage,
the time and date the syringe was prepared and
your name.
You must clearly indicate if the syringe contains
high-alert medications like heparin.
You must properly disinfect the port prior
to injection to prevent bacteria from passing into
the blood when penetrated by the needle.
To ensure the port is disinfected, first clean
your hands and then put on clean gloves.
Next decontaminate the injection port with an
antiseptic such as chlorhexidine, iodophor or
70 percent alcohol.
Rub the port vigorously with friction for 10 to 15
seconds. Once the port has been decontaminated, inject
the medication. Remove the needle and immediately discard
it and the syringe in an infectious waste container.
Finish the procedure by removing and discarding
your gloves and performing proper hand hygiene.
Because improper injection practices have resulted in
transmission of hepatitis viruses in dialysis
centers, please use these safe injection procedures
to ensure patient safety.