Standard precautions for hemodialysis unit

➡️First Hemodialysis

Entry points to the patient's circulatory system

The circulatory system is entered through some means, such as making an arteriovenous connection or an artificial vein using surgical vascular grafting, or other temporary access devices, such as using a central venous catheter through the jugular vein.

(Jugular vein), or subclavian vein, or femoral vein .

➡️Infection control measures during hemodialysis sessions

Procedures for connecting the patient to the hemodialysis machine via the arteriovenous connection and separation procedures

➡️Infection control recommendations are followed when connecting the patient to or disconnecting from dialysis machines, taking into account the following

• Wash your hands or rub them with alcohol before the procedure.
• Wear appropriate personal protective equipment (clean gloves – disposable gloves). Other tools may be required (such as eye protection – surgical mask) according to the risk assessment before the procedure.
• Use sterile gauze when connecting or disconnecting.
• Disinfect the insertion site before connection and after disconnection with a suitable disinfectant (such as iodide "Povidone Iodine 10%), taking into account the contact time.
• Follow the anti-contamination method when connecting the patient to or disconnecting the dialysis machine.
• After separation, pressure is applied to the fistula site and covered with sterile gauze. Then, medical tape is placed over the sterile bandage. It is not permissible to place the tape directly over the fistula.
• Remove personal protective equipment after completing the procedure and then wash your hands.
• Procedures for connecting the patient to the hemodialysis machine via a central venous catheter and separation procedures
• Surgical hands should be washed or rubbed with alcohol before the procedure.
• Wear appropriate personal protective equipment (such as sterile gloves and a clean gown) before the procedure.
• Use sterile cotton or gauze when connecting or disconnecting.
• Clean the insertion site of the central venous catheter using sterile gauze soaked in an alcohol solution (60-95%) before connection and after disconnection, taking into account the contact time.
• Follow the anti-contamination method in handling the central venous catheter when connecting the patient to the hemodialysis machine or disconnecting it.
• The central venous catheter insertion site is covered with sterile gauze and then medical tape is placed over the sterile dressing. The tape is not allowed to be placed directly over the catheter.
• Remove personal protective equipment after completing the procedure and wash hands.

➡️Second Washing using a proton membrane

The main components of peritoneal dialysis include

• Insertion of a catheter into the peritoneal cavity, which can be placed without surgery or by surgical incision.
• Solution is a solution that is available for use.
• Determine and organize the process of introducing the solution into the peritoneal cavity and draining it using an accurate schedule and system for the number of hours of the dialysis process.

➡️Precautions to be taken when performing peritoneal dialysis

• The anti-contamination method must be followed during the insertion and connection of the peritoneal dialysis catheter and during the dialysis solution change procedures.
• Sterile gloves are worn during the placement and handling of the peritoneal dialysis catheter.
• A surgical mask is used during connection and disconnection procedures to reduce the risk of infection with Staph. Aureus bacteria transmitted through the nose.
• The external site of the catheter should be kept clean and dry.
• The catheter should be properly secured in a way that minimizes the chances of it being removed accidentally and causing wounds to the surrounding skin area.
• Patients should be educated on the proper care of the external catheter site if continuous infusion is used outside the hospital.
• Patients and staff should monitor for early symptoms of infection if they occur.

➡️Infection control procedures for patients and healthcare staff in dialysis units

