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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1178-1184

Assessment of safety measures in hemodialysis units in Sharkia Governorate


1 Department of Internal Medicine and Nephrology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Nephrology, Abukabir Central Hospital, Sharkia, Egypt

Date of Submission28-Mar-2022
Date of Decision16-Apr-2022
Date of Acceptance17-Apr-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Mohamed M M. Soliman
Hehia City, Sharkia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_104_22

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  Abstract 


Background
Hemodialysis (HD) is one of renal replacement therapies for patients who need dialysis acutely and for many patients as maintenance therapy.
Objectives
To assess safety measures in HD units in Sharkia Governorate.
Patients and methods
This was a cross-sectional study done over 3 years on 22 HD units in Sharkia Governorate.
A questionnaire was designed for the assessment of infection control measures in HD units.
Results
Regarding hand washing facilities, all units mostly fulfilled the majority of criteria. On assessing personal protection, all units mostly fulfilled the majority of criteria, with no significant difference between central and peripheral units. Regarding dealing with furniture and sheets, there was no significant difference between central and peripheral units, and mostly all units fulfilled the criteria. Regarding environmental cleansing, machine cleansing and bed cleansing were adequate in most of the units. Separation between storage areas and treatment areas was associated more with peripheral units, but not significantly. All units were perfect in dealing with blood stains. On assessing vaccination of the staff to hepatitis B virus, there was no significant difference between central and peripheral units. One central and two peripheral units reported isolation of hepatitis B virus-infected patients.
Conclusion
All studied units showed satisfactory percentage regarding methods for preventing pollution. They were very good regarding environmental cleansing and were ideal in dealing with furniture and sheets.

Keywords: dialysis, hemodialysis, infection control, safety, units


How to cite this article:
Khamis SS, Emara MM, Kasim HE, Soliman MM. Assessment of safety measures in hemodialysis units in Sharkia Governorate. Menoufia Med J 2022;35:1178-84

How to cite this URL:
Khamis SS, Emara MM, Kasim HE, Soliman MM. Assessment of safety measures in hemodialysis units in Sharkia Governorate. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:1178-84. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1178/359644




  Introduction Top


Hemodialysis (HD) is one of renal replacement therapies for patients who need dialysis acutely and for many patients as maintenance therapy. It provides excellent, rapid clearance of solutes[1].

End-stage renal disease (ESRD) is associated with significantly increased morbidity and mortality resulting from cardiovascular disease and infections, accounting for 50 and 20%, respectively, of the total mortality in patients with ESRD[2].

HD patients as well as the dialysis staff are vulnerable to contracting health-care-associated infections due to frequent and prolonged exposure to many possible contaminants in the dialysis environment. The extracorporeal nature of the therapy, the associated common environmental conditions, and the immune compromised status of HD patients are major predisposing factors. The evident increased potential for transmission of infections in the HD settings led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions[3].

The CDC recommends that health care personnel use standard precautions during patient care in all health care settings to prevent pathogen transmission. Standard precautions include hand hygiene, use of personal protective equipment, and respiratory hygiene/cough etiquette[4].

The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve the understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety[5].

The aim of this work was to assess safety measures for patients in HD units in Sharkia Governorate, aiming to improve the quality of medical services provided by the health care providers in HD units in Sharkia Governorate.


  Patients and methods Top


The study was approved by the ethical committee of the hospital, Faculty of Medicine, Menoufia University. This study was conducted on 22 randomly selected HD units in Sharkia Governorate, Egypt (four central units in big cities; Zigzag and 10th of Ramadan city and 18 peripheral units in small cities).

Inclusion criteria

All patients with ESRD under regular HD in these units were included.

Methods

A modified safety questionnaire from the Ministry of Health was used to assess infection-control measures in HD units. This questionnaire was designed to assess infection control measures in HD units. It is divided into sections: general information about the unit, cleanliness of the place, hand washing, personal protection, methods for preventing pollution, dealing with furniture and sheets, environment cleansing, dealing with waste products, occupational health, and isolation.

The process of HD in these units was monitored from the start of work to the end to assess all of the infection-control aspects and the defects in these units. For example, I have to follow up all the medical team to determine the extent of their commitment to wear personal protective equipment, commitment to wash hands, etc. I have also to follow up nurses while dealing with patients and HD machines to know how to follow the infection control policies. Moreover, I communicated with physicians, nurses, patients, and workers in all units to be fully aware of the extent of their commitment to vaccination against hepatitis B virus (HBV).

