APIC

IMPLEMENTATION
GUIDE

Infection
Prevention and
Control in
Dialysis Settings
INFECTION PREVENTION
AND CONTROL
IN DIALYSIS SETTINGS
About the Implementation Guide Series

About APIC
The Association for Professionals in Infection Control and Epidemiology (APIC) is the
leading professional association for infection preventionists (IPs) with more than 15,000
members. Our mission is to advance the science and practice of infection prevention
and control. APIC advances its mission through patient safety, education, implementation
science, competencies and certification, advocacy, and data standardization. Visit us
at apic.org.
 2|

APIC Implementation Guides help infection preventionists apply current scientific knowledge and best
practices to achieve targeted outcomes and enhance patient safety. This series reflects APIC’s commitment
to implementation science and focus on the utilization of infection prevention research. Topic-specific
information is presented in an easy-to-understand and use format that includes numerous examples
and tools. Visit www.apic.org/implementationguides to learn more and to access all the titles in the
Implementation Guide series.

© 2022 by the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) All rights
reserved. Use of this APIC publication does not grant any right of ownership or license to any user.

Printed in the United States of America

First printing, March 2022
ISBN: 978-1-933013-83-1

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and/or agents (collectively, “APIC”) provides this book solely for the purpose of providing information to
APIC members and the general public. The material presented in this book has been prepared in good
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Acknowledgments
Accomplishing this comprehensive update
required input and expertise from a broad
array of experts from practice and research
settings. The Association for Professionals in
Infection Control and Epidemiology gratefully
acknowledges the following individuals for
their valuable contributions.

Managing Editor Table of Contents

Tara Millson, DNP, RN, CIC, FAPIC Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Section 1: Fundamentals of Chronic

Contributing Authors
Virginia (Ginnie) Asp, RN, MPH, CIC, FAPIC
Heather Bernard DNP, RN, CIC, FAPIC,
NYSDOH Infection Preventionist
Susan Cali, MSN, RN, MHA, CIC, FAPIC,
Infection Preventionist, Research Analyst
CACI/CDC NHSN
Kidney Disease, End-Stage Renal
Disease, and Dialysis . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2: Hemodialysis, Vascular
Access, and Risk of Infection . . . . . . . . . . . . . . . . 10
Section 3: Preventing Access-Related
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Amber Paulus, BSN, RN, CPHQ, Mid-Atlantic Section 4: Standard and Transmission-
Renal Coalition Based Precautions . . . . . . . . . . . . . . . . . . . . . . . . . 24
Darlene Rodgers, BSN, RN, CNN, CPHQ,
Section 5: Cleaning and Disinfection
Intermountain Quality Innovations
of the Environment and Equipment
in the Dialysis Setting . . . . . . . . . . . . . . . . . . . . . . . 32
Reviewers
Section 6: Screening and Immunization . . . . . . 36
Nicole Gualandi, SN/MPH RN CIC FAPIC,
Epidemiologist, CDC Section 7: Surveillance . . . . . . . . . . . . . . . . . . . . . . 42
Shannon Novosad, MD, MPH Epidemic
Intelligence Service Officer at CDC Section 8: Safety Culture and Quality
Improvement in Dialysis . . . . . . . . . . . . . . . . . . . . 48
Alan Kliger, MD, Vice President, Medical
Director of Clinical Integration Yale New Section 9: Emergency Preparedness
Haven Health Systems in the Dialysis Setting . . . . . . . . . . . . . . . . . . . . . . . 53
Tamara Kear PhD, RN, CNN, FAAN, Executive
Section 10: Peritoneal Dialysis . . . . . . . . . . . . . . . 56
Director, American Nephrology Nurses
Association Section 11: Infection Prevention
Jessica Rindels, RN, BSN, MBA, CIC, Children’s Considerations for Special Populations . . . . . . . 60
Mercy Hospital
Section 12: Bringing It All Together:
Implementation Strategies . . . . . . . . . . . . . . . . . . 63
APIC Editorial and
Production Services
Silvia Quevedo, CAE Director, Practice
Guidance and Research
Chris Ruiz, Research Coordinator
Elizabeth Nishiura, Copyeditor
 4 | Introduction
INTRODUCTION
Over 700,000 people in the United States are
affected by end-stage kidney disease (ESKD), and
the prevalence of ESKD is estimated to be increas-
ing by 20,000 persons a year.1 The treatment of
choice for ESKD is kidney transplant; however,
there is a shortage of organs available for trans-
plantation. Thus, in the US, ESKD is usually treated
with hemodialysis in outpatient dialysis centers
and, less commonly, with home hemodialysis or
peritoneal dialysis.
Infections are substantial causes of hospitalization
and mortality among hemodialysis patients in the
United States. The increased risk of infection in
this patient population is mainly due to:
• Frequency of bloodstream access, often through
catheters
• The immunocompromised status of the dialysis
patient
• Proximity to other dialysis patients during
treatment
• Nonadherence to recommended infection
control practices by caretakers and healthcare
workers
While some risk factors for infection are not
modifiable, many infections are preventable
through adherence to infection prevention and
control recommendations. For instance, elevated
bloodstream infection rates are associated with
the high number of catheters used for blood-
stream access,2 and hepatitis C outbreaks in
several outpatient dialysis centers have been
associated with poor environmental cleaning and
disinfection practices.3 The science of infection
prevention and control has been advancing over
time, but infection remains a major cause of
morbidity and mortality because infection control
standards are not uniformly implemented or
followed in US dialysis facilities.4
In 2010, recognizing the need for resources in the
dialysis setting, the Association for Professionals in
Infection Control and Epidemiology (APIC)
published a Guide to the Elimination of Infection in
Hemodialysis to provide evidence-based guidance
for the development of infection prevention and
control programs in hemodialysis settings. Since
that time, there have been several advances in the
techniques used in dialysis setting to prevent
infection. For example, the Centers for Disease
Control and Prevention (CDC) launched the
Making Dialysis Safer for Patients Coalition5 in
2016 to bring awareness to core interventions that
have been shown to reduce the rate of blood-
stream infection by 50%.6 Additionally, programs
such as the American Society of Nephrology’s
(ASN’s) Nephrologists Transforming Dialysis
Safety7 initiative have advanced our understanding
of how the prevalent work culture in a dialysis
facility affects the risk of infection, thereby helping
to improve safety culture in dialysis.
Given such advances in the science of infection
prevention and control, APIC decided to revise its
2010 publication to offer an updated review of the
literature, suggest modern prevention strategies
and tools, and identify techniques to overcome
barriers to the successful implementation of and
adherence to prevention efforts.
Purpose of Guide
The purpose of this revised Implementation Guide
is to provide updated information and tools for
infection prevention and control in acute, chronic,
and home hemodialysis settings, and consider-
ations for special populations and peritoneal
dialysis.
The first step in updating the guide was identify-
ing experts from the fields of infection prevention
and dialysis nursing as authors for each section.
These contributors developed the recommenda-
tions contained in each section through the review
 5 | Introduction
of published references from expert sources,
including the CDC, ASN, Centers for Medicare &
Medicaid Services, National Kidney Foundation,
and APIC. Recommendations included in this
guide are supported by strong evidence and
regulatory requirements.
Scope of this Publication
This guide is intended for use by the individual
accountable for infection prevention and control in
a dialysis setting or another setting where dialysis
is being conducted. This person may be an
infection preventionist (IP), a physician, a dialysis
nurse, or an administrator. The guide is intended to
support the development of an enhanced infection
prevention program, offer surveillance techniques
to identify risk and opportunities for improvement,
and share strategies for performance and quality
improvement projects.
Typically, only hospital-based dialysis units will
have an IP readily available. Outpatient and
home-based dialysis programs will often not
have a dedicated IP. It is important that whoever
is accountable for an infection prevention and
control program is adequately trained and
competent in this role.
APIC Competency Model and
This APIC Implementation
Guide
The APIC Competency Model, first introduced in
2012 and updated in 2019,8 was created to meet
the demands of the expanding field of infection
prevention. Surveillance, prevention, and control of
infections have become major priorities for dialysis
providers and other healthcare organizations.
Increasingly, IPs need to build competency in this
area to strengthen and support efforts to improve
patient safety in dialysis settings. This Implemen-
tation Guide can help IPs understand how to apply
infection prevention research to the dialysis
setting.
References
1. US Renal Data System. 2016 annual data
report. National Institute of Diabetes and
Digestive and Kidney Diseases. Accessed
January 2, 2022. https://www.usrds.org/
previous-adrs/2010-2019
2. Nguyen DB, Arduino MJ, Patel PR. Hemodialy-
sis-associated infections. In Chronic Kidney
Disease, Dialysis, and Transplantation, 4th ed.
Philadelphia, PA: Elsevier; 2019:389-410.e8. doi:
10.1016%2FB978-0-323-52978-5.00025-2
3. Fabrizi F, Messa P. Transmission of hepatitis C
virus in dialysis units: a systematic review of
reports on outbreaks. Int J Artif Organs.
2015;38(9):471-480. doi:10.5301/ijao.5000437
4. Chenoweth CE, Hines SC, Hall KK, et al.
Variation in infection prevention practices in
dialysis facilities: results from the National
Opportunity to Improve Infection Control in
ESRD (end-stage renal disease) Project. Infect
Control Hosp Epidemiol. 2015;36(7):802-806.
doi:10.1017/ice.2015.55
5. Centers for Disease Control and Prevention.
Making Dialysis Safer For Patients Coalition.
Last reviewed February 14, 2020. Accessed
January 5, 2022. https://www.cdc.gov/dialysis/
coalition/index.html
6. Patel PR, Yi SH, Booth S, et al. Bloodstream
infection rates in outpatient hemodialysis
facilities participating in a collaborative
prevention effort: a quality improvement
report. Am J Kidney Dis. 2013;62(2):322-330.
doi:10.1053/j.ajkd.2013.03.011
7. American Society of Nephrology. Nephrolo-
gists Transforming Dialysis Safety. Accessed
January 2, 2022. https://www.asn-online.org/
ntds
8. Association for Professionals in Infection
Control and Epidemiology. APIC competency
model. Accessed January 5, 2022. https://apic.
org/professional-practice/infection-preven-
tionist-ip-competency-model
 6 | Section 1: Fundamentals

SECTION 1:
FUNDAMENTALS OF CHRONIC KIDNEY
DISEASE, END-STAGE RENAL DISEASE,
AND DIALYSIS

Chronic Kidney Disease people (9 in 10) do not know they have CKD until
it becomes very advanced.2
In the United States, 37 million people, including
The only way to diagnose CKD is through blood
15% of adults, are living with chronic kidney
and urine tests. A serum creatinine test measures
disease (CKD).1,2 This means 1 in every 7 Americans
the level of creatinine (a waste product produced
is directly affected by CKD.2 CKD is defined as
by muscles) in blood and provides an estimate of
abnormalities of kidney structure or function,
how well the kidneys filter GFR. The urine test
present for ≥3 months, with implications for
checks for protein in the urine (proteinuria; a sign
health.3 For a patient to be diagnosed with CKD,
of kidney damage). The preferred measurement
at least 1 marker of kidney damage or decreased
for testing of proteinuria is the urine albumin-
glomerular filtration rate (GFR) must be present
creatinine ratio (ACR).3
for ≥3 months (Table 1.1).3
The severity of kidney disease is evaluated using
With CKD, kidneys become damaged over time
staging guidelines. Current recommendations use
and cannot clean blood as well as healthy kidneys.2
“CGA” (cause, GFR category, and albuminuria
When the kidneys do not work well, waste and
category) to classify/stage CKD.3 Cause of CKD
extra water build up in the body and may cause
is assigned based on presence or absence of
other health problems, including heart disease and
systemic disease and the location within the
high blood pressure. CKD is often considered a
kidney of observed or presumed pathological
silent disease because people may not feel ill or
anatomic findings.3 Refer to Tables 1.2 and 1.3,
notice any symptoms until CKD is advanced. Most
respectively, for GFR and albuminuria categories.3

Table 1.1. Criteria for Chronic Kidney Disease

Albuminuria >30 mg/day

Urine sediment abnormalities (e.g., hematuria, red cell casts)
Electrolyte and other abnormalities due to tubular disorders
Markers of kidney damage
Abnormalities detected by histology
Structural abnormalities detected by imaging
History of kidney transplantation
Decreased GFR GFR <60 mL/min/1.73 m2

Abbreviation: GFR, glomerular filtration rate.

Source: KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.3
 7 | Section 1: Fundamentals

Table 1.2. G
 FR Categories in Staging Kidney Dysfunction

GFR Category GFR (mL/min/1.73 m2 Terms

Stage 1 (G1) ≥90 Normal to high
Stage 2 (G2) 60-89 Mildly decreased
Stage 3a (G3a) 45-59 Mildly to moderately decreased
Stage 3b (G3b) 30-44 Moderately to severely decreased
Stage 4 (G4) 15-29 Severely decreased
Stage 5 (G5) <15 Kidney failure

Abbreviation: GFR, glomerular filtration rate.

SourceL adapted from: KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease.3

Table 1.3. A
 lbuminuria in Staging Kidney Dysfunction

ACR (approximate equivalent)

Category AER (mg/24 hours) (mg/mmol) (mg/g) Terms
A1 <30 <3 <30 Normal to mildly increased
A2 30-300 3-30 30-300 Moderately increased
A3 >300 >30 >300 Severely increased

Abbreviations: ACR, albumin-creatinine ratio; AER, albumin excretion rate.