• It is necessary to wash, disinfect, or rub hands with alcohol if they are apparently clean before handling it.
• Dialysis unit workers must wear appropriate personal protective equipment to prevent exposure to blood in the event of blood spills or spray resulting from cuts or tears in the dialysis connections or dialysis filter membranes, as this occurs in the event of increased pressure within these connections.
• Clean, single-use gloves should be used before performing any procedure that does not penetrate the body's natural defenses and when handling various surfaces and tools, including the dialysis machine. These gloves can be used to connect the patient to the dialysis machine, while adhering to the no-touch method.
• Sterile gloves should be used when inserting a central venous system or inserting a peritoneal dialysis catheter.
• A member of the health team is assigned to handle supplies from the warehouses to a central location in the dialysis rooms. This member does not interact with patients during dialysis sessions.
• The central location is not handled by the person in charge of connecting or disconnecting the patient from the dialysis machine, but rather by the nursing staff on duty.
• In the event that there are no nursing staff available to handle the procedure, the nursing staff will prepare the delivery or separation supplies for one patient only immediately before the procedure and will not leave any supplies on the machines during the dialysis sessions.
• All dialysis equipment that has been handled once or taken to a specific patient station must be disposed of immediately after use (if intended for reuse) or cleaned, disinfected or sterilized before reuse or storage (if intended for multiple uses).
• A separate area should be designated for the placement of central venous catheters for patients outside the dialysis room.
• A sterile kit of supplies and equipment must be prepared for each patient when connecting central venous catheters.
• Heparin must be prepared immediately before use to the patient and the method of preventing contamination must be followed when giving it to the patient during the dialysis session.
• Patients should be instructed on the proper care of the dialysis catheter insertion site.
• To avoid blood contamination with bacteria and contamination of blood tubes, the following procedures should be followed
• Keep IV tubing away from the waste container during the dialysis machine preparation process.
• Hands should always be washed after handling waste.
• Disinfect the containers designated for disposing of waste resulting from the filtration process daily.
• Cleaning and disinfecting the outside of the dialysis machines.
• Disinfecting the internal and external tubes of the washing solution.

➡️Cleaning and disinfecting dialysis machines

• The external surfaces of the machine must be cleaned and disinfected after each patient.
• The internal and external tubes of the washing solution must be disinfected.
• The manufacturer's instructions must be followed in writing.
• Perform flushing and disinfection procedures for the single-pass machine at the beginning and end of the day or according to the manufacturer's instructions.
• For recycling machines (currently in short supply), rinsing and disinfection procedures are performed between patients.
• The same cleaning and disinfection methods are followed if blood leakage occurs, regardless of the type of dialysis machine used.
• The manufacturer's instructions for the disinfectant used to disinfect the dialysis machine must be followed.

➡️Environmental cleanliness in the dialysis unit

• Policies and protocols for cleaning and disinfecting surfaces and equipment in the dialysis unit should be written, including thorough cleaning before any disinfection is performed.
• The patient station must be cleaned and disinfected after a dialysis session, including the dialysis bed, various nearby surfaces, dialysis solution containers, and waste containers.
• Bed sheets and blankets should be changed between each patient.
• The hazardous waste bag should be disposed of immediately after each session.
• Spills of blood and other fluids must be dealt with immediately.
• Other standard infection control procedures are followed regarding environmental cleanliness.
• Monitoring the quality of water used in the dialysis process

➡️Handling waste from dialysis units

• All items to be disposed of should be placed in bags thick enough to prevent leakage. Waste from the dialysis unit may be contaminated with blood and should be handled accordingly.
• The cleaning staff in the dialysis unit should remove waste after each session.
• Sharps are disposed of immediately after use in their own safety containers. There should be a container near each patient service area.
• Dialysis Unit Workers
• Persons exposed to infection due to their work should be provided with regular training and guidance. New employees should also be provided with training and guidance before they begin work in the dialysis units.
• All dialysis unit staff should be vaccinated against hepatitis B.
• Workers must wear appropriate personal protective equipment.
• Staff members should not eat or drink in the dialysis area.
• No special measures or restrictions are recommended for healthcare providers infected with blood-borne pathogens (hepatitis B, hepatitis C, and HIV ) .

➡️Environmental factors and design of dialysis units

➡️Basic principles of design

• Provide adequate space away from the patient service area for storage of clean and sterile materials.
• Allocating halls or rooms for dialysis for patients infected with hepatitis B, away from the rest of the patients, with a work team assigned to deal with them during the dialysis period (so that they do not provide the service to the rest of the patients during the same shift period), provided that the dialysis requirements for these patients and all the necessary equipment for them are separate from those designated for other patients.
• Allocating halls or rooms for kidney dialysis for patients infected with the hepatitis C virus, away from the rest of the patients, with a work team assigned to deal with them during the dialysis period (so that these people do not provide the service to the rest of the patients during the same shift period), provided that the dialysis requirements for these patients and all the necessary equipment for them are separate from that allocated to other patients.
• In the event that there are halls or rooms for HIV-positive patients, special machines must be allocated for them for dialysis, away from the rest of the patients, with a work team assigned to deal with them during the dialysis period (so that they do not provide the service to the rest of the patients during the same period of care), and the dialysis supplies for these patients and all the necessary equipment for them must be separate from those allocated to other patients.
• A store is allocated for all water treatment equipment and filters.
• A storage area is designated for dialysis solution containers.
• A place is designated for the temporary storage of hazardous medical waste, as well as a place for storing contaminated sheets and bedding until transportation.
• Records required in the dialysis unit
• A comprehensive record of the number and names of all dialysis patients in the unit annually.
• A special record for all dialysis machines in the unit, including their types / dates of entry into service / maintenance history / emergency events for each machine. A special record for each patient, including medical history / date of start of dialysis sessions in the unit, serological analysis prior to the start of dialysis in the unit, results of serological and chemical analyses for the patient, dialysis machine number, blood transfusions, days and duration of dialysis sessions.
• A comprehensive registry of serological test results for all patients in Oujda.
• A comprehensive blood transfusion record for all patients in the unit.
• A record of chemical analysis results for all patients in the unit.
• A log of emergency events occurring in the unit, including machine breakdowns.
• A record of water sampling and analysis results.
• A record of the unit's water treatment plant maintenance and filter change dates.
• A special register of the names of the health team in the unit, along with the results of their periodic serological tests and their vaccinations.
• A record of patients' vaccinations against hepatitis B.
• A special register for investigating outbreaks of blood-borne infections or bacterial and viral infections occurring in the unit.

➡️Patient Care Guidelines

• Dialysis requires awareness from the patient to reduce the risk of diseases that may be caused by infections and
• It may also result in death, and there are steps that must be taken to educate the patient, including
• Patients should be educated on the need to keep the dialysis catheter insertion site clean and dry at all times, and the importance of patient personal hygiene and its relationship to insertion site infection should be emphasized.
• Educating patients about the proper way to care for the site of the dialysis catheter insertion and the necessity of their awareness of the symptoms and signs of infection and reporting them immediately. These symptoms include fever, feeling cold, shivering, pain, redness, or the appearance of infiltration around the site.
• Patients are allowed to eat meals during dialysis.

➡️Measures to combat the transmission of hepatitis B virus

·       The following should be followed to prevent transmission of hepatitis B virus among patients undergoing dialysis

·       Vaccinate patients against this disease.

·       Adherence to standard infection control precautions for all patients undergoing hemodialysis.

·       Regular serological testing every 3 months for hepatitis B surface antibody ( HBsAg ) and rapid review of test results.

·       The following should be considered when a positive seroconversion occurs for hepatitis B surface antibody ( HBsAg )

·       Reviewing patients' periodic laboratory test results to identify new cases.

·       are retested for hepatitis B surface antibody ( HBsAg ) .

·       Isolation of positive cases.

·       Investigate potential sources and causes of infection to determine whether it has been transmitted within or outside the dialysis unit, and review the methods and procedures used in the dialysis unit.

·       are retested for hepatitis B surface antibody ( HBsAg ) after three months along with anti-HBs tests to determine the need for medical consultation and evaluation.

➡️Insulation

• A separate place is allocated for the treatment of patients positive for hepatitis B surface antibody ( HBsAg ).
• Allocating machines, equipment, tools, supplies and medicines for these patients.
• Health teams are assigned to deal with dialysis patients infected with hepatitis B during dialysis sessions.
• Patients with chronic viral hepatitis can transmit the infection to others, in addition to being more susceptible to other chronic liver diseases. They are advised on ways to prevent transmission of the infection to others or their family members and spouses, and the necessity of vaccinating them against hepatitis B. The presence of chronic liver diseases or their development must be assessed according to the guidelines followed in medical practice (through medical consultation or referral to a specialist doctor when necessary).

➡️Vaccination

Dialysis patients and the health team in the dialysis units should be vaccinated against hepatitis B. This vaccination is done by injection into the deltoid muscle only in a series of vaccinations as follows the first dose is given, then the second dose is given a month later, and the third dose is given six months after the first dose.

Since the immune response in patients with kidney failure is weaker than in healthy people, they are vaccinated with a double dose of the vaccine or with the dose specified by the manufacturer, and they are given a booster dose every 5 years or if the concentration of antibodies in the blood reaches less than 0.1 milli-international units/ml at any time.

➡️Hepatitis C virus transmission control measures

Transmission of hepatitis C virus in dialysis units can be prevented by strict adherence to standard infection control precautions with all dialysis patients. Patients infected with hepatitis C virus should be isolated from other patients, and regular tests for hepatitis C virus antibodies should be performed every 3 months to monitor the spread of the virus within the units and ensure that precautions are implemented appropriately and consistently.

When a positive seroconversion occurs for antibodies to the hepatitis C virus, the following should be taken into account

Reviewing the results of periodic laboratory tests every 3 months, which were performed for all other patients and the health team, to determine whether there are additional cases.

Isolation of positive cases.

Investigate potential sources and causes of infection to determine whether it has been transmitted within or outside the dialysis unit, and review the methods and procedures used in the dialysis unit.

Follow up on the results of serological tests for all patients every 3 months.

➡️Insulation

Patients who are positive for hepatitis C antibodies should be isolated from other negative patients.

Allocating machines, equipment, tools, supplies and medicines for these patients.

Allocating a health team for these patients during dialysis sessions.

Patients should be educated about ways to prevent further damage to their own lives and transmission of the infection to others, and should be vaccinated against hepatitis B.

HIV prevention

Infection control precautions are sufficient to prevent transmission of the virus from one patient to another, with care taken to isolate infected patients in the dialysis units of fever hospitals.

The following tests are performed for all patients with renal vesicle disease before starting treatment and every 3 months

HBsAg  Hepatitis B surface antibody

HCV Ab Antibodies to Hepatitis C Virus

HIV Ab Antibodies to HIV

➡️Prevent bacterial diseases

• Follow the guidelines for the optimal use of antibiotics.
• Standard infection control precautions are sufficient to prevent transmission to and from patients or colonizers of some bacterial species, including antimicrobial-resistant strains. However, other precautions (such as contact isolation precautions) must be taken when dealing with certain patients who are at high risk of transmitting infection to others.

➡️General notes

Ensure adherence to isolation precautions for contact-transmitted diseases for patients colonized or infected with antibiotic-resistant microorganisms (e.g., MRSA, VRSA, VRE) during dialysis sessions for these patients.

Staff caring for patients with antibiotic-resistant dialysis should wear appropriate personal protective equipment, including gowns, and remove these protective equipment immediately after contact with the patient. Dialysis should be performed in a designated area, as far away from other patients as possible (at the end of the unit or as far away from other patients as possible).

➡️Isolation Dialysis Unit Protocol

1. Cancellation of routine testing for hepatitis C antibodies every three months for chronically infected patients
2. Patients newly infected with HCV +VE are confirmed positive for the test, then the patient is transferred to the positive patients’ hall, and PCR tests are performed at the same time, according to the following
3. If the immediate analysis is positive, the patient remains in the positive room and the analysis is repeated six months later.
4. If the analysis remains positive after six months, the patient remains in the positive room and the analysis and follow-up will not be repeated until after treatment.
5. If the immediate analysis or after six months is negative, it will be transferred to the negative hall.
6. Patients who have received complete treatment for hepatitis C and have a negative PCR test result will be transferred to the negative room.
7. Allocate at least one room for patients infected with viruses B and C.
8. Modifying the number of doses of hepatitis B vaccination to four doses (1, 2, 0, 6).
9. Emphasizing the need to allocate a dialysis machine for non-dialyzed patients until they are classified
10. If the water sample taken from the water treatment unit in the dialysis department does not meet the required specifications, a committee will be formed to carry out the necessary maintenance, and the sample will be transferred to the central laboratories by the Environmental Health Supervisor in the Directorate.