Questionnaire about safety measures in hemodialysis units

Unit name

Date of assessment:



Statistical analysis

Data collected were coded, entered, and analyzed using Microsoft Excel software. Data were then imported into Statistical Package for the Social Sciences (SPSS, version 20.0, SSPS Inc, Chicago, USA) software for analysis. The following tests were used to test differences for significance: difference and association of qualitative variable by χ2 test, differences between quantitative independent groups by t test or Mann–Whitney, and correlation by Pearson's correlation or Spearman's.

As per satisfactory outcome of the questionnaire, accepted safe score is above 75%.


  Results Top


Regarding hand washing facilities within units, such as basins, soaps, and disinfectants for hand washing, all studied units fulfilled their criteria. The only difference was in drying hands, as it was associated more with peripheral units than central units, but not significant [Table 1].
Table 1: Hand wash distribution among studied units

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On assessing personal protection domain of the studied units, all units mostly fulfilled the majority of criteria with no significant difference between central and peripheral units except gloves change after each use, commitment to nontouch method, and uncontaminated plastic roller, as they were associated more with peripheral units, but not statistically significant [Table 2].
Table 2: Personal protection distribution among studied units

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Regarding dealing with furniture and sheets, there was no significant difference between central and peripheral units and mostly all units fulfilled the criteria but sheets sent in impermeable bags to the laundry and storing clean sheets and furnishing in clean place were slightly associated with peripheral units [Table 3].
Table 3: Dealing with furniture and sheets distribution among studied units

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On assessing environmental cleansing domain, regarding machine cleansing and bed cleansing, mostly all units were adequate, but it was slightly associated with central units, but not significant. On the contrary, separation between storage areas and treatment areas was associated more with peripheral units but was not significant, and all units were perfect regarding dealing with blood stains [Table 4].
Table 4: Environment cleansing distribution among studied units

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On assessing vaccination of the health care workers to HBV, there was no significant difference between central and peripheral units. Only one central and two peripheral units reported isolation of HBV-infected patients, whereas this was nonapplicable in all of the other units [Table 5].
Table 5: Occupational health and hepatitis B virus isolation among studied units

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  Discussion Top


Uremia is a clinical syndrome marked by elevated concentrations of urea in the blood and associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function[6].

ESRD is defined as irreversible decline in kidney function that is severe enough to be fatal in the absence of dialysis or transplantation. Chronic kidney disease and ESRD are associated with systemic inflammation and acquired immunodeficiency, which promote cardiovascular disease, body wasting, and infections as leading causes of death. This phenomenon persists despite dialysis-related triggers of immune deregulation having been largely eliminated. It has also been proposed that changes in the gastrointestinal microbiota and increased intestinal permeability to endotoxin lead to a persistent activation of the innate immune system, resulting in the induction of immune-regulatory mediators that then suppress both innate and adaptive immunity. In addition, immune responses may also be impaired by poor nutritional status, malnutrition, and vitamin D deficiency[7].

HD is the mainstay therapy that is offered to patients with ESRD who cannot undergo renal transplantation. The main purpose of HD is the provision of sufficient and safe patient treatment, which contributes to the better physical condition of the patient and it prevents further problems and complications that are due to uremia[8].

In an environment where multiple patients receive dialysis concurrently, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly through contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel[9].

Lapses in infection control practice, such as hand hygiene and environmental cleaning, have been associated with bloodstream infections and hepatitis C virus (HCV) outbreaks. The CDC strongly recommends several infection control procedures, including practice of hand hygiene, appropriate catheter care, use of antiseptic agents, checklists, and staff and patient education, all of which are vital to reducing infections. Dialysis personnel should be thoroughly trained in standard precautions and other infection control measures as outlined by the CDC and other organizations, such as the Association for Professionals in Infection Control and Epidemiology[10].

Hand hygiene is an important measure for preventing vascular access–related infections, and dialysis facilities should ensure the availability of easily accessible hand washing sinks and alcohol-based hand sanitizers. Opportunities for hand hygiene include before touching a patient, before aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings[10].

Hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody titers should be obtained before starting dialysis, and HBsAg titers should be checked monthly if hepatitis B surface antibody titers are not at the desired level. If patients are HBsAg positive, they should be dialyzed in an isolation room with dedicated equipment. It is recommended that a staff member be dedicated to the care of these patients for that shift. Moreover, baseline and routine (annual or biannual) HCV antibody screening is beneficial for early diagnosis and possible treatment, thus reducing transmission risk[10].

In this study, we attempted to assess infection-control parameters in HD units in the Sharkia Governorate, Egypt, to reduce the infectious complications of HD, which include bacterial infections caused by contaminated equipment, other bacterial infections (including vascular access infections), and blood-borne viruses (BBV) (primarily the HBV and HCV).

This study was done on 22 randomly selected HD units in Sharkia Governorate (four central units in big cities such as Zagazig and 10th of Ramadan city and 18 peripheral units in small cities). A questionnaire was designed for the assessment of infection control measures in HD units, which is considered as one of the most important areas of safety risk in dialysis facilities.

As per satisfactory outcome of the checklist, accepted safe score is above 75% and the total score of all units was above this score.

Regarding hand washing facilities within units, basins, soaps, and disinfectants for hand washing, all studied groups fulfilled their criteria. The only difference was in drying hands. as it was associated with peripheral more than central units but was not statistically significant.

The clinical practice guidelines suggested that there should be at least one hand wash basin in each segregation area of dialysis[11].

Khamis et al.[12] assessed safety measures in HD units in Menoufia Governorate. Regarding the hand washing practice, the presence of soap and basin was achieved in all units, whereas the practice of hand swabbing by antiseptics among the working staff was to some extent in 89.5%. The availability of antiseptic was good in 78.9%. In contrast, drying of hands after wash was bad in 73.7%, to some extent in 21.1%, and good in 5.3%.

On assessing personal protection domain of the studied units, all units mostly fulfilled majority of criteria with no significant difference between central and peripheral units except gloves change after each use, commitment to nontouch method, and uncontaminated plastic roller as they were associated more with peripheral units but not significant.

The clinical practice guidelines suggested that there should be sufficient supplies of personal protective equipment, which are of different sizes to suit the needs of staff, in the renal units and at the point of patient care[11].

Khamis et al.[13] assessed safety measures in HD units in Qalyubia Governorate. Nonsterile gloves were available in 94.7% of the studied units, sterile gloves were available in 47.4% of units, plastic gowns were available in 52.6% of the units, and 63.2% of the units did not change gloves after each use.

Loveday et al.[14] recommended that gloves must be worn for any invasive procedure, contact with any sterile site, and non-intact skin or mucus membrane, all activities that are considered as carrying a risk of exposure to blood or body fluids, and when handling sharp or contaminated devices.

On assessing environmental cleansing domain, regarding machine cleansing and bed cleansing, mostly all units were adequate, but it was slightly associated with central units and was not significant. On the contrary, separation between storage areas and treatment areas was associated with peripheral units more but was not significant, and all units were perfect regarding dealing with blood stains.

The clinical practice guidelines suggested that the environmental surfaces of the renal units should be cleaned and disinfected when they become visibly soiled or after contamination[11].

Khamis et al.[15] assessed safety measures in HD units in Dakhlia Governorate. They found that in 100% of the studied units, there were containers of concentrated solutions (tight lid). Moreover, machines were cleaned in 88.8% of the studied units, beds were cleaned in 88.8% of the units, and 27.7% of units did not show complete separation between storage areas and the patient treatment area. An overall 38.8% of the studied units did not follow the protocol for removal of blood stains.

Karkar et al.[3] suggested that in the health care setting, contamination of environmental surfaces with various pathogens and the persistence of these pathogens on surfaces can be an important and frequent source of transmission of infectious agents through the frequent hand touching of health care workers. The environment in HD units is particularly prone for contamination with blood-borne pathogens such as HBV, HCV, HIV, and other infectious agents such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and Clostridium difficile. Microorganisms can survive on environmental surfaces for varying periods of time, ranging from few hours to days and months. To prevent and control the spread of environmentally transmitted pathogens, cleaning and disinfection of the external surfaces of equipment (HD machine, dialysis chair or bed, procedure trolley, and other environmental surfaces inside the HD units, especially those that are frequently touched by patients and staff, should be performed between all patient treatments (irrespective of the patient diagnosis).