Source: Reprinted from KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease.3

According to current estimates, CKD is more

common in people aged 65 years or older, women,
Blacks, and Hispanics.2 Diabetes and high blood
pressure are the major causes of CKD in adults.
Other risk factors include heart disease, obesity, a
family history of CKD, past damage to the kidneys,
and older age.2

CKD progression is assessed by monitoring GFR

and albuminuria. KDIGO guidelines include recom-
mendations for the frequency of patient monitor-
ing based on GFR and albuminuria categories;
follow-up should occur at least once a year and
may be required 4 or more times throughout a
year (Figure 1.1).3
 8 | Section 1: Fundamentals

Figure 1.1. Definition and Identification of CKD Progression

Note: The GFR and albuminuria grid reflects the risk of progression by intensity of coloring (green, yellow, orange, red,
deep red). The numbers in the boxes are a guide to the frequency of monitoring (number of times per year).
Source: Reprinted from KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease.3

End-Stage Kidney Disease
If kidney damage is severe and kidney function is
very low, a patient will need dialysis or a kidney
transplant for survival. Kidney failure, stage 5 CKD,
treated with dialysis or a kidney transplant is
called end-stage kidney disease (ESKD, also
known as end-stage renal disease [ESRD]),
defined as a medical condition in which a person’s
kidneys function at a level too low to sustain life
without treatment by dialysis or kidney replacement
(transplant).2 When kidney function is this dimin-
ished, the kidneys cannot effectively remove waste
or excess fluid from the body or balance electrolytes
and maintain appropriate hormone production.
In 2017, nearly 125,000 people in the United States
started treatment for ESKD.4 Overall, the number
of prevalent ESKD cases continues to rise by
20,000 cases per year.4 As of 2017, there were
746,557 cases of ESKD in the United States.5
Among prevalent cases, 62.7% were receiving
hemodialysis (HD) therapy, 7.1% were being treated
with peritoneal dialysis (PD), and 29.9% had a
functioning kidney transplant.5 Among patients
being treated with HD, 98% used in-center HD, and
2% used home HD.5
Dialysis
Dialysis is a therapy that replaces many functions
of the kidney by removing metabolic waste
products through a natural (peritoneum) or
 9 | Section 1: Fundamentals

artificial (hemodialyzer) semipermeable mem-

brane. Diffusion and hydraulic pressure gradients Supplemental
allow for the passage of some molecules through
Resources
the membrane from areas of higher concentration
to areas of lower concentration. Dialysis can be American Nephrology Nurse Association.
used to prolong the life of patients with ESKD Core curriculum for nephrology nursing.
while they await transplant; furthermore, if the This resource provides clinical information
patient is an unsuitable candidate for transplant or on the “how-to” of dialysis and is an
a kidney is not available, dialysis may sustain life excellent primer for an infection preven-
for many months or years. Dialysis may also be tionist new to the dialysis setting.
used temporarily as a therapy for patients with Available at http://annanurse.org
acute renal failure or as a treatment in critically ill
patients to remove cytokines from the blood APIC Text, Chapter 40: Dialysis. This
during septic shock. resource contains a great synopsis of
important infection prevention and control
considerations for the dialysis setting.
Available at http://apic.org/resources/
References
apic-text
1. American Kidney Fund. Chronic kidney
disease (CKD). Accessed January 5, 2022.
https://www.kidneyfund.org/kidney-disease/
chronic-kidney-disease-ckd
2. Centers for Disease Control and Prevention.
Chronic kidney disease in the United States,
2019. Published March 5, 2019. Accessed
January 2, 2022. https://www.cdc.gov/kidney-
disease/pdf/2019_National-Chronic-Kid-
ney-Disease-Fact-Sheet.pdf
3. Kidney Disease Improving Global Outcomes.
KDIGO 2012 clinical practice guideline for the
evaluation and management of chronic kidney
disease. Kidney Int Suppl. 2013;3(1). https://
kdigo.org/guidelines/ckd-evaluation-and-man-
agement
4. Nguyen D, Shugart A, Lines C, et al. National
Healthcare Safety Network (NHSN) dialysis
event surveillance report for 2014. Clin J Am
Soc Nephrol. 2017;12(7):1139-1146. doi:10.2215/
cjn.11411116
5. US Renal Data System. 2019 USRDS Annual
Data Report: Epidemiology of Kidney Disease
in the United States. National Institute of
Diabetes and Digestive and Kidney Diseases.
Accessed January 2, 2022. https://www.usrds.
org/media/2371/2019-executive-summary.pdf
 10 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

SECTION 2:
HEMODIALYSIS, VASCULAR ACCESS,
AND RISK OF INFECTION

Hemodialysis through the dialyzer in the opposite direction. The

Hemodialysis (HD) is the process of removing
toxins, excess fluid, and electrolytes from the
blood through an artificial membrane enclosed in
a dialyzer and using a dialysis machine (Figure 2.1).
The fluid that is used for HD is called dialysate.
Dialysate is a mixture of 3 essential components:
purified water, acetate, and bicarbonate. During
HD, the dialysate is mixed in internal fluid path-
ways of the dialysis machine. The HD process
occurs by circulating a patient’s blood through a
dialyzer in one direction and circulating dialysate
blood and the dialysate never mix; instead, mole-
cules are exchanged through the membrane via
principles of diffusion and hydraulic pressure. After
passing through the dialyzer and collecting waste
from the blood, the dialysate effluent is then
discarded into a drain, which is typically contained
within a wall box at the dialysis station.
The HD process puts a patient at risk of infection
because the normally sterile bloodstream must be
accessed several times each week using needles
or a central venous catheter (CVC). The risk of
infection varies with the type of access used.

Figure 2.1. The Dialysis Process

Source: https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis
 11 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

Vascular Access Types

Table 2.1 summarizes the common types of
vascular access used for intermittent HD.

Table 2.1. Common Vascular Access Types

Type Method Pros Cons

Arteriovenous A surgical anastomosis is
fistula created between an artery
and a vein to create a large
vessel for cannulation and
flow
Arteriovenous A synthetic graft is used to
graft create the anastomosis
between an artery and vein
Tunneled CVC Cuffed catheters are inserted
into large veins through a
tunnel under the skin
Nontunneled Catheter is percutaneously
CVC placed through the skin
directly into a large vein.
• Preferred access type
• Lowest risk of infection
and complications
Risk of infection
comparable to AVF
Immediate access to
bloodstream for HD
Immediate access to
bloodstream
Requires 6 weeks to 4
months of maturation
before AVF can be used
• Requires 3-6 weeks of
maturation before AVG
can be used
• Higher rate of
complication compared
to AVF
• Life span of graft is
shorter than that of AVF
Much higher rate of
infection than AVF or AVG
Highest risk of infection

Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC, central venous catheter.

Central Venous Catheters To reduce the risk of complications and to preserve

When acute dialysis is needed, a central venous
catheter (CVC) can be inserted for immediate
access to the bloodstream. A cuffed or noncuffed
catheter may be used; however, if a catheter is
expected to be in place for more than 3 weeks, a
tunneled, cuffed venous catheter is recommended.1,2
possible future access sites, KDOQI guidelines1 and
the Centers for Disease Control and Prevention2
state that the right internal jugular is the preferred
access site. Femoral catheters should only be
placed for short-term use (<5 days) because they
are associated with increased infection risk.2 Table
2.2 describes several risk factors associated with
CVC access–related infections.1-3
 12 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

Table 2.2. I nfection Risk Factors Associated with Central Venous Catheter Access1-3

Risk Factor Description

Site of insertion • Patients with femoral catheters are more susceptible to infections than those
with thoracic catheters; this may relate to accumulation of sweat and moisture
around the exit site.
• Temporary (nontunneled) catheters placed in the internal jugular vein are
associated with higher infection rates than those placed in the subclavian vein.
• The subclavian location is associated with the highest rate of catheter-associated
central venous stenosis.
Duration of use • The risk for infection increases linearly with time.
Local factors • Inadequate personal hygiene, use of occlusive transparent dressing, and
accumulation of moisture around the exit site may all increase infection risk.
• Nasal and skin colonization with Staphylococcus aureus as well as bacterial
colonization of hemodialysis catheters can be risk factors for systemic infection.
Systemic factors • Immunosuppression, diabetes mellitus, low albumin levels, and elevated ferritin
levels are all systemic risk factors for infection.
Exit site • The catheter exit site is a common location for access-related complications
and infections. These complications often result in the need to replace or
exchange catheters if continued use is necessary.
• Infections may occur external to the cuff in tunneled catheters.
• Infections that extend into the tunnel proximal to the cuff are classified as
tunnel infections; these are often more serious and can be associated with
bacteremia.

Management of CVC-related infections should ment.4 Insertion of this material is considered a

include antimicrobial therapy and patient-centric
decision-making regarding catheter removal and
replacement. Often, removal of the HD catheter is
the most appropriate clinical course for patients
with CVC-related infections. However, patients
whose vascular access options are exhausted may
not be able to receive critical dialysis treatment if
a CVC is no longer an option. Therefore, the care
team would need to consider the best course for
the patient depending on the specific clinical case.
Arteriovenous Grafts
Arteriovenous grafts (AVGs) use foreign material
that white blood cells cannot penetrate. Therefore,
they pose a moderate risk for infection.4
A variety of autologous, homologous, and heterol-
ogous materials can be used to create AVGs.4
Currently, expanded polytetrafluoroethylene
(ePTFE) is a preferred material for graft develop-
prosthesis, and patients with ePTFE grafts should
be closely monitored for the development of
stenosis/thrombotic complications. Such compli-
cations are generally reparable.
Bacterial infections are a significant risk of AVGs
and are associated with considerable mortality
and death in this population.
Arteriovenous Fistulas
Native arteriovenous fistulas (AVFs) are the access
mode with the lowest risk of infection. Clinical
practice guidelines recommend AVFs as the best
form of access because many observational
studies have shown that patients with AVFs have
fewer access complications than those with AVGs
or CVCs.2
 13 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection
Outpatient Dialysis Centers
Most HD patients in the United States will receive
HD in an outpatient dialysis center that is not a
part of a hospital. Patients in this setting typically
receive intermittent HD (3-4 hours per session),
with 3 treatments each week.
Outpatient dialysis centers are staffed by regis-
tered nurses, licensed practical nurses, and/or
technicians, as well as an interdisciplinary team
specially trained in caring for renal patients. In
most cases, a person specially trained in infection
prevention and control is not present in each of
these units, although an infection preventionist
(IP) may be available as a part of a larger organi-
zation or as a consultant. The medical director is
responsible for infection prevention and control in
these facilities, and this task is often delegated to
another staff person for implementation and
surveillance.
Outpatient HD centers have characteristics unique
among healthcare facilities: Patients usually
receive HD treatment in the same center for
months or years on a repetitive basis, and this
treatment is life sustaining but not curative.
Patients are treated in three or four shifts per day;
therefore, the staff are subject to periods of
intense activity when treatment for one shift of
patients is terminated and treatment for the next
shift is initiated.
Outpatient HD facilities are designed in a number
of ways. Some are open plan because this design
may help staff visualize and manage machine
alarms during treatment and provide rapid patient
interventions as needed. Other facilities are
designed in a manner that uses half walls to
separate patients into groups or pods. Whereas
the open plan design provides no physical barriers
between patients, the pod design with half walls
can serve as a reminder to staff regarding hand
hygiene and personal protective equipment (PPE)
removal between patients. Whether open or
pod-based, the designs of HD facility layouts are
driven by the need for proximity of the dialysis
machines, the central acid and water supply, the
drain used for dialysate, and electrical power
outlets.
Each dialysis station will typically contain a dialysis
machine, a separate IV pole (if one is not included
on the machine), a reclining chair (or space for a
bed), a drain, and a wall box with connections for
treated water and sometimes for the acid bath.
There should be adequate space between stations
(e.g., 6 feet minimum) to allow for staff movement,
and to prevent cross contamination. Hand hygiene
stations, PPE, and sharps containers should be
within proximity of each station.
In some outpatient HD centers, the acid portion of
dialysate is plumbed in from larger storage con-
tainers, and the connections are in the wall box
behind each station. Other facilities may use
smaller, individual containers for the acid, which
may be connected to the machine from the front.
Some facilities have an isolation room and can
care for patients with hepatitis B virus or other
types of infection that require special isolation.
(See Section 4 for more information on recom-
mendations for care of patients with hepatitis B
virus.)
All surfaces in the dialysis setting should be easy
to clean. Medication and supply carts should be
stationary and should never be taken from station
to station because transport of carts between
stations can cause cross contamination. Medica-
tion preparation and administration should comply
with all local, state, and federal regulations. Areas
for equipment, medication preparation, and
supplies should be clearly distinguished as clean
or dirty. There should be clearly designated sinks
available for hand hygiene for patients and staff,
with separate sinks available for dumping liquid
waste.
The outpatient HD center should include a water
room, where municipal water is treated to be used
in HD, as well as a dirty utility room, where trash
and hazardous waste are stored before disposal.
Refer to Section 5 for further guidance on cleaning
and disinfection.
 14 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection
Acute Care Setting
When chronic dialysis patients are hospitalized,
they often need to continue their dialysis treat-
ments in the hospital.
Some hospitals have an inpatient HD unit that is
set up similarly to an outpatient dialysis center.
This inpatient unit may be staffed by either
hospital employees or contracted staff. In many
hospital HD units, an IP is available as a part of the
larger organization.
Bedside or Portable Hemodialysis
In the acute care setting, dialysis may be done in
the patient room using a portable reverse osmosis
(RO) water treatment system. Water and dialysate
used for this treatment must meet the same
standards as those provided for in-center treat-
ment.5 (See Section 7 for further information on
water systems.) Dialysis staff should be familiar
with how the portable RO system functions, as
well as the monitoring requirements.
The source of the water used in bedside dialysis
may be from the hand-washing sink; in such cases,
alternative options for hand hygiene should be
made available.
The machine may drain into a sink or commode; it
is important to ensure that there is an air gap, and
the discharge tubing must not touch the water in
either location. The tubing should be secured to
maintain the gap and prevent backflow, contact,
and splatter.
Continuous Renal Replacement
Therapy
Continuous renal replacement therapy (CRRT)
may be chosen over intermittent HD in the acute
care setting because of patient factors such as
hemodynamic instability, large volumes of fluid
administration, or brain injury.6,7 CRRT requires a
CVC and usually occurs in an intensive or critical
care setting. To minimize risk of infection in CRRT
patients, dialysate care and monitoring, machine
care (including cleaning, disinfection, storage, and
maintenance), and care and storage of CRRT
supplies are all important. Direct communication
with critical care staff allows the IP to perform risk
assessments, observe practices, identify and
address problems, and offer support. Table 2.3
describes infection prevention and control consid-
erations for CRRT modalities.6,8,9
 15 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

Table 2.3. S
 pecial Considerations for CRRT Modalities

Topic Description
CRRT modalities • The CRRT modality depends on the mechanism that drives solute removal.6
– CVVH: Dialysate fluid is not required.
– CVVHD: Dialysate fluids are used
– CVVHDF: Replacement fluid and dialysis fluid are used.
– SCUF: Slow continuous ultrafiltration is indicated for fluid overload and
contraindicated for uremia or hyperkalemia.
CRRT water and • CRRT is an acute procedure, typically performed in the ICU.
equipment • IPC principles for machine cleaning and disinfection, and care and storage of
clean and soiled dialysis equipment are the same as for intermittent dialysis.
• Assess how the feed water is tested and treated. Observe risks for water
contamination in the environment, such as dirty wall boxes. It may be necessary
to regularly flush water from dialysis or CRRT hookup sites to eliminate biofilm.
Catheter access • CRRT modalities require a HD catheter.
• Assess catheter insertion and catheter care.8
Staffing • ICU staff or specially trained dialysis nurses are typically responsible for CRRT.
• Assess staff adherence to IPC measures during dialysis machine operation.
COVID-19 • Limit the HCP exposed to patients with suspected or confirmed COVID-19 to
those essential for their care.9
• Disposal of dialysis effluent from suspected or confirmed COVID-19 patients can
follow standard facility protocols. HCP caring for the patient in the patient room
or disposing of effluent from the CRRT machine should wear recommended
PPE.9

Abbreviations: CRRT, continuous renal replacement therapy; CVVH, continuous venovenous hemofiltration; CVVHD,
continuous venovenous hemodialysis; CVVHDF, continuous venovenous hemodiafiltration; HCP, healthcare personnel;
HD, hemodialysis; ICU, intensive care unit; IPC, infection prevention and control; PPE, personal protective equipment;
SCUF, slow continuous ultrafiltration.

Long-Term Care
An estimated 10% of nursing home residents are
dialysis patients. As the US population ages, this
number is likely to increase.10-12
Skilled nursing facility (SNF) residents receiving
in-center dialysis spend long, tiring days going to
and from their thrice-weekly dialysis treatments.
As an alternative option, approved nursing homes
may contract with an outpatient dialysis center to
perform HD and peritoneal dialysis services within
their facility, while the Centers for Medicare and
Medicaid Services (CMS) regulates the operational,
logistical, physical, and staffing guidelines.13
If an SNF trains its own staff to provide HD, the
SNF must contract with a CMS-approved home
dialysis provider. The home dialysis provider
performs training and oversees follow-up for the
SNF dialysis facility, just as they do for home HD
patients who are not SNF residents.14
Dialysis performed at an SNF may reduce trans-
portation costs and increase dialysis efficiency.
However, this nontraditional setting may present
unique infection prevention and control challeng-
es. In 2019, a hepatitis C virus transmission was
epidemiologically linked between 2 patients in a
SNF providing dialysis services.15 It is essential that
proper infection prevention and control proce-
dures are in place and that there is adequate
 16 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

oversight of the program. Table 2.4 presents

infection prevention and control considerations for
performing dialysis in an SNF setting.13,16

Table 2.4. S
 pecial Considerations for Dialysis in Skilled Nursing Facilities

Topic Description
SNF’s • Contract with a home dialysis provider for services.
responsibilities • Build a safe environment within the SNF facility for dialysis, including water
treatment, storage, and waste management.
Home dialysis • Oversee dialysis training and follow-up as would be done for HHD.
provider’s • Perform all resident care responsibilities before, during, and after dialysis
responsibilities
treatments, as described in the SNF contract.
Advantages of SNF • Dialysis at the SNF offers the option of more frequent, shorter dialysis
dialysis treatments, which may improve the resident’s quality of life.
IPC issues • SNF residents receiving dialysis are at risk for infection due to their age and
underlying conditions.
• Fistulas and graft access are difficult to create in older adults; access challenges
may also be related to length of stay and other factors.
• Dialysis may be performed in the resident room, or a multi-resident “den”
(which is comparable to a mini dialysis facility); there may be unique IPC
challenges in each area such as lack of treatment space and inadequate
medication preparation areas.
• Initial competency and routine audits of staff practices must be performed.
• To ensure that dialysis care and the dialysis environment are safe and meet CMS
conditions of participation, it is important for the IP to be involved in facility
design, construction, and later operational phases.13
Regulatory issues • CMS considers the SNF to be the patient’s home; therefore, CMS regulations for
home dialysis apply to SNFs that provide dialysis.16

Abbreviations: CMS, Centers for Medicare & Medicaid Services; HD, hemodialysis; HHD, home hemodialysis; IP, infection
preventionist; IPC, infection prevention and control; SNF, skilled nursing facility.

Home Hemodialysis HHD patients must be willing to perform treat-

In 2017, 2% of all CKD stage 5 patients (approxi-
mately 9,500 patients) in the United States chose
a home hemodialysis (HHD) modality.17 Notably,
this number had more than doubled in the previ-
ous 10 years17 and may continue to increase over
the coming years.
ments independently or with a caregiver, away
from the direct supervision of dialysis center staff.
HHD patients may prefer to self-cannulate access,
and they may periodically dialyze at a dialysis
center for various reasons—for example, if they are
traveling or if they have more severe illness or
issues with their home care setup.

HHD requires less disruption to a patient’s family
life and employment because patients do not need
to travel for frequent in-center dialysis. “During the
COVID-19 pandemic, HHD was advocated as one
strategy to help limit dialysis patients’ exposure to
the virus.”18
IPs can be an infection prevention and control
resource for HHD centers. Table 2.5 describes
infection prevention and control considerations
for HHD.5,16,19-22
 17 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

Table 2.5. S
 pecial Considerations for Home Hemodialysis

Topic Description
Patient benefits • HHD offers flexibility for scheduling treatments. Some HHD patients dialyze
nocturnally or use a combination of shorter and more frequent dialysis
sessions.19,20
• HHD may Increase quality of life and well-being.19,20
• HHD reduces the risk of infection transmission from other patients or healthcare
personnel.
Vascular access • Patients receiving HHD may be at risk for vascular access complications,
including infections, which can lead to hospitalizations.20
• Self-cannulation should be encouraged.
• Patients with buttonhole access may be at higher risk for infection.21
Patient training • Initial training should include:
– ESKD management
– How to do the procedure
– What to report to healthcare team
– Resources and how to access them
– How to monitor and record health status
– Handling medical and nonmedical emergencies
– Infection control precautions
– Proper waste storage and disposal for that locale
• Retraining may be necessary.
• HHD trainers must meet CMS licensure and practice requirements, and they
must be experienced patient educators.16
• Not every center provides HHD training.
Regulatory • CMS requires that water and dialysate meet the ANSI/AAMI RD52:2004/Annex
requirements C standards.5,22
• CMS mandates that the HHD training center is responsible for doing home
visits, making sure there are backup plans, being available for consultations,
monitoring equipment and water safety, and care planning.16
• CMS enumerates the content for HHD training as well as follow-up
requirements, including ongoing support.16

Abbreviations: ANSI/AAMI, American National Standards Institute/Association for the Advancement of Medical Instru-
mentation; CMS, Centers for Medicare & Medicaid Services; ESKD, end-stage kidney disease; HHD, home hemodialysis.

2. O’Grady NP, Alexander M, Burns LA, et al.

References Guidelines for the prevention of intravascular
1. Lok CE, Huber TS, Lee T, et al; KDOQI Vascular catheter-related infections. Am J Infect
Access Guideline Work Group. KDOQI clinical Control. 2011;39(4 Suppl 1):S1-S34. doi:10.1016/j.
practice guideline for vascular access: 2019 ajic.2011.01.003
update. Am J Kidney Dis. 2020;75(4 suppl
3. Hoen B, Paul-Dauphin A, Hestin D, et al.
2):S1-S164. doi:10.1053/j.ajkd.2019.12.001
EPIBACDIAL: a multicenter prospective study
of risk factors for bacteremia in chronic
 18 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection
hemodialysis patients. J Am Soc Nephrol.
1998;9:869-876. doi:10.1681/ASN.V95869
4. Woo K. Arteriovenous graft creation for
hemodialysis and its complications. UpToDate.
Last updated February 24, 2021. Accessed
January 2, 2022. https://www.uptodate.com/
contents/arteriovenous-graft-creation-for-he-
modialysis-and-its-complications
5. Centers for Disease Control and Prevention.
Dialysis safety, water use in dialysis. Last
reviewed October 15, 2020. Accessed January
2, 2022. https://www.cdc.gov/dialysis/guide-
lines/water-use.html
6. Cerdá J, Ronco C. Modalities of continuous
renal replacement therapy: technical and
clinical considerations. Semin Dial.
2009;22(2):114-122.
doi:10.1111/j.1525-139X.2008.00549.x
7. Macedo E, Mehta RL. Continuous dialysis
therapies: core curriculum 2016. Am J Kidney
Dis. 2016;68(4):645-657. doi:10.1053/j.
ajkd.2016.03.427
8. Centers for Disease Control and Prevention.
Dialysis safety: core Interventions. Last re-
viewed June 15, 2016. Accessed January 2,
2022. https://www.cdc.gov/dialysis/preven-
tion-tools/core-interventions.html
9. Centers for Disease Control and Prevention.
Considerations for providing hemodialysis to
patients with suspected or confirmed
COVID-19 in acute care settings. Updated July
7, 2020. Accessed January 5, 2022. https://
www.cdc.gov/coronavirus/2019-ncov/hcp/dial-
ysis/dialysis-in-acute-care.html
10. Suresh S. Nursing home dialysis: rapidly
growing and complicated. ASN Kidney News.
2019;11(4):14-15. https://www.kidneynews.org/
view/journals/kidney-news/11/4/kid-
ney-news.11.issue-4.xml
11. US Renal Data System. Reference tables:
patient characteristics and census. In: USRDS
2019 Annual Data Report: Atlas of Chronic
Kidney Disease and End-Stage Renal Disease
in the United States. National Institute of
Diabetes and Digestive and Kidney Diseases.
Published 2019. Accessed January 5, 2022.
https://www.usrds.org/annual-data-report
12. Centers for Medicare & Medicaid Services.
Fiscal year 2021 state and national atlas for
dialysis facility reports. Updated December 23,
2020. Accessed February 12, 2021. https://
data.cms.gov/quality-of-care/medicare-dialy-
sis-facilities
13. Centers for Medicare & Medicaid Services.
Medicare: quality, safety, and oversight—gen-
eral information. Last modified December 1,
2021. Accessed January 10, 2022. https://www.
cms.gov/Medicare/Provider-Enroll-
ment-and-Certification/SurveyCertification-
GenInfo
14. Home Dialysis Central. Home dialysis in skilled
nursing. Published July 12, 2016. Accessed
January 2, 2022. https://homedialysis.org/
news-and-research/news/home-dialysis-in-
the-news/articles/311-home-dialy-
sis-in-skilled-nursing-facilities
15. Wagner J, Gandhi A, Johnson B, et al. Hepatitis
C virus transmission at a long-term care
facility (LTCF) providing hemodialysis
services—Georgia, United States, 2019.
Infect Control Hosp Epidemiol.
2020;41(S1):s248-s249. doi:10.1017/
ice.2020.808
16. Centers for Medicare & Medicaid Services.
Conditions for coverage for end-stage renal
disease facilities. Condition: care at home. 42
CFR §49.100. Accessed January 2, 2022.
https://www.ecfr.gov/cgi-bin/text-idx?node=pt
42.5.494&rgn=div5#se42.5.494_1100
17. US Renal Data System. Reference table D.
Treatment modalities. Table D1. Percentages
and counts of ESKD by treatment modality. In:
2019 USRDS Annual Data Report: Epidemiolo-
gy of Kidney Disease in the United States.
National Institute of Diabetes and Digestive
and Kidney Diseases. https://www.usrds.org/
annual-data-report
18. Mario Cozzolino, Ferruccio Conte, Fulvia
Zappulo, Paola Ciceri, Andrea Galassi, Irene
Capelli, Giacomo Magnoni, Gaetano La Manna,
COVID-19 pandemic era: is it time to promote
home dialysis and peritoneal dialysis?, Clinical
Kidney Journal, Volume 14, Issue Supple-
ment_1, March 2021, Pages i6–i13, https://doi.
org/10.1093/ckj/sfab023
 19 | Section 2: Hemodialysis, Vascular Access, and Risk of Infection

19. National Kidney Foundation. Home hemodialy-

sis. Accessed January 2, 2022. https://www.
kidney.org/atoz/content/homehemo
20. Tomori K, Okada H. Home hemodialysis:
benefits, risks, and barriers. Contrib Nephrol.
2018;196:178-183. doi:10.1159/000485719
21. Vachharajani T, Wong L, Niyyar V, Abreo K,
Mokrzycki M. Buttonhole cannulation of
arteriovenous fistulas in the United States.
Kidney360. 2020;1(4):306-313. doi:10.34067/
KID.0000052020
22. Association for the Advancement of Medical
Instrumentation. ANSI/AAMI RD52:2004:
Dialysate for Hemodialysis, Annex C: Special
Considerations for Home Hemodialysis.
Arlington, VA: Association for the Advance-
ment of Medical Instrumentation; 2004, 2009.
 20 | Section 3: Preventing Access-Related Infection

SECTION 3:
PREVENTING ACCESS-RELATED INFECTION

The risk of bacteremia in patients with a central
venous catheter (CVC) is seven times greater than
in those with an arteriovenous fistula (AVF).1 The
National Kidney Foundation-Kidney Dialysis
Outcomes Quality Initiative (KDOQI)2 and the
Centers for Disease Control and Prevention (CDC)3
recommend that an AVF be created and used for
long-term hemodialysis (HD) because of the lower
risk of infection. If an AVF cannot be established,
an arteriovenous graft (AVG) is the next preferred
method for vascular access. To further reduce the
risk of infection, the arm is preferred over the
thigh as the AVF location.
dressed. Patient education and use of a vascular
access coordinator can help mitigate some of the
barriers associated with long-term retention of
CVCs. However, the type of vascular access most
compatible with a patient’s life goals and desired
quality of life should dictate the vascular access
approach selected by clinicians, as discussed in
the 2019 KDOQI clinical practice guideline for
vascular access.2 Careful inspection and monitor-
ing of the vascular access are of paramount
importance in early detection of vascular access
site-related infections.
The CDC has published core interventions proven
to reduce dialysis-related bloodstream infections

Reducing Vascular Access (Table 3.1).4,5 Interventions specific to vascular

Infection Risk in
Hemodialysis
Efforts to prevent vascular access–related infec-
tion should focus on increasing placement of AVFs
and minimizing insertion of CVCs. Barriers to
catheter removal and/or permanent vascular
access placement should be identified and ad-
access include catheter/vascular access care
observations and assessing staff adherence to
aseptic technique when connecting and discon-
necting catheters and during dressing changes.
Catheter hub disinfection is another important
intervention; it is focused on hub scrubbing before
accessing a CVC.

Table 3.1. Core Interventions for Infection Reduction in Dialysis

Intervention
Surveillance and feedback
using NHSNa
Hand hygiene observations
Catheter/vascular access
care observations
Staff education and
competency
Description
Conduct monthly surveillance for infections using CDC’s NHSN. Calculate
facility rates for BSIs and compare to rates in other NHSN facilities. Actively
share results with frontline clinical staff.
Perform observations of hand hygiene opportunities monthly and share
results with clinical staff.
Perform observations of vascular access care and catheter accessing
quarterly. Assess staff adherence to aseptic technique when connecting
and disconnecting catheters and during dressing changes. Share results
with clinical staff.
Train staff on infection control topics, including access care and aseptic
technique. Perform competency evaluation for skills such as catheter care
and accessing every 6-12 months and upon hire.
 21 | Section 3: Preventing Access-Related Infection

Patient education/ Provide standardized education to all patients on infection prevention

engagement
Catheter reduction
Chlorhexidine for skin
antisepsis
Catheter hub disinfection
Antimicrobial ointment
topics, including vascular access care, hand hygiene, risks related to
catheter use, recognizing signs of infection, and instructions for access
management when away from the dialysis unit.
Incorporate efforts (e.g., through patient education, vascular access
coordinator) to reduce catheters by identifying and addressing barriers to
permanent vascular access placement and catheter removal.
Use an alcohol-based chlorhexidine (>0.5%) solution as the first-line skin
antiseptic agent for central line insertion and during dressing changes.
Povidone-iodine (preferably with alcohol) or 70% alcohol are alternatives
for patients with chlorhexidine intolerance.
Scrub catheter hubs with an appropriate antiseptic after cap is removed
and before accessing. Perform every time catheter is accessed or
disconnected. If a closed needleless connector device is used, disinfect
connector device per manufacturer’s instructions.
Apply antibiotic ointment or povidone-iodine ointment to catheter exit
sites during dressing change. See information on selecting an antimicrobial
ointment for hemodialysis catheter exit sites on CDC’s Dialysis Safety
website (http://www.cdc.gov/dialysis/prevention-tools/core-interventions.
html#sites). Use of chlorhexidine-impregnated dressing might be an
alternative.

Abbreviations: BSI, bloodstream infection; CDC, Centers for Disease Control and Prevention; NHSN, National Health-
care Safety Network.
See Section 7 of this guide.
a

Source: Adapted from references 4 and 5.

Staff and Patient Education
and Competencies
Staff who care for dialysis patients must be trained
on the tasks they perform, including how to perform
them safely. Whether staff receive education
through a formal trade school or college or through
on-the-job training, it is important that they receive
annual training to ensure competency is maintained.
In addition, staff should receive training on an
ongoing basis for new products and policies.
In some states, the dialysis technician functions as
a nurse extender to provide direct patient care
under the supervision of licensed nursing staff. The
role and scope of responsibilities for the technician
should comply with all local, state, and federal
regulations. Dialysis facilities should have a pro-
gram in place to assess and maintain the compe-
tency levels of technicians and other healthcare
personnel on at least an annual basis.
The facility’s competency program should cover
the core interventions identified by the CDC as
proven methods to improve care and reduce
bloodstream infections (Table 3.1).
Staff should be made aware of and educated on
National Healthcare Safety Network surveillance
definitions6 (see Section 7) and the outcomes of
the surveillance performed in their facilities.
Interventions should be annotated, and line graphs
can be used to track the effects of prevention
efforts. Graphs showing that improvement efforts
reduce infections can foster staff engagement.6
Hand hygiene observations should be performed
to monitor for compliance, and the monitoring
results should be shared with staff. Discussion of
the results and reinforcement of best practices are
extremely important. Staff should be encouraged
to support each other and remind each other
when compliance criteria are not met. Many tools
are available to be used to evaluate compliance,
 22 | Section 3: Preventing Access-Related Infection
including an audit tool and other resources from
CDC.4,7
Catheter and vascular access care is a critical part
of HD patient care. Staff competency in accessing
central lines should be evaluated at least annually
to ensure compliance. Monitoring staff throughout
the year can help reinforce the crucial steps to
prevention bloodstream infections.
Vascular access care is equally important and
should also be monitored to ensure safe, standard-
ized practices. Standardization is critical: every
staff member must perform the same steps in the
prevention efforts. Performance improvement
activities can address staff deviations from stan-
dards of care and evaluate whether there are
better ways to provide care.4,7
Chlorhexidine has been shown to reduce infection
when used consistently in the care of access sites.8
Patients can be taught to use chlorhexidine swabs
while staff are preparing the dialysis station for
their treatment. Assigning this responsibility to
patients helps give them ownership of their care.
Staff should always monitor the process to ensure
patient compliance, but this can be very effective
in engaging patients in their care.4,7
Facilities should develop procedures for care of
access sites. This may include application of
antimicrobial ointments when the HD treatment is
completed, or the ointment may be used if dress-
ings are applied to central line sites according to
the product’s instructions for use. Whatever the
facility’s protocol may be, staff should demon-
strate the knowledge and competency required to
perform the task correctly. Competency can be
evaluated by staff monitoring fellow staff mem-
bers, or a facility leader can perform monitoring.
Patients should also be knowledgeable regarding
care of the access site and engaged in site care
when they are away from the clinic setting.
Consistent reinforcement of best site-care practic-
es is key for staff and patients involved in the
continuum of dialysis patient care.4,7
The CDC has developed multiple downloadable
audit tools that dialysis facilities can use to devel-
op a standard process of care.7 The tools cover
central line care and access, cannulation and
decannulation, the scrub-the-hub protocol, and
the process of routine cleaning and disinfecting
stations between patient use. The CDC offers
downloadable checklists,7 which can be posted in
the dialysis center and used during patient visits.
Because patient engagement and education are
crucial for preventing infections and ensuring
prompt interventions when infections occur,
patients should receive ongoing education on best
practices, including how to self-assess signs and
symptoms of infection, bathing, hand hygiene, and
troubleshooting issues outside the clinic. Staff can
reinforce patient education messages by asking
questions and discussing problems that occur
outside the clinic with the patient at each visit.
Dialysis centers can also provide written guidelines
for patients to keep readily available in the home
setting.4
References
1. Hoen B, Paul-Dauphin A, Hestin D, et al.
EPIBACDIAL: a multicenter prospective study
of risk factors for bacteremia in chronic
hemodialysis patients. J Am Soc Nephrol.
1998;9:869-876. doi:10.1681/ASN.V95869
2. Lok CE, Huber TS, Lee T, et al; KDOQI Vascular
Access Guideline Work Group. KDOQI clinical
practice guideline for vascular access: 2019
update. Am J Kidney Dis. 2020;75(4 suppl
2):S1-S164. doi:10.1053/j.ajkd.2019.12.001
3. O’Grady NP, Alexander M, Burns LA, et al.
Guidelines for the prevention of intravascular
catheter-related infections. Am J Infect
Control. 2011;39(4 Suppl 1):S1-S34. doi:10.1016/j.
ajic.2011.01.003
4. Centers for Disease Control and Prevention.
Dialysis safety: core Interventions. Last re-
viewed June 15, 2016. Accessed January 3,
2022. https://www.cdc.gov/dialysis/preven-
tion-tools/core-interventions.html
5. Centers for Disease Control and Prevention.
CDC approach to BSI prevention in dialysis
facilities. Accessed January 3, 2022. https://
 23 | Section 3: Preventing Access-Related Infection

www.cdc.gov/dialysis/PDFs/Dialysis-Core-In-
terventions-5_10_13.pdf
6. Centers for Disease Control and Prevention.
National Healthcare Safety Network. Accessed
January 3, 2022. https://www.cdc.gov/nhsn/
index.html
7. Centers for Disease Control and Prevention.
Dialysis safety: audit tools and checklists. Last
reviewed September 25, 2017. Accessed
January 4, 2022. https://www.cdc.gov/dialysis/
prevention-tools/audit-tools.html
8. Chaiyakunapruk N, Veenstra DL, Lipsky BA,
Saint S. Chlorhexidine compared with povi-
done-iodine solution for vascular catheter-site
care: a meta-analysis. Ann Intern Med.
2002;136(11):792-801. doi:10.7326/0003-4819-
136-11-200206040-00007
 24 | Section 4: Standard and Transmission-Based Precautions
SECTION 4:
STANDARD AND TRANSMISSION-BASED
PRECAUTIONS
Standard Precautions
It is well known that the practice of standard
precautions is the foundation of infection preven-
tion. Standard precautions are applied to all
patients during all interactions across the continu-
um of care.1 Standard precautions are particularly
important when caring for chronic hemodialysis
(HD) patients because these patients are vulnera-
ble to infections due to the high-risk process of
HD and the need for prolonged periods of vascu-
lar access. There are repeated opportunities for
the transmission of infection in dialysis units where
multiple patients are receiving care.2
Practices covered under standard precautions
include hand hygiene, the use of personal protec-
tive equipment (PPE), respiratory hygiene, appro-
priate patient placement, appropriate handling of
textiles and laundry, and safe injection practices.1
Hand Hygiene
Hand hygiene has been a long-standing interven-
tion used to reduce the acquisition of healthcare-
associated infections.3 Dialysis procedures present
situations with a high risk for the acquisition of
infections; therefore, hand hygiene must be a
high-priority intervention in the overall infection
prevention and control program. The Centers for
Medicare & Medicaid Services requires that hand
hygiene be performed between all patient encoun-
ters and when entering and exiting the dialysis
station.4
Handwashing sinks in dialysis units must be clearly
labeled and dedicated to handwashing. These
sinks must also remain clean, with no items placed,
cleaned, or drained in them.4
It is also essential to have adequate hand-sanitiz-
ing products at points of use throughout the
dialysis unit to ensure that they are readily avail-
able for staff and patients to use before, during,
and after activities. Alcohol-based hand sanitizer3
is more convenient and efficient than handwashing
with soap and water, and it is the preferred
hand-sanitizing product for these types of care
settings. However, using an alcohol-based hand
sanitizer is not advised when hands are visibly
soiled, and it may not be advisable when caring
for a patient infected with a spore-forming organ-
ism (such as Clostridioides difficile)—in those
situations, handwashing with soap and water is
necessary.3
Achieving 100% hand hygiene compliance among
staff is easier said than done in dialysis settings, as
staff are constantly moving from patient station to
patient station throughout a shift. Karkar5 estimat-
ed a minimum of 30 hand hygiene events per
dialysis session per patient. In a demonstration
project, Millson and colleagues6 found that staff
felt tremendous stress while transitioning patients
on and off dialysis machines and admitted to
taking shortcuts, eliminating what they thought
was the least-risky intervention to save time. This
evidence demonstrates the need to ensure that
hand hygiene supplies are available and easy to
use, and that there are constant reminders to
perform hand hygiene whenever necessary.
Personal Protective Equipment
The use of PPE (gloves, gowns, and mouth, nose,
and eye protection) is required whenever it can be
anticipated that a patient interaction may involve
contact with blood or body fluids.1 Given the
routine potential for exposure to blood-contami-
 25 | Section 4: Standard and Transmission-Based Precautions
nated items in the dialysis setting, staff are re-
quired to don gloves any time they have contact
with the patient or the patient’s dialysis machine.
There are many opportunities during dialysis
procedures for exposures. To increase staff
compliance with PPE requirements, it is critical
that an adequate PPE supply is available at the
point of use.2
When performing procedures, dialysis staff must
wear gowns, masks, and eye protection such as
goggles or face shields to protect themselves from
exposure from spattering of blood, and they
should change this PPE if it becomes soiled.2
Procedures requiring PPE include:
• Initiation and termination of dialysis
• Cleaning of dialyzers
• Centrifugation of blood
Respiratory Etiquette
To prevent transmission of infections, especially
during times when respiratory infection rates are
high, standard precautions include the practice of
respiratory etiquette. Facilities must be vigilant in
identifying patients and visitors with respiratory
infections prior to or immediately upon entry into
the dialysis unit so that separation can be imple-
mented if deemed necessary. As part of this effort,
patients and visitors should be instructed to report
their symptoms prior to or immediately upon
entry into the facility. Ensure that these instruc-
tions are available in multiple languages.1
It is also important to encourage patients and
visitors to practice respiratory etiquette by cover-
ing their nose and mouth when they cough or
sneeze. To facilitate respiratory etiquette, posters
that illustrate the proper use of tissues, masks, and
hand sanitizer should be posted at the entrance of
the facility. Facilities may consider providing
access to these materials to support compliance
with use.
Safe Injection Practices
In the dialysis care environment, injections are a
routine aspect of care. Therefore, if injections are
not practiced safely in dialysis settings, healthcare
workers and patients are at high risk of transmis-
sion of bloodborne pathogens. Single-use medica-
tion vials must not be punctured more than once,
and residual medication from two or more vials
should not be combined, as these practices
compromise sterility.2
Transmission-Based
Precautions
Healthcare delivery has shifted to locations
outside of traditional healthcare settings, and it is
important to adapt infection control guidelines to
the nature of the care provided in these nontradi-
tional settings, with priority on the greatest risks
to patients.1 In particular, attention must be paid to
treatment areas with quick or frequent patient
turnover, as these areas can increase infection risk
if they are inadequately cleaned or when infec-
tious patients are not recognized soon enough.1
Peer-reviewed evidence has found that the most
common modes of infection transmission in
outpatient settings include contaminated solutions
or equipment, as well as person-to-person trans-
mission from healthcare personnel or patients
through droplet or airborne transmission.1
Although contact transmission plays a major role
in transmission of bloodborne pathogens in
dialysis settings, contact precautions are not
routinely recommended for dialysis patients
infected or colonized with multidrug-resistant
bacteria. This is mostly because contact transmis-
sion is not well documented in HD centers; it
occurs less frequently in these centers than in
hospitals, and environmental contamination is also
less likely to occur in dialysis facilities than in acute
care settings because the length of time the
patient is in the dialysis facility is relatively brief.2
 26 | Section 4: Standard and Transmission-Based Precautions
Management of Patients
with Hepatitis B
Because hepatitis B virus (HBV) can survive on
surfaces for long periods and chronically infected
patients can infect others, isolation of HBV-positive
patients in a private room or other area separated
from HBV-susceptible patients is recommended;
the objective is to keep HBV-positive patients
away from common areas for dialysis treatments.
The isolated room or area should have dedicated
staff, equipment, medications, and supplies that
are not also used by HBV-susceptible patients.2
The following are additional infection prevention
and control practices specifically designed to
prevent transmission of HBV from patients with
chronic HBV infection receiving dialysis treat-
ment:7
• Vaccinate susceptible patients and staff against
hepatitis B.
• Isolate patients who test positive for the HBV
surface antigen.
• Perform surveillance for infections and other
adverse events.
• Provide infection control training and education.
Management of Patients
with Hepatitis C
Hepatitis C Virus (HCV) is not transmitted as easily
through occupational exposure as HBV. Therefore,
HCV-positive patients do not need to be isolated
from other patients.2 HCV-positive persons should
be evaluated for the presence of chronic hepatitis
and educated on how to prevent additional harm
to their liver and what they can do to prevent
transmitting HCV to others.2
Implementing Precautions
Implementation of appropriate infection preven-
tion and control practices in dialysis settings is
challenging because staff encounter blood and
body fluids so frequently. Infection prevention and
control practices are stricter in HD units than other
patient care units because of the greater risk and
frequency at which contamination with blood and
infectious pathogen can occur.2 Restrictions on the
use of common supplies, equipment, medications,
and medication/supply carts in the dialysis envi-
ronment include the following:2
• Items taken to a patient’s dialysis station should
be disposed of; dedicated for a single patient’s
use only; or cleaned and disinfected before they
are moved to a common area or used on anoth-
er patient.
• Unused medications or supplies (e.g., syringes,
alcohol swabs) taken to the patient’s station
should be disposed of and not returned to a
common area.
• Medications must be prepared in a designated
area separate from the patient treatment area,
preferably in a dedicated medication room.
• Clean and dirty areas must be identifiable and
separate.
• Each patient’s medications must be delivered
separately, and shared medication carts should
not be used.
• Common supply carts used to store cleaning
and disinfection supplies must be located in a
designated area away from patient stations to
avoid contamination; these carts must not be
moved between patient stations.
As noted previously, Millson and coauthors6 found
that dialysis center staff felt rushed to complete all
daily tasks and were the most stressed during the
transition of placing patient on and off machines.
Under these pressures, the personnel in this study
would often eliminate or take shortcuts in steps
essential for preventing infection transmission.
Dialysis care providers must develop effective
strategies to implement infection prevention and
control measures. These strategies should engage
a multidisciplinary team that includes frontline
staff, patients, infection prevention experts, depart-
ment leadership, and performance improvement
staff. The multidisciplinary approach helps ensure
that the dialysis unit is set up to accommodate the
busy environment and to make patient care
processes as easy, efficient, and safe as possible.
 27 | Section 4: Standard and Transmission-Based Precautions

The Centers for Disease Control and Prevention
have outlined required strategies for implementing
standard precautions, which include the presence
of the following:8
• A facility policy and standard operating proce-
dure
• Staff engagement and involvement
• Immediately available supplies and equipment
strategically located near dialysis stations, stored
in a clean and sanitary manner
• Standardized tools and checklists for educating
and assessing staff practice
• Staff education on hire and at least annually
• A competency program for staff that includes
demonstration of standard precaution elements
on hire and at least annually
• Observation audits and regular feedback to staff
Table 4.1 summarizes barriers to implementation of
standard and transmission-based precautions in
dialysis settings and strategies to overcome them.
Refer to Table 4.2 for additional resources that can
help assist in implementation of standard precau-
tions and safe care provision in dialysis facilities.4,7-24

Table 4.1. Overcoming Challenges in Implementing Precautions

Challenge Implementation Strategies

Knowledge deficit about
appropriate practices
Inadequate policies and procedures
Products being unavailable, difficult
to use, or stored in inconvenient
locations
Time limitations and competing
priorities
• Provide staff and patient education.
• Schedule regular audits and provide regular feedback to patients
and staff.
• Periodically review and update policies and procedures.
• Place products strategically throughout the unit for convenient
use by staff and patients.
• Post visual cues to remind staff and patients of the importance of
hand hygiene.
• Encourage staff and patients to speak up when opportunities for
improvement are apparent.

Table 4.2. A
 dditional Resources for Implementing Standard Precautions in Dialysis Settings

Resource Description and Uses

Regulations and facility standards

Medicare and Medicaid Programs;
conditions for coverage for end-
stage renal disease facilities; final
rule4
Interpretive guidance on CMS
conditions for coverage for ESKD
facilities7
CDC infection prevention and
control assessment tool for
hemodialysis facilities8
• CMS conditions for coverage for ESKD facilities, as published in
the Code of Federal Regulations
• Use to understand CMS requirements for infection control
practices
• CMS ESKD surveyor training guidance on the CMS requirements
and how they are interpreted
• Use to assist in interpretation of final CMS rule for implementation
• Tool for surveyors assessing requirements in dialysis facilities
• Use to assess practices in dialysis settings to ensure that
minimum safety standards are in place
 28 | Section 4: Standard and Transmission-Based Precautions
Resource
CDC audit tools and checklists 9
Hand hygiene
WHO hand hygiene poster10
CDC clean hands count campaign11
CDC clean hands save lives 12
PPE
CDC healthcare-associated
infections: protecting healthcare
personnel13
Respiratory etiquette
CDC healthy habits to prevent flu14
CDC respiratory hygiene/cough
etiquette in healthcare settings15
Safe injection practices
CDC injection safety: one and only
campaign16
CDC FAQs regarding safe practices
for medical injections17
Description and Uses
• Standardized tools and checklists for dialysis care
• Use to audit infection control practices
• Hand hygiene poster specifically for dialysis units
• Use as a visual cue to remind staff and patients to perform hand
hygiene
• Webpage with free promotional materials to encourage hand
hygiene
• Use to support a hand hygiene campaign
• Webpage with education, evidence, and other promotional
materials
• Obtain education and promotional materials to improve hand
hygiene
• Webpage that includes training materials and visual cues for the
use of PPE
• Use the slides for training staff, and use posters as reminders
about selection and proper use of PPE; the trainer’s guide can be
used to assist the trainer in providing adequate education
• Webpage that includes visual cues and educational and
promotional tools to promote healthy practices during influenza
season
• Use tools and promotional materials to improve practices to
prevent influenza
• Respiratory hygiene implementation resources, including posters,
training information, and promotional materials
• Use tools to implement a respiratory hygiene program including
educational materials for staff and patients
• A webpage with resources for implementing a injection safety
program
• Use the promotional tools, including videos, pocket guides, audit
tools, and posters to help inform patients and healthcare
personnel about the importance of safe injection practices
• Answers to common questions related to safe injection practices
including topics related to medication preparation and
administration and proper use of single-dose and multidose vials
• Use as a reference for staff education and training
 29 | Section 4: Standard and Transmission-Based Precautions

Resource Description and Uses

CDC safe injection checklist 18
CDC safe injection practices to
prevent transmission of infections
to patients19
• An injection safety checklist to monitor adherence to safe
injection practices in healthcare settings
• Use to audit adherence to safe injection practices
• Recommendations for injection safety
• Use reference to implement best practice guidelines for safe
injection practices

Staff and patient education/training

CDC dialysis safety infection • Tools for implementing infection prevention practices in dialysis
prevention tools20 settings
• Use to train staff in infection prevention
AHRQ safety program for end- • Toolkit for preventing infections in dialysis patients
stage renal disease facilities toolkit21 • Use to help clinicians ensure that safe care, develop culture of
safety, and engage patients and families
CDC dialysis safety clinician • Tools to develop dialysis staff competencies and educational
education22 programs for staff and patients
• Use the educational videos and other resources to teach infection
control in dialysis settings
CDC conversation starter to prevent • Guide to discussing infection prevention with dialysis patients
infections23 • Use to educate patients and ensure they are involved and
engaged in infection prevention
CDC speak up video24 • Video to encourage patient involvement in preventing infection,
featuring stories of dialysis patients and their experience in safe
care
• Use to encourage patients to be involved in their care

Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CDC, Centers for Disease Control and Prevention;
CMS, Centers for Medicare & Medicaid Services; ESKD, end-stage kidney disease; FAQ, frequently asked questions;
PPE, personal protective equipment; WHO, World Health Organization.

References
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L,
Healthcare Infection Control Practices Adviso-
ry Committee. Guideline for isolation precau-
tions: preventing transmission of infectious
agents in healthcare settings. Last reviewed
July 22, 2019. Accessed January 3, 2022.
https://www.cdc.gov/infectioncontrol/guide-
lines/isolation/index.html
2. Centers for Disease Control and Prevention.
Recommendations for preventing transmission
of infections among chronic hemodialysis
patients. MMWR Recomm Rep. 2001;50(RR-
5):1-43. https://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5005a1.htm
3. Boyce JM, Pittet D; Healthcare Infection
Control Practices Advisory Committee;
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. Guideline for hand hygiene in health-
care settings. Recommendations of the
Healthcare Infection Control Practices Adviso-
ry Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. Society for
Healthcare Epidemiology of America/Associa-
tion for Professionals in Infection Control/
Infectious Diseases Society of America.
MMWR Recomm Rep. 2002;51(RR-16):1-CE4.
4. Centers for Medicare & Medicaid Services.
Medicare and Medicaid Programs; conditions
 30 | Section 4: Standard and Transmission-Based Precautions
for coverage for end-stage renal disease
facilities; final rule. 42 CFR parts 405, 410, 413
et al. Published April 15, 2008. Accessed
January 3, 2022. https://www.cms.gov/
Regulations-and-Guidance/Legislation/
CFCsAndCoPs/Downloads/ESKDfinalrule0415.
pdf
5. Karkar A. Hand hygiene in haemodialysis units.
Open Access Lib J. 2016;3:e2953. doi:10.4236/
oalib.1102953
6. Millson T, Hackbarth D, Bernard H. A demon-
stration project on the impact of safety culture
on infection control practices in hemodialysis.
Am J Infect Control. 2019;47:1122-1129.
doi:10.1016/j.ajic.2019.02.026
7. Centers for Medicare & Medicaid Services. Part
494 Conditions for coverage for end-stage
renal disease facilities—interpretive guidance.
Final versions 1. Published October 5, 2008.
Accessed January 3, 2022. https://www.cms.
gov/Medicare/Provider-Enrollment-and-Certi-
fication/GuidanceforLawsAndRegulations/
downloads/ESKDpgmguidance.pdf
8. Centers for Disease Control and Prevention.
Infection prevention and control assessment
tool for hemodialysis facilities. Version 1.4.
Published September 2016. Accessed January
5, 2022. https://www.cdc.gov/infectioncontrol/
pdf/icar/dialysis.pdf
9. Centers for Disease Control and Prevention.
Dialysis safety: audit tools and checklists. Last
reviewed September 25, 2017. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
prevention-tools/audit-tools.html
10. World Health Organization. Your 5 moments
for hand hygiene in haemodialysis in ambula-
tory settings. Published March 2012. Accessed
January 3, 2022. https://www.who.int/gpsc/
5may/haemodialysis.pdf
11. Centers for Disease Control and Prevention.
Clean hands count campaign. Last reviewed
March 15, 2016. Accessed January 3, 2022.
https://www.cdc.gov/handhygiene/campaign/
index.html
12. Centers for Disease Control and Prevention.
Handwashing: clean hands save lives. Last
reviewed October 12, 2021. Accessed January
3, 2022. https://www.cdc.gov/handwashing
13. Centers for Disease Control and Prevention.
Healthcare-associated infections: protecting
healthcare personnel. Last reviewed October
21, 2021. Accessed January 5, 2022. https://
www.cdc.gov/hai/prevent/ppe.html
14. Centers for Disease Control and Prevention.
Healthy habits to help prevent flu. Last re-
viewed October 21, 2021. Accessed January 3,
2022. https://www.cdc.gov/flu/prevent/
actions-prevent-flu.htm
15. Centers for Disease Control and Prevention.
Respiratory hygiene/cough etiquette in
healthcare settings. Last reviewed August 1,
2009. Accessed January 3, 2022. https://www.
cdc.gov/flu/professionals/infectioncontrol/
resphygiene.htm
16. Centers for Disease Control and Prevention.
Injection safety: one and only campaign. Last
reviewed December 3, 2019. Accessed January
3, 2022. https://www.cdc.gov/injectionsafety/
one-and-only.html
17. Centers for Disease Control and Prevention.
FAQs regarding safe practices for medical
injections. Last reviewed June 20, 2019.
Accessed January 3, 2022. https://www.cdc.
gov/injectionsafety/providers/provider_faqs.
html
18. Centers for Disease Control and Prevention.
Safe injection checklist. Accessed January 3,
2022. https://www.cdc.gov/injectionsafety/
PDF/Safe-Injection-Checklist-P.pdf
19. Centers for Disease Control and Prevention.
Safe injection practices to prevent transmis-
sion of infections to patients. Last reviewed
April 1, 2011. Accessed January 3, 2022. https://
www.cdc.gov/injectionsafety/ip07_stan-
dardprecaution.html
20. Centers for Disease Control and Prevention.
Dialysis safety infection prevention tools. Last
reviewed October 31, 2017. Accessed January
3, 2022. https://www.cdc.gov/dialysis/preven-
tion-tools/index.html
21. Agency for Healthcare Research and Quality.
AHRQ Safety program for end-stage renal
disease facilities–toolkit. Last reviewed Janu-
ary 2015. Accessed January 3, 2022. https://
www.ahrq.gov/patient-safety/settings/ESKD/
resource.html
 31 | Section 4: Standard and Transmission-Based Precautions

22. Centers for Disease Control and Prevention.

Dialysis safety: clinician education. Last
reviewed January 29, 2020. Accessed January
3, 2022. https://www.cdc.gov/dialysis/clini-
cian/index.html
23. Centers for Disease Control and Prevention.
Conversation starter to prevent infections in
dialysis patients. Last reviewed September 21,
2016. Accessed January 3, 2022. https://www.
cdc.gov/dialysis/patient/conversation-starter.
html
24. Centers for Disease Control and Prevention.
Speak up–video for patients. Last reviewed
February 7, 2020. Accessed January 3, 2022.
https://www.cdc.gov/dialysis/patient/speak-
up-video.html
 32 | Section 5: Cleaning and Disinfection
SECTION 5:
CLEANING AND DISINFECTION OF THE
ENVIRONMENT AND EQUIPMENT IN THE
DIALYSIS SETTING
The hemodialysis setting presents a challenge for
environmental cleaning and disinfection because
of the spatial proximity of patients and the demands
for rapid turnover of stations. Studies have
demonstrated that surfaces within the dialysis
patient treatment area are often contaminated
with blood.1 If contaminated surfaces are not
adequately cleaned and disinfected, bloodborne
and other pathogens may remain alive and
infectious for days.1-3
Numerous outbreaks of infectious disease in the
dialysis setting have been related to inadequate
cleaning and disinfection.4 Although not exhaus-
tive, this section will outline the routine cleaning
and disinfection processes that should be in place
in the dialysis setting and discuss techniques to
ensure that these processes are reliably followed.
Choice of Agent
Inpatient and outpatient dialysis facilities should
use an Environmental Protection Agency (EPA)–
registered hospital disinfectant for low-level and
intermediate-level disinfection.5 Any EPA-registered
hospital disinfectant is acceptable for use as a
low-level disinfectant and may be used for routine
disinfection of noncritical environmental surfaces
(e.g., external surfaces of dialysis machines, chairs,
beds, counters, tabletops, and reusable equip-
ment), with the following exceptions (all EPA lists
can be accessed from reference 5):
• If a patient is suspected or confirmed to be
infected with SARS-CoV-2 (also known as
COVID-19), use agents included on EPA List N
for routine disinfection.
• If a patient is suspected or confirmed to be
infected or colonized with Candida auris, use
agents included on the EPA’s list for C. auris for
routine disinfection. Alternatively, use an agent
effective against Clostridium difficile spores from
EPA List K.
Intermediate-level disinfection is used for surfaces
that are visibly contaminated with blood or body
fluids. Intermediate-level disinfectants are more
potent and able to kill hardier organisms. EPA-reg-
istered disinfectants that are labeled as tubercu-
locidal or have a kill claim for hepatitis B virus
(HBV) and human immunodeficiency virus (HIV)
are acceptable for use as intermediate-level
disinfectants. For convenience, the Centers for
Disease Control and Prevention (CDC) recom-
mends that facilities choose an intermediate-level
disinfectant for all routine and intermediate-level
disinfection rather than having two different
products, which may lead to improper use.6
It is important that all staff read and follow the
manufacturer instructions for use (IFU) on the
package of any agent used for cleaning or disin-
fection. Many products are sold in a “ready-to-use”
format and do not require any additional dilution.
If dilution is required, ensure that the manufacturer
IFU are followed for proper concentration and
disinfection, surface contact time, and for storage.
Procedure for Cleaning and
Disinfection of the Dialysis
Station
Cleaning is the removal of visible dirt or organic
material from a surface. Disinfection is the elimina-
 33 | Section 5: Cleaning and Disinfection
tion of pathogenic microorganisms on inanimate
objects. In the presence of visible soiling or blood,
cleaning must take place prior to disinfection. A
dialysis station (or patient station) is defined as
the dialysis machine, a purified water connection,
the dialysate concentrate container or connection,
the treatment chair, and other patient furniture or
equipment within the dialysis station.
Surface Cleaning and Disinfection
Before disinfection of the dialysis station begins,
all surfaces should be inspected for the presence
of visible soil. A low-level disinfectant can be used
to clean soiled surfaces. Visible blood must be
cleaned up using an intermediate level tubercu-
locidal disinfectant, followed by a second applica-
tion of disinfectant. Blood tubing should be
removed from the dialysis machine, placed in a
leakproof container and discarded. Some dialysis
machines will have a priming bucket attached to
the side of the machine; if present, this should be
emptied prior to disinfection. All single-use
supplies should be discarded, and reusable
equipment should be moved to the area where it
will be cleaned and disinfected.
External surfaces of dialysis machines should be
cleaned and disinfected after each patient. Dialysis
staff should begin disinfection after the patient
has left the dialysis station to minimize the risk of
cross contamination. All surfaces of the dialysis
station should be disinfected, including the dialysis
machine priming bucket (if applicable). If present
in the station, drawers and recliners should be fully
opened to ensure that all surfaces are disinfected.
The disinfected surfaces should remain wet for the
entire contact time, as indicated by the manufac-
turer, and allowed to air dry.
Internal Disinfection
of Dialysis Machines
Internal parts of dialysis machines should be
disinfected on a regular basis per manufacturer
IFU with products such as chlorine-based disinfec-
tants (e.g., bleach) or heat disinfection. Some
alarm occurrences (such as blood leaks or flooded
transducers) may require staff to remove the
machine from service until an internal cleaning and
check by biomedical staff is completed. If fluid
such as water or dialysate is permitted to sit in the
machine overnight, the internal pathways should
be disinfected prior to the first patient use the
next day.
Wall Boxes
Wall boxes (the recesses in the wall where the
connections for treated water, acid and base
concentrates, and the waste drain are located) are
a potential source of infection. The connections,
hoses, and surfaces of wall boxes are considered
contaminated and should be disinfected at least
daily, or more frequently if visibly dirty.7
Biofilm may develop on the connection hoses for
the acid, bicarbonate, and treated water and
contaminate the hands of healthcare workers
when touched. Staff touching any part of a wall
box should change gloves and perform hand
hygiene before moving on to another task.
The wall box is considered a part of the dialysis
station, and disinfection should not begin until the
patient has left the station.
Drains of wall boxes should be routinely disinfect-
ed as a preventive measure to reduce the rate of
biofilm formation. Waste from the dialysis machine
should not be allowed to backflow into the ma-
chine. This can be accomplished by allowing an air
gap between the drain and the drain hose.
Supplies
Clean supplies should be stored in an area that is
clearly separated from contaminated areas where
used supplies are handled.
If a common supply cart is used in the patient care
area, this should remain in a designated area and
be far enough away from the dialysis stations to
avoid contamination with blood. Supply carts
should remain stationary and not be moved
 34 | Section 5: Cleaning and Disinfection

between stations. Ensure that only clean hands are or mucus membranes from exposure to potentially
used to access the supply cart. infectious material.

Items taken to a dialysis station must be either
dedicated to that patient or discarded. Reusable
equipment (such as a blood pressure cuff or
stethoscope) must be cleaned and disinfected
before being returned to a clean area or used on
another patient. Manufacturer IFU should be
followed for disinfection or reprocessing of
multiuse items.
Items that cannot be disinfected (such as adhesive
tape) and single-use items must be dedicated to
one patient.
Contaminated items such as used equipment,
blood specimens, and biohazard containers
cannot be stored or reprocessed in an area where
unused supplies, clean equipment, or medications
are handled.
Handling Potentially Infectious Waste
Items saturated with blood should be placed into a
leakproof bag and housed in a leakproof container
labeled with a biohazard symbol. When handling
these items, personnel should wear gloves, at a
minimum, and don additional personal protective
equipment as necessary to protect skin, clothing,
Contaminated material should be stored away
from the patient care area and protected from
casual access. Waste generated in a hemodialysis
facility may be contaminated with blood and is
considered potentially infectious regulated medi-
cal waste; dispose of it according to local, state,
and federal laws governing medical waste.8
Sharps, such as needles used for hemodialysis
treatment, must be disposed of in a punc-
ture-proof sharps container labeled with a biohaz-
ard symbol. The sharps container should be large
enough for this purpose to reduce the risk of
needlestick injuries.
Implementation
Risk of infection in the dialysis setting can be
reduced by adherence to procedures for the
disinfection and maintenance of equipment. Staff
should be well trained and knowledgeable about
how to clean and disinfect surfaces, and they
should understand the implications for deviating
from established procedures. Table 5.1 identifies
strategies to improve adherence.5,6,9

Table 5.1. O
 vercoming Challenges to Cleaning and Disinfection

Challenge Implementation Strategies Resources

Knowledge deficit of
appropriate disinfection
practices
Inadequate policies and
procedures
• Ensure that staff are well trained CDC Checklists and audit tools9
on hire.
• Assess staff competency at least
annually.
• Schedule regular audits of
performance and provide
feedback.
• Establish written protocols for Environmental surface disinfection in
cleaning and disinfection. dialysis facilities: notes for clinical
managers6
• Use a log to document daily,
weekly, and monthly preventive
measures.
 35 | Section 5: Cleaning and Disinfection

Challenge Implementation Strategies Resources

Failure to follow correct
steps
Inadequate supply of
products
Time limitations and
competing priorities
• Standardize the order in which CDC Checklists and audit tools9
stations are cleaned and
disinfected.
• Implement a checklist of steps to
ensure adherence.
• Make disinfectants available EPA-registered disinfectants5
throughout the unit in strategic
places for convenient use by
staff.
• Ensure that patients are Environmental surface disinfection in
scheduled to allow for enough dialysis facilities: notes for clinical
patient-free time at each station managers6
for cleaning and disinfection.
• Consider implementing a facility-
wide patient-free interval to
ensure that there is adequate
time for thorough disinfection.

References
1. Nguyen DB, Gutowski J, Ghiselli M, et al. A
large outbreak of hepatitis C virus infections in
a hemodialysis clinic. Infect Control Hosp
Epidemiol. 2016;37(2):125-133. doi:10.1017/
ice.2015.247
2. Girou E, Chevaliez S, Challine D, et al. Determi-
nant roles of environmental contamination and
noncompliance with standard precautions in
the risk of hepatitis C virus transmission in a
hemodialysis unit. Clin Infect Dis.
2008;47(5):627-633. doi:10.1086/590564
3. Noskin GA, Stosor V, Cooper I, Peterson LR.
Recovery of vancomycin-resistant enterococci
on fingertips and environmental surfaces.
Infect Control Hosp Epidemiol. 1995;16(10):577-
581. doi:10.1086/647011
4. Centers for Disease Control and Prevention.
Dialysis-related outbreaks: current. Last
reviewed September 28, 2020. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
reports-news/outbreaks.html
5. Environmental Protection Agency. Selected
EPA-registered disinfectants. Last updated
December 7, 2021. Accessed January 3, 2022.
https://www.epa.gov/pesticide-registration/
selected-epa-registered-disinfectants
6. Centers for Disease Control and Prevention.
Environmental surface disinfection in dialysis
facilities: notes for clinical managers. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
pdfs/collaborative/env_notes_feb13.pdf
7. Centers for Disease Control and Prevention.
Dialysis safety: dialysis wall boxes and drains.
Last reviewed October 25, 2019. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
guidelines/wall-boxes.html
8. Centers for Disease Control and Prevention.
Recommendations for preventing transmission
of infections among chronic hemodialysis
patients. MMWR Recomm Rep. 2001;50(RR-
5):1-43. https://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5005a1.htm
9. Centers for Disease Control and Prevention.
Dialysis safety: audit tools and checklists. Last
reviewed September 25, 2017. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
prevention-tools/audit-tools.html
 36 | Section 6: Screening and Immunization
SECTION 6:
SCREENING AND IMMUNIZATION
Screening and immunization are important
preventive services and are key to improving
health and reducing death and disability. Together,
these interventions can significantly reduce risk
from infection within a population. Screening and
immunization are especially important for end-
stage kidney disease (ESKD) patients because
their immunocompromised state leads to more
severe illness from infection and less-robust
immune response to vaccination.
Screening
Screening is a vital part of an infection prevention
and control program because it helps identify
disease early and prevent transmission. Because
screening recommendations change periodically
as medical technology and treatments advance,
this section can only provide as a broad overview
of the rationale for screening for select diseases in
the dialysis patient population. For up-to-date
recommendations, please check resources from
the Centers for Disease Control and Prevention
(CDC),1 the National Kidney Foundation Kidney
Disease Outcomes Quality Initiative (KDOQI),2 and
the Centers for Medicare & Medicaid Services
(CMS) conditions for coverage for ESKD facilities.3
Hepatitis C
The prevalence of hepatitis C virus (HCV) in the
US chronic hemodialysis (HD) population is high
(7.3%).4 HCV has been epidemiologically shown to
spread in dialysis facilities, especially when there is
lack of adherence to infection prevention and
control measures such as environmental cleaning
and disinfection and medication safety.4,5
Antiviral medication can eradicate the hepatitis C
virus, leading to cure in infected HD patients. Thus,
screening for infection with HCV is an important
strategy to identify and treat patients infected
with HCV, as well as a key to detecting possible
transmission of new cases in dialysis settings.
Patient screening for HCV is recommended upon
initiation of dialysis and every 6 months thereafter
while a patient is receiving maintenance dialysis.2
Any newly identified case of hepatitis C in a
dialysis patient must be investigated for potential
links or transmission that might have occurred in
the dialysis center. Table 6.1 reviews the interpreta-
tion of findings from HCV tests.6
 37 | Section 6: Screening and Immunization
Table 6.1. Interpreting Hepatitis C Test Results6
Anti-HCV HCV-RNA Interpretation
• Acute hepatitis C
+ +
• Chronic hepatitis C
• Resolved hepatitis C
• Acute HCV during low-level
+ – viremia
• False-positive anti-HCV test
• False-negative HCV-RNA test
• Early acute HCV
• Chronic HCV in a setting of
– + immunosuppressed state
• False-positive HCV-RNA test
– – • No infection
Abbreviations: Anti-HCV, hepatitis C virus antibody; HCV-RNA, hepatitis C virus RNA; HCV, hepatitis C virus.
Hepatitis B
Hepatitis B virus (HBV) is one of the major causes
of liver disease globally. It can cause cirrhosis and
liver failure, and it also causes about half of all
hepatocellular carcinoma cases, the sixth most
common cancer worldwide. In most immunocom-
petent adults, infection with HBV will be followed
by antibody production, elimination of the virus,
and immunity from future HBV infections. However,
in immunocompromised individuals, including
ESKD patients, most HBV infections will result
in chronic disease without the production of
antibodies, leading to lifelong risk of liver disease
and infectivity.7
HBV is stable in the environment and can remain
viable on surfaces for up to 7 days.7 Because of
the frequency of bloodstream access in the
dialysis setting, there is increased risk that
HBV-susceptible patients and staff will acquire
HBV through inadvertent exposure to infected
blood from contaminated surfaces or equipment,
even in the absence of visible blood. Preventive
measures have been successful in significantly
Action
Report to local or state health department
HCV-RNA test every 6 months anti-HCV
in a previously negative patient should
also be reported to the health department
Report to local or state health department
Anti-HCV test every 6 months6
decreasing the prevalence of HBV in the US
dialysis population to 0.9%.7 Chief among these
measures is vaccination of HBV-susceptible
patients and healthcare workers.
Because of the risk of HBV transmission in dialysis
settings, patient screening for HBV is recommend-
ed prior to HD initiation. The presence of hepatitis
B surface antigen (HBsAg) in a serologic test
indicates acute or chronic infection with HBV, and
patients with positive tests must therefore be
isolated and use dedicated equipment and sup-
plies.8 (See Section 4 for additional information on
HBV precautions.)
The presence of the antibody to HBsAg (anti-HBs)
is indicative of immunity if the titer is ≥10mIU/mL.8
The absence of anti-HBs may indicate susceptibili-
ty to HBV, and these patients should be vaccinat-
ed and have monthly serologic testing until tests
indicate immunity. Routine screening of HEP B
titer is recommended to ensure the patient has
immunity or to determine whether a vaccine
booster is needed. Table 6.2 outlines HBV test
results and interpretation.8
 38 | Section 6: Screening and Immunization
Table 6.2. I nterpreting Hepatitis B Test Results8
HBsAg Anti-HBc IgM Anti-HBc Anti-HBs
– – – –
+ – – –
+ + + –
– + + –
– + – +
+ + – –
– + – –
– – – +
Abbreviations: Anti-HBc, antibody to hepatitis B core antigen; anti-HBs, antibody to hepatitis B surface antigen;
HBsAg, hepatitis B surface antigen; IgM, immunoglobulin M.
Tuberculosis
Screening for tuberculosis (TB) is recommended
in the dialysis population because immune dys-
function and frequent contact with the healthcare
environment could lead to an outbreak in situa-
tions where a TB infection went untreated and
undetected. In this population, a latent TB infec-
tion is more likely to progress to active disease,9
which may then be transmitted to other high-risk
patients. Nosocomial transmission of TB has been
reported in hemodialysis facilities.10 To reduce this
risk, baseline TB screening should be done on all
patients. Patients should also be periodically
rescreened based on epidemiological risk.
Current methods to screen for latent TB infection
(LTBI) include the tuberculin skin test (TST) and
immunological tests using IFN-y release assays
(IGRAs). In immunocompromised persons such as
patients with ESKD, the TST may not be sensitive
or specific enough to detect LTBI; existing guide-
lines recommend using IGRAs to screen these
patients.11
Interpretation
Susceptible
Acute infection, early
Acute infection
Acute infection, resolving
Past infection, recovered and immune
Chronic infection
False positive (i.e., susceptible), past infection, or
low-level chronic infection
Immune if titer is ≥10mIU/mL
Immunization
Vaccine response is less robust in patients with ad-
vanced kidney disease than in healthy populations.
Compared to persons without ESKD, dialysis
patients have a lower average antibody titer after
vaccination, and fewer patients retain adequate
antibody titers after immunization.12
Ideally, patients with chronic kidney disease (CKD)
will receive routine recommended vaccines early
in the course of their disease to ensure there are
enough protective antibodies if their disease
advances toward ESKD. However, not all CKD
patients are aware that they have renal disease,
and many will not see a nephrologist until they
are in later stages of CKD. As a result, many
patients are not fully immunized when they begin
dialysis treatment.
The following are among the vaccines recommended
by the Advisory Committee on Immunization
Practices for US adults with CKD:13
• Pneumococcal disease
• Influenza
• Hepatitis B
This list is not all-inclusive, and it is imperative to
check with the CDC14 and professional societies
 39 | Section 6: Screening and Immunization
such as the National Kidney Foundation15 for
current guidelines. Vaccination recommendations
for the CKD population may vary by region or
country based on epidemiological risk, and they
may change over time as new vaccines (e.g.,
COVID-19 vaccines) are developed.
There may be contraindications for live attenuated
vaccines in patients with renal disease, and
recommendations vary based on age (e.g., children,
older adults). Vaccine dose and administration
schedules are different for ESKD patients than for
other patients, and it is important to review
dosage and vaccine schedule for this population.13
Influenza and Pneumococcal Disease
Dialysis patients have a high incidence of respira-
tory infections, with mortality rates significantly
higher than the general population. Among
dialysis patients, vaccination against influenza
reduces the risk of critical illness by 81% and
hospitalization related to influenza by 14%, and
it is also associated with significant reductions in
all-cause mortality (32%) and cardiac death (16%).16
Similarly, vaccination for pneumococcal disease
can reduce the risk of pneumonia by 45% and
invasive pneumococcal disease by 75%. Being
vaccinated for both influenza and pneumococcus
reduces the risk of all-cause mortality in dialysis
patients by 27%.17
Improving Vaccination Rates
HD patients typically attend dialysis units 2 or 3
times per week, and these encounters provide an
opportune time to discuss and administer vaccines.
However, dialysis patients in the United States
remain underimmunized. A study published in
2017 found that vaccination rates in dialysis
patients averaged 44% for pneumococcus, 73%
for HBV, and 76% for influenza.18
One unfortunate reason for underimmunization
may be vaccine hesitancy in dialysis patients, their
caregivers, and even dialysis personnel. Vaccine
hesitancy is an outcome behavior that results from
complex decision-making influenced by a wide
range of factors. These factors are defined as the
three C’s: complacency, confidence, and conve-
nience.19 Complacency exists when a person’s
perceived risk of disease is low enough that they
deem the vaccine unnecessary. Confidence is the
amount of trust a person places in the system that
develops, recommends, and delivers the vaccine.
Convenience refers to perceptions regarding the
affordability or geographical accessibility of
vaccination. Any combination of complacency,
lack of confidence, and inconvenience may be in
play when dealing with vaccine hesitancy.
One way to overcome factors related to vaccine
hesitancy is through communication. When
discussing vaccine recommendations with vaccine-
hesitant dialysis patients, it is important to listen to
their perspective without judgment. Try to under-
stand which factor(s) may be influencing their
decision to refuse vaccination and engage in a
discussion around each of those points. Compla-
cency issues may be addressed with education
about the effect of kidney disease on the immune
system, and the risk of hospitalization and death
from respiratory illnesses that may be preventable
with vaccination. Confidence in vaccine recom-
mendations can be enhanced by sharing patient
education material from reputable sources, such
as the National Kidney Foundation or the CDC.
Convenience factors may be addressed by offering
vaccination during a regularly scheduled dialysis
or clinic appointment at low or no cost.
Dialysis centers may consider using vaccination
rates as an internal performance measure. Although
vaccination of patients is not yet used as a perfor-
mance indicator in some of the programs that
drive quality improvement in the industry, such as
the CMS ESRD [end-stage renal disease] Quality
Incentive Program, interventions at the facility
level can improve vaccination coverage and
reduce the risk of complications from vaccine-
preventable disease. For example, dialysis centers
with vaccination protocols have been shown to
improve vaccination rates and decrease morbidity
and mortality in patients with ESKD.20 Bond and
coauthors found that facility-wide standing orders
are effective at promoting vaccination, especially
 40 | Section 6: Screening and Immunization
for HBV and pneumococcal disease.21
References
1. Centers for Disease Control and Prevention.
Dialysis safety: guidelines, recommendations
and resources. Last reviewed November 17,
2017. Accessed January 3, 2022. https://www.
cdc.gov/dialysis/guidelines/index.html
2. Kidney Disease: Improving Global Outcomes
(KDIGO) Hepatitis C Work Group. KDIGO 2018
clinical practice guideline for the prevention,
diagnosis, evaluation, and treatment of
hepatitis C in chronic kidney disease. Kidney
Int Suppl. 2018;8(3):91-165. doi:10.1016%2Fj.
kisu.2018.06.001
3. Centers for Medicare & Medicaid Services.
ESRD conditions for coverage: interpretive
guidance. Final version 1.1. Published October
3, 2008. Accessed January 3, 2022. https://
www.cms.gov/Medicare/Provider-Enroll-
ment-and-Certification/GuidanceforLawsAnd-
Regulations/downloads/ESRDpgmguidance.
pdf
4. Fabrizi F, Messa P. Transmission of hepatitis C
virus in dialysis units: a systematic review of
reports on outbreaks. Int J Artif Organs.
2015;38(9):471-480. doi:10.5301/ijao.5000437
5. Wagner J, Gandhi A, Johnson B, et al. Hepati-
tis C virus transmission at a long-term care
facility (LTCF) providing hemodialysis ser-
vices—Georgia, United States, 2019. Infect
Control Hosp Epidemiol.
2020;41(S1):s248-s249. doi:10.1017/
ice.2020.808
6. American Society of Nephrology. Hepatitis C
testing and monitoring algorithm. Published
March 29, 2019. Accessed January 3, 2022.
https://www.asn-online.org/ntds/re-
sources/20190509-NCHHSTP_NTDS-HCV_
Subcommittee_Algorithm.pdf
7. Ayub MA, Bacci MR, Fonseca FL, Chehter EZ.
Hemodialysis and hepatitis B vaccination: a
challenge to physicians. Int J Gen Med. 2014
Feb 3;7:109-14. doi: 10.2147/IJGM.S57254. PMID:
24520201; PMCID: PMC3917955.
8. Centers for Disease Control and Prevention.
Recommendations for preventing transmission
of infections among chronic hemodialysis
patients. MMWR Recomm Rep. 2001;50(RR-
5):1-43. https://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5005a1.htm
9. Mazurek GH, Jereb J, Vernon A, et al. Updated
guidelines for using interferon gamma release
assays to detect Mycobacterium tuberculosis
infection—United States, 2010. MMWR
Recomm Rep. 2010;59:1–25. https://www.cdc.
gov/mmwr/preview/mmwrhtml/rr5905a1.
htm?s_cid=rr5905a1_e
10. Centers for Disease Control and Prevention.
Tuberculosis transmission in a renal dialysis
center—Nevada, 2003. MMWR Morb Mortal
Wkly Rep. 2004;53(37):873-875.
11. Segall L, Covic A. Diagnosis of tuberculosis in
dialysis patients: current strategy. Clin J Am
Soc Nephrol. 2010;5(6):1114-1122. doi:10.2215/
CJN.09231209
12. Kato S, Chmielewski M, Honda H, et al. Aspects
of immune dysfunction in end-stage renal
disease. Clin J Am Soc Nephrol. 2008;3:1526-
1533. doi:10.2215/CJN.00950208
13. Centers for Disease Control and Prevention.
Guidelines for vaccinating kidney dialysis
patients and patients with chronic kidney
disease summarized from Recommendations
of the Advisory Committee on Immunization
Practices (ACIP). Published December 2012.
Last reviewed July 2015. Accessed January 3,
2022. https://www.cdc.gov/vaccines/pubs/
downloads/dialysis-guide-2012.pdf
14. Centers for Disease Control and Prevention.
Renal disease and adult vaccination. Last
reviewed May 2, 2016. Accessed January 3,
2022. https://www.cdc.gov/vaccines/adults/
rec-vac/health-conditions/renal-disease.html
15. National Kidney Foundation. Which vaccina-
tions do I need? Accessed January 3, 2022.
https://www.kidney.org/atoz/content/vaccina-
tions
 41 | Section 6: Screening and Immunization

16. Bond TC, Spaulding AC, Krisher J, McClellan

W. Mortality of dialysis patients according to
influenza and pneumococcal vaccination
status. American Journal of Kidney Diseases:
Official Journal of the National Kidney Foun-
dation. 2012 Dec;60(6):959-965. DOI: 10.1053/j.
ajkd.2012.04.018. PMID: 22694948.
17. Gilbertson DT, Guo H, Arneson TJ, Collins AJ.
The association of pneumococcal vaccination
with hospitalization and mortality in hemodial-
ysis patients. Nephrol Dial Transplant.
2011;26(9):2934-2939. doi:10.1093/ndt/gfq853
18. Shen AK, Kelman JA, Warnock R, et al. Benefi-
ciary characteristics and vaccinations in the
end-stage renal disease Medicare beneficiary
population, an analysis of claims data 2006-
2015. Vaccine. 2017;35(52):7302-7308.
doi:10.1016/j.vaccine.2017.10.105
19. MacDonald NE; SAGE Working Group on
Vaccine Hesitancy. Vaccine hesitancy: defini-
tion, scope and determinants. Vaccine.
2015;33(34):4161-4164. doi:10.1016/j.vac-
cine.2015.04.036
20. Kausz A, Pahari D. The value of vaccination in
chronic kidney disease. Semin Dial.
2004;17(1):9-11.
doi:10.1111/j.1525-139x.2004.17104.x
21. Bond TC, Patel PR, Krisher J, et al. Association
of standing-order policies with vaccination
rates in dialysis clinics: a US-based cross-sec-
tional study. Am J Kidney Dis. 2009;54(1):86-
94. doi:10.1053/j.ajkd.2008.12.038
 42 | Section 7: Surveillance
SECTION 7:
SURVEILLANCE
Surveillance is an extremely important part of
understanding the impact of infection prevention
in the dialysis setting so that infection prevention
and control efforts can be modified as needed.
The importance is reflected in the fact that the
Centers for Disease Control and Prevention (CDC)
core interventions to reduce dialysis-related
bloodstream infections (BSIs)1 include conducting
monthly surveillance and providing feedback to
staff. This intervention is an effective means to
engage frontline staff in infection prevention efforts.
National Healthcare Safety
Network
The National Healthcare Safety Network (NHSN)
is the most widely used healthcare-associated
infection surveillance system in the United States.
It provides facilities, states, regions, and the federal
government with data needed to identify problem
areas, measure progress of prevention efforts,
and ultimately eliminate healthcare-associated
infections.2
NHSN includes a Dialysis Component to monitor
the infections that lead to the highest morbidity
and mortality for the dialysis patient population.
Reporting is voluntary, but facilities that participate
in the Centers for Medicare & Medicaid (CMS) End-
Stage Renal Disease Quality Incentive Program
(QIP) must submit dialysis-related infection events
to NHSN.3
QIP is a value-based purchasing program, also
known as pay-for-performance, which links
payment to facility performance on quality of care
measures. Poor QIP performance can lead to
reduced payments for a dialysis facility. Reporting
dialysis events to NHSN is one part of the overall
QIP, and facilities must submit 12 months of data
for each year of QIP participation.4 To use NHSN
for surveillance and comply with the CMS QIP,
each facility must enroll and set up an account at
the online enrollment site.5 Step-by-step instruc-
tions and an enrollment checklist are available.
Data submitted for the QIP program are publicly
available at the CMS facility compare website.6
The Dialysis Event Surveillance Component is
specific to the outpatient hemodialysis setting.
This component consists of three events:
• Positive blood cultures
• Pus, redness, or increased swelling at the
vascular access site
• Intravenous (IV) antimicrobial starts
Facilities are instructed to report all positive blood
cultures from specimens collected as an outpa-
tient or within one calendar day after a hospital
admission. The suspected source of the positive
blood culture must be indicated (i.e., vascular
access, a source other than vascular access,
contamination, or uncertain). All IV antimicrobial
starts must be reported regardless of the reason
or duration of treatment.
There is one caveat in reporting a dialysis event:
the 21-day rule. This rule states that no new event
of the same type should be reported for 21 days
after the date of the previous event of the same
type. For example, if a positive blood specimen is
reported for a patient, a second positive specimen
for that patient within the next 21 days would not
be reported as a new event.7 From these 3 events,
the following measures are generated and may be
used by facilities and others for quality improve-
ment efforts: BSI, local access site infection (LASI),
access-related bloodstream infection (ARBSI), and
vascular access infection (VAI). Denominators for
these measures are unique to the dialysis setting
and include patients with each vascular access
type who received hemodialysis at the center
during the first 2 working days of the month to
 43 | Section 7: Surveillance

estimate the number of patient-months consid- Staphylococcus spp., which could potentially
ered at risk for dialysis events.4 indicate poor compliance with skin or catheter
prep, or the data may show elevated rates of BSIs
Another module available for use by dialysis caused by gram-negative water organisms, which
facilities is the Dialysis Prevention Process Mea- may indicate poor environmental cleaning practices.
sures (PPM). This module requires audits to be Thus, surveillance can provide a wealth of knowledge
performed during critical infection prevention useful for developing standards of care for staff to
activities. Audit areas include hand hygiene follow in performing patient care and other duties.
compliance, access connection and disconnection
procedures, exit-site care, disinfection of dialysis
Data Analysis and Display
stations, and medication safety practices. This is a
voluntary module but provides additional support Facilities participating in NHSN surveillance can
and feedback for prevention efforts.8 retrieve their own data from the NHSN application
at any time. A variety of reports are available, and
An additional module in the Dialysis Component is
there are many analysis fields to choose from. For
healthcare provider and patient influenza vaccina-
example, the facility can sort and report by access
tion surveillance. Although influenza vaccination is
device or dialysis event type, or generate a line list
no longer a required reporting measure, providing
by event type, or facility type. If an organization
the annual flu vaccine can help protect dialysis
reports staff influenza vaccine data, it can obtain a
patients from serious flu complications and death.
report regarding the types of personnel who
These modules are not required as part of the QIP
received the vaccine.
reporting methodology.9,10
The analysis tool within the NHSN application11 has
Each month, the NHSN facility administrator or
a diverse range of uses in patient care and quality
primary facility contact completes a monthly
improvement efforts. The more detail a facility
reporting plan. This plan is entered into the NHSN
enters in the NHSN application, the more informa-
application to identify the data the facility will
tion it can obtain to drive improvement processes.
report for the month. At present, NHSN surveillance
Figure 7.1 presents the reports that can be run
is not available for some key areas such as perito-
from the NHSN application, Figure 7.2 is an
neal dialysis and hemodialysis in the home setting.
example of a line listing generated from NHSN
data, and Figure 7.3 shows a frequency table of
Quality Improvement vascular events. These figures are based on test
file examples, not actual data from a facility.
Using data collected for NHSN surveillance and
other data sources, each facility or organization
can develop quality improvement projects to
improve the care and outcomes of each patient.
For instance, if the facility performs poorly in hand
hygiene, it can develop a hand hygiene campaign
to improve compliance. If the incidence of BSI is
greater than expected, an improvement plan
based on best practices can be implemented.

Data can identify what types of vascular access

are associated with infections and the infectious
organisms that are occurring in the clinic. For
example, the facility may find elevated rates of
BSIs caused by gram-positive organisms such as
 44 | Section 7: Surveillance

Figure 7.1. NHSN Application Reports Figure 7.3. F

 requency Table of Vascular Events
by Quarter

Figure 7.2. P
 artial Example of Line Listing for Dialysis Events
 45 | Section 7: Surveillance

Water Surveillance testing. Water systems may include the following

components to remove chemical and biological
Surveillance and monitoring of water cultures are impurities:
extremely important for the safety of the hemodi- • Water softener and brine tank
alysis patient population. A patent can be exposed • Carbon filters (in series)
to 300-600 liters of water each week during
• Particulate or sediment filters
hemodialysis treatments. This exposure increases
• Reverse osmosis filters
the risk of patients developing infections from
waterborne pathogens.12 • Deionization tanks
• Ultraviolet lights
Water Systems • Ultrafilters

To reduce the risk that water cultures and endo- Table 7.1 describes the components of a water
toxins might exceed recommended limits, water system and potential problems which the infection
systems should be engineered for efficiency based preventionist should be aware of.
on the facility’s source water and contaminant

Table 7.1. Components of Dialysis Water Treatment Systems and Potential Problems

Component Purpose Potential problems

Water softener and Reduce magnesium and
brine tank calcium in incoming water
Carbon filters (in series) Remove free chlorine,
chloramine, and organic
material from incoming
water
Particulate (sediment) Remove sediment from
filter water that could clog the
system
Reverse osmosis Use osmotic and hydrostatic
pressures over
semipermeable membranes
to remove ions and organics
Deionizer Contain resin beds that
remove cations and anions
Ultraviolet light Reduce microbial
contamination
Ultrafilters Remove bacteria and
endotoxins
• Must be regenerated with the brine once
depleted. If regeneration is done during
hemodialysis, this can result in elevated
sodium levels in effluent or hypernatremia in
patients
• Bacterial contamination has been reported in
portable systems
• Must be tested and monitored by dialysis staff
for patient safety
• Prone to bacterial contamination because of
porosity and affinity for organics
• Temperature and pH of incoming water affect
the ability of carbon beds to remove free
chlorine and chloramine
• Bacterial growth can occur on the filter, which
can lead to bacteremia and pyrogenic
reactions
• Membranes can become degraded or fouled,
or leak
• Does not remove bacteria or endotoxins and
can contribute to substantial bacterial growth
• May be ineffective if the radiant energy is
insufficient to reach microorganisms
• Does not remove endotoxins
• This last component before the distribution
loop does not eliminate the need for
monitoring of bacteria and endotoxins in
product water
 46 | Section 7: Surveillance

Distribution Systems and Wall Boxes Chemical and Microbiological

The distribution system, or the way that the
purified water is distributed to the dialysis stations,
should avoid joints, dead-end pipes, and any
branches or taps that could be a potential source
for bacteria.13
Dialysis wall boxes are frames recessed at each
hemodialysis station that contain connections for
the dialysis machine to access the water distribu-
tion system, other concentrates, and dispose of
waste products. Every facility should develop
policies about the specific frequency and methods
for wall box surface disinfection that include the
following points:
• Wall box surface disinfection should be one at
least once a day.
• Wipes or other supplies used to disinfect the
wall boxes should not be used to disinfect other
surfaces.
• Staff should perform hand hygiene after coming
into contact with the wall boxes or any of its
components.
Standards
Water systems and distribution systems in dialysis
centers should be disinfected on a regular basis to
prevent growth and accumulation of gram-nega-
tive bacteria and endotoxins. A regular schedule
for obtaining cultures and monitoring results will
ensure that the disinfection procedures in place
are appropriate and increase patient safety.
The Association for the Advancement of Medical
Instrumentation (AAMI) provides chemical and
microbiological standards for the following
aspects of water use in hemodialysis:
• Equipment and processes used to purify water
for the preparation of concentrates and dialy-
sate and the reprocessing of dialyzers for
multiple use
• The devices used to store and distribute this
water
• The allowable and action threshold levels of
water contaminants, bacterial cell counts, and
endotoxins

See Section 5 for additional information on wall Refer to Table 7.2 for information from the CDC12
boxes. on maximum allowable chemical contaminants
and bacterial/endotoxin limits in the relevant AAMI
standards.13,14

Table 7.2. A
 AMI Standards for Water in Dialysis Centers

Total Viable Count, CFU/mL Endotoxin Level, EU/mL

Reference Document Allowable Level Action Levela Allowable Level Action Levela
AMMI RD52:200412
(minimum regulatory <200 ≥50 <2 ≥1
requirement)
ANSI/AMMI/ISO
13959:201413
<100 ≥50 <0.25 ≥0.125
(CDC preferred
recommendation)11

Abbreviations: AAMI, Association for the Advancement of Medical Instrumentation; CFU, colony-forming unit; EU,
endotoxin unit.
a
“Action level” indicates that once these levels are measured in the product water, corrective measures should be
promptly taken to reduce the levels of bacteria/endotoxins.
Source: Adapted from reference 12 using data from references 13 and 14.
 47 | Section 7: Surveillance
Internal Reporting
Surveillance is an important component of the
quality assessment and performance improvement
(QAPI) program in dialysis facilities. Infection rates,
infection control, vascular access types, and water
culture/endotoxin results should all be evaluated
as a part of QAPI,15 which is explained in greater
detail in Section 8. In addition, these metrics are a
part of a robust infection prevention and control
program and should be reported regularly to the
infection control committee if one exists within the
larger organization.
References
1. Centers for Disease Control and Prevention.
Dialysis safety: core interventions. Last re-
viewed June 15, 2016. Accessed January 4,
2022. https://www.cdc.gov/dialysis/preven-
tion-tools/core-interventions.html
2. Centers for Disease Control and Prevention.
National Healthcare Safety Network (NHSN).
Accessed January 4, 2022. https://www.cdc.
gov/nhsn/index.html
3. Centers for Medicare & Medicaid Services.
ESRD Quality Incentive Program. Modified
December 1, 2021. Accessed January 4, 2022.
https://www.cms.gov/medicare/quality-initia-
tives-patient-assessment-instruments/ESRD-
qip
4. Centers for Disease Control and Prevention.
National Health Safety Network dialysis event
surveillance. Last reviewed December 29, 2021.
Accessed January 4, 2022. https://www.cdc.
gov/nhsn/dialysis/event/index.html
5. Centers for Disease Control and Prevention.
National Health Safety Network 5-step enroll-
ment for outpatient dialysis facilities—CMS
QIP. Last reviewed November 30, 2021.
Accessed January 4, 2022. https://www.cdc.
gov/nhsn/dialysis/enroll.html
6. Centers for Medicare & Medicaid Services.
Facility compare. Accessed January 4, 2022.
https://www.medicare.gov/care-compare/?pro-
viderType=DialysisFacility&redirect=true
7. Centers for Disease Control and Prevention.
Dialysis event surveillance protocol. Published
January 2022. Accessed January 4, 2022.
https://www.cdc.gov/nhsn/pdfs/pscmanual/8p-
scdialysiseventcurrent.pdf
8. Centers for Disease Control and Prevention.
National Health Safety Network dialysis
prevention process measures. Last reviewed
January 15, 2021. Accessed January 4, 2022.
https://www.cdc.gov/nhsn/dialysis/pro-
cess-measures/index.html
9. Centers for Disease Control and Prevention.
National Health Safety Network surveillance
for healthcare personnel (HCP) flu vaccination.
Last reviewed September 21, 2021. Accessed
January 4, 2022. https://www.cdc.gov/nhsn/
hps/vaccination/index.html
10. Centers for Disease Control and Prevention.
National Health Safety Network surveillance
for dialysis patient influenza vaccination. Last
reviewed January 15, 2021. Accessed January
4, 2022. https://www.cdc.gov/nhsn/dialysis/
patient-vaccination/index.html
11. Centers for Disease Control and Prevention.
National Health Safety Network dialysis event
reporting: data analysis manual. Accessed
January 4, 2022. https://www.cdc.gov/nhsn/
pdfs/dialysis/dialysis-analysis-manual.pdf
12. Centers for Disease Control and Prevention.
Dialysis safety: water use in dialysis. Last
reviewed October 15, 2020. Accessed January
4, 2022. https://www.cdc.gov/dialysis/guide-
lines/water-use.html
13. Association for the Advancement of Medical
Instrumentation. Dialysate for Hemodialysis.
AAMI/ANSI RD52:2004. Arlington, VA: Associ-
ation for the Advancement of Medical Instru-
mentation; 2004.
14. Association for the Advancement of Medical
Instrumentation. Guidance for the Preparation
and Quality Management of Fluids for Hemodi-
alysis and Related Therapies. ANSI/AAMI/ISO
13959:2014. Arlington, VA: Association for the
Advancement of Medical Instrumentation; 2014.
15. Centers for Medicare & Medicaid Services.
Conditions for coverage for end-stage renal
disease facilities. Condition: water and dialy-
sate quality. 42 CFR §49.40. https://ecfr.
federalregister.gov/current/title-42/chapter-IV/
subchapter-G/part-494
 48 | Section 8: Safety Culture and Quality Improvement in Dialysis
SECTION 8:
SAFETY CULTURE AND QUALITY
IMPROVEMENT IN DIALYSIS
Safety Culture
When a dialysis facility is a ”microsystem” within a
larger healthcare system, the support of the larger
system is critical to ensuring the safety culture.
However, cultural change is mostly achieved at the
facility level.1
It is important to note that a safe environment
does not guarantee an environment without
errors. The organization must plan for errors to
occur and set up processes to identify when they
happen. If an error occurs, the organization must
promptly put actions in place to mitigate harm,
and determine how processes can be changed so
that particular error does not happen again in the
future. It is also important to understand that most
errors are system failures, not errors of an individ-
ual, and blaming should be avoided.
Interdisciplinary Teams
Interdisciplinary teams (IDTs) play a key role in
both the safety culture and the quality improve-
ment activities within a dialysis facility. The team
approach allows dialysis facility staff to work
toward common goals, pool expertise, and prob-
lem solve issues together.
There are 2 distinct IDT teams in dialysis facilities,
each with specific goals and requirements per the
Centers for Medicare & Medicaid Services condi-
tions for coverage for end-stage kidney disease
(ESKD) facilities:2
• Patient assessment and plan of care IDT—This
team consists of the patient or the patient’s
designee (if the patient chooses), a registered
nurse, a physician treating the patient for ESKD,
a social worker, and a registered dietitian. This
team works collaboratively to discuss patient
status, address patient needs, and create an
individualized and comprehensive plan of care
for each patient through regular meetings.
• Quality assessment and performance improve-
ment (QAPI) IDT—The professional members of
this IDT team must minimally consist of a
physician, a registered nurse, a masters-pre-
pared social worker, and a registered dietitian;
the team is led by the medical director. Team
members work together to review facility
aggregate data to improve facility-based
practices and outcomes and increase patient
satisfaction and safety. They also collaborate to
implement and continually monitor the facility’s
QAPI program.
Dialysis is a complex procedure and, as such,
carries with it multiple safety risks, which must be
continually monitored. Table 8.1 categorizes the
types of safety risks.
Given these risks, a safety culture is paramount in
the dialysis care setting. Garrick and colleagues3
identified the key elements of safety culture in the
dialysis environment, including:
• Acknowledge the high-risk nature of the activity.
• Establish safety as a key goal in policies and
procedures.
• Evaluate errors as “system failures,” not as an
individual’s failures.
• Commit needed resources, including time and
technology.
• Recognize that a “safe” environment is not error
free.
• Report “near misses” and events in blame- and
retaliation-free environment.
 49 | Section 8: Safety Culture and Quality Improvement in Dialysis

Table 8.1. S
 afety Risks Associated with Dialysis identify opportunities for improving care, and
create action plans that result in performance
Type of Risk Examples improvement. The QAPI program is more than a
Patient safety Miscommunication regulatory requirement as it allows dialysis facili-
hazards ties to use continuous, organized methods to
Documentation errors
ensure that the highest quality of care for the
Failure to follow policy/
procedure patients they serve is sustained over time.

Lapses in infection control Required elements of the CMS QAPI program

and prevention
include the following:
• Review aggregate patient data to evaluate the
Patient safety Medication errors following facility patient outcome indicators:
events Cannulation issues – Adequacy of dialysis
Falls – Nutritional status
General safety Power failures – Mineral metabolism and renal bone disease
events associated measures
Blocked fire exits
with the physical
plant or – Anemia management
environment – Vascular access
Equipment issues Contaminated wall boxes • Evaluate the following facility performance
measures and indicators:
– Water and dialysate monitoring
– Equipment maintenance
• Develop processes for peer review and analysis
of root cause. – Hemodialyzer reuse program if practiced at
the facility
These elements are included in the dialysis facility’s • Identify medical injuries and medical errors:
CMS-required QAPI program, which is led by the
– Patient or staff injury
QAPI IDT.2
– Treatment errors
– Intradialytic morbidities
Quality Assessment and – Medication omissions or errors

Performance Improvement – Other events such as blood loss, transfers,

In 2008, CMS updated the conditions of coverage
for ESKD facilities2 to include the requirement for
a robust QAPI program. QAPI is the coordinated
application of two mutually reinforcing aspects of
a quality management system: quality assessment
and performance improvement. CMS requires that
each participating dialysis facility must implement
a QAPI program of its own design that reflects the
facility’s organization and services offered. The
QAPI program should review data related to
patient outcomes, complaints, medical injuries,
and medical errors. This detailed data review
should be used to identify potential problems,
hospitalizations, and deaths
• Use the following methods to assess patient
satisfaction and grievances:
– Grievance investigations
– Satisfaction surveys
• Evaluate and improve infection control:
– Track incidence of infection to identify trends
and establish baseline information on infec-
tion incidence
– Develop recommendations and action plans
to minimize infection transmission
– Promote immunization
– Take actions to reduce future incidence
 50 | Section 8: Safety Culture and Quality Improvement in Dialysis
CMS further requires that the dialysis facility must
set priorities for performance improvement by
considering the prevalence and severity of identified
problems and giving priority to improvement
activities that affect clinical outcomes or patient
safety. The facility must immediately correct any
identified problems that threaten the health and
safety of patients.
All elements of the QAPI program must be clearly
documented and made available to state survey
agencies and CMS upon request.
Antimicrobial Use and
Resistance
As documented elsewhere in this guide, the risk
of infection in the dialysis population is high. It is
therefore not surprising that patients receiving
hemodialysis (HD) have a greater chance of
antibiotic exposure than other individuals. Annually,
it can be expected that intravenous antibiotics will
be administered to approximately 1 in 3 patients
receiving maintenance HD.4
Receiving dialysis through a central venous
catheter, increases a patient’s risk of catheter-re-
lated bloodstream infection and their potential
need for antibiotic therapy. Frequent antibiotic
administration may increase the likelihood that the
patient will become colonized or infected with an
multidrug-resistant organism and face challenges
of antibiotic resistance. Inappropriate use and
overuse of antibiotics are also associated with
Clostridioides difficile infections.
A key resource on antimicrobial use in the care of
dialysis patients is a recent literature review from
the Antibiotic Stewardship in Hemodialysis
(ASHD) White Paper Writing Group, a collabora-
tion between the Centers for Disease Control and
Prevention (CDC) and the American Society of
Nephrology.4 This publication notes the challenges
with antibiotic prescribing in the United States,
summarizes current literature on antibiotic use in
the outpatient hemodialysis setting, and highlights
strategies to improve antibiotic prescribing in
hemodialysis. Evidence-based recommendations
for an antibiotic stewardship program within the
dialysis setting are provided, and the authors
identify research gaps and suggest future direc-
tion for this important clinical topic.
Patient Engagement
To optimize success in diagnostic and therapeutic
recommendations or interventions, it is essential
that the healthcare team effectively communicate
and engage with the patient and members of their
personal support system (e.g., their family).5 One
key consideration in patient engagement is the
specific patient’s social determinants of health
(SDoH).6 SDoH are defined as “the conditions in
the environments where people are born, live,
learn, work, play, worship, and age that affect a
wide range of health, functioning, and quality-
of-life outcomes and risks.”7 Understanding SDoH
helps healthcare providers recognize how health
outcomes are affected by patients’ lives outside of
the healthcare setting. By identifying individual
challenges that may affect the patient’s ability or
willingness to follow medical suggestions for
treatment, healthcare personnel can adopt a more
patient-centered approach to care, allowing each
patient to be a participant in their care, rather than
solely the recipient of treatment that they may not
understand or wish to receive.
Tools for patient engagement may be classified in
three increasing levels of collaboration/activation.
Tools in the first level passively provide informa-
tion. An example is written education in the form
of a flyer. Tools in the second level use more
collaborative methods that promote patient
participation in care discussions and decisions.
Examples include open-ended questions, pa-
tient-focused care plan meetings, and web-based
decision aids. Finally, the most active and collabo-
rative methods involve active participation of
patients as partners in healthcare interventions. An
example of an interactive or collaborative method
of patient engagement includes an audit of a
procedure such as a catheter connection proce-
dure using the CDC audit checklist.8
 51 | Section 8: Safety Culture and Quality Improvement in Dialysis
According to Bear and Stockie,9 many challenges
need to be overcome to achieve full patient
engagement in dialysis settings. For example,
healthcare providers must be trained in patient
engagement techniques and supported to over-
come their fears about change, as well as cultural
expectations that the physician (not the patient) is
the center of care. Also, facility leaders must
recognize that patient engagement may conflict
with other priorities during patient encounters and
be prepared to find solutions to these conflicts.
Bear and Stockie therefore recommend that
facilities develop “an information-based implemen-
tation plan” to advance patient engagement at the
facility level; they also support efforts by regulatory
agencies to require healthcare systems and
facilities to demonstrate commitment to patient
engagement and patient-centered care.
References
1. Jackson J. Chapter 1: The impact of safety
culture on infection prevention. In: Nephrolo-
gists Transforming Dialysis Safety (NTDS): A
Curriculum to Achieve Zero Preventable
Infections. American Society of Nephrology.
Accessed January 4, 2022. https://www.
asn-online.org/ntds/olm.aspx
2. Centers for Medicare & Medicaid Services.
Medicare and Medicaid Programs; conditions
for coverage for end-stage renal disease
facilities; final rule. 42 CFR parts 405, 410, 413
et al. Published April 15, 2008. Accessed
January 4, 2022. https://www.cms.gov/
Regulations-and-Guidance/Legislation/
CFCsAndCoPs/Downloads/ESKDfinalrule0415.
pdf
3. 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(4):680-688.
doi:10.2215/CJN.06530711
4. Apata IW, Kabbani S, Neu AM, et al. Opportu-
nities to improve antibiotic prescribing in
outpatient hemodialysis facilities: a report
From the American Society of Nephrology
and Centers for Disease Control and Preven-
tion Antibiotic Stewardship White Paper
Writing Group. Am J Kidney Dis.
2021;77(5):757-768. doi:10.1053/j.
ajkd.2020.08.011
5. Philipneri M. Chapter 26: Patient education/
engagement. In: Nephrologists Transforming
Dialysis Safety (NTDS): A Curriculum to
Achieve Zero Preventable Infections. American
Society of Nephrology. Accessed January 4,
2022. https://www.asn-online.org/ntds/olm.
aspx
