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 catheter,
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 catheter,
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 should 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 sterile syringes
filled with sterile saline. These supplies are typically
placed on top of the clean barrier on the tray
attached to the dialysis chair.
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.
To further reduce the risk of catheter contamination
You may also want to ask patients to wear masks.
Scrubbing catheter ports or hubs is one of the most critical
processes to preventing contamination of the connecting
site and inside of the catheter exposed to the patient's blood.
Before cleaning the connection area, place a sterile
or new clean barrier under the catheter.
The connection area of each catheter consists of a
Luer lock fitting under the catheter lumen or hub
that is covered by a cap when the catheter is not
in use. There are two approaches recommended for proper
scrubbing of the catheter connection area.
In the first and more commonly used approach
you disinfect the cap at exposed areas of the catheter near
the connection site by scrubbing it.
Use an antiseptic agent like chlorhexidine, alcohol or
providone iodone before removing the cap and connecting the
dialysis blood lines to the Luer lock connector.
With this approach, the areas under the secure
caps are assumed to be protected and sterile.
If they're not, you might contaminate the inside of
the catheter and could expose the patient's blood to harmful
bacteria. The second approach requires an extra step.
You scrub the Luer lock hub of the catheter located under
the cap with antiseptic agent before you connect the
catheter hubs to the dialysis machines lines and tubing.
Vigorously rub alcohol wipes across the hub for
proper cleansing and to thoroughly remove any visible
blood or clots. You must do this to properly to prevent
bacteria from getting into the patient's blood stream
and circulating through the body. If you don't perform
this step properly, you're putting the patient at risk of
septicemia or bacteremia, which are the major blood stream
infections that occur all too frequently in dialysis
patients with catheters. After you clean each hub,
connect a sterile syringe to the Luer lock hub. After the hubs
are cleaned, standard protocol is to remove the
anticoagulant and to check to make sure each port
is able to aspirate blood into the syringe.
Next, remove the syringes, one at a time, and connect
the dialysis blood line to the Luer lock hub. Do this
before removing the second syringe and connecting
the second dialysis blood line. To ensure safety, refer to the
Access of Central Venous Catheter for Initiation of
Dialysis Checklist to make sure that you always follow
proper procedure. Most dialysis patients with catheter-based
vascular access use tunneled dialysis catheters.
You need to inspect and clean the exit site.
Before taking care of the exit site, perform your hand
hygiene and assemble your supplies, including
antiseptic agent, clean gloves, personal protective
equipment, a new dressing, and antibiotic ointment.
Because exit site care poses a risk for you to be
contaminated with infected body fluids, you must wear
personal protective equipment.
Remove the old dressing and discard it in an
appropriate infectious waste receptacle. Once you've
done this, remove your gloves and perform hand hygiene.
Put on clean gloves and inspect the exit site and tunnel
for redness, heat, swelling, tenderness or pus
or other discharge. Then cleanse the area with an
antiseptic solution like chlorhexidine by
using an outward circular pattern.
Start at the exit site and move outward in a circular pattern.
Once the area is dry, apply anti-microbial ointment
to the exit site and then apply a fresh dressing.
Finally, remove your gloves and perform proper hand hygiene.
To ensure safety, refer to the Central Venous Catheter
Exit Site Care Checklist to ensure that you
always follow proper procedures.