Regarding vaccination of the health care workers to HBV, there was no significant difference between central and peripheral units. Only one central and two peripheral units reported isolation of HBV-infected patients, whereas this was nonapplicable in all of the other units.

The clinical practice guidelines suggest that the renal units should have in place a comprehensive BBV protocol to prevent the transmission, minimize the incidence, facilitate early detection, and guide the management of BBV infections[11].

Malhotra et al.[16] suggested that HBV infection is less prevalent than HCV in HD units. The introduction of HBV vaccination, isolation of HBV-positive patients, use of dedicated dialysis machines, and regular surveillance for HBV infection have dramatically reduced the spread of HBV in this setting.

Limitation of study

This is a questionnaire-based study. There is a limited number of previous studies on this topic. Multicenter randomized and controlled studies are needed.


  Conclusion Top


We found that most of the dialysis units are in a large percent clean in general. All studied units showed satisfactory percentage for all points regarding methods for preventing pollution. They were very good in all items with respect to environmental cleansing and were ideal in dealing with furniture and sheets.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Daugirdas JT, Blake PG, Ing TS. Handbook of dialysis. Chicago: Lippincott Williams & Wilkins; 2007.  Back to cited text no. 1
    
2.
Kato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y, et al. Aspects of immune dysfunction in end-stage renal disease. Clin J Am Soc Nephrol 2008; 3:1526–1533.  Back to cited text no. 2
    
3.
Karkar A, Bouhaha BM, Dammang ML. Infection control in hemodialysis units: a quick access to essential elements. Saudi J Kidney Dis Transplant 2014; 25:496.  Back to cited text no. 3
    
4.
Eduardo KL, Alan SK, Gerald H. Infection control and prevention in outpatient hemodialysis facilities. Nephrol Self-Assessment Prog 2019; 18:3–8.  Back to cited text no. 4
    
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Garrick R, Kliger A, Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol 2012; 7:680–688.  Back to cited text no. 5
    
6.
Zemaitis MR, Foris LA, Chandra S. Uremia. Treasure Island, FL, USA: Stat Pearls Publishing; 2020.  Back to cited text no. 6
    
7.
Anders HJ, Andersen K, Stecher B. The intestinal microbiota, a leaky gut and abnormal immunity in kidney disease. Kidney Int 2013; 83:1010–1016.  Back to cited text no. 7
    
8.
Chauhan R, Mendonca S. Adequacy of twice weekly hemodialysis in end stage renal disease patients at a tertiary care dialysis centre. Indian J Nephrol 2015; 25:329.  Back to cited text no. 8
    
9.
Awad AM, Ntoso A, Connaire JJ, Hernandez GT, Dhillon K, Rich L, et al. An open-label, single-arm study evaluating the immunogenicity and safety of the hepatitis B vaccine HepB-CpG (HEPLISAV-B®) in adults receiving hemodialysis. Vaccine 2021; 39:3346–3352.  Back to cited text no. 9
    
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Vijayan A, Boyce JM. 100% use of infection control procedures in hemodialysis facilities: call to action. Clin J Am Soc Nephrol 2018; 13:671–673.  Back to cited text no. 10
    
11.
Lui SL, Yap D, Cheng V, Chan TM, Yuen KY. Clinical practice guidelines for the provision of renal service in Hong Kong: infection control in renal service. Nephrology 2019; 24:98–129.  Back to cited text no. 11
    
12.
Khamis S, Koura M, Ragheb A, Ezz-El-Din A. Assessment of safety measures in hemodialysis units in Menoufia. Menouf Med J 2018; 31:443.  Back to cited text no. 12
    
13.
Khamis SS, Kora MA, El Barbary HS, Gharib SM. Assessment of safety measures in hemodialysis units in Qalyubia Governorate. Menouf Med J 2017; 30:672.  Back to cited text no. 13
    
14.
Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014; 86:S1–S70.  Back to cited text no. 14
    
15.
Khamis SS, Yasin YS, Omara MM, Saleh NEN. Safety measures in Dakhlia hemodialysis units. Menouf Med J 2018; 31:429.  Back to cited text no. 15
    
16.
Malhotra R, Soin D, Grover P, Galhotra S, Khutan H, Kaur N. Hepatitis B virus and hepatitis C virus co-infection in hemodialysis patients: A retrospective study from a tertiary care hospital of North India. J Nat Sci Biol Med 2016; 7:72.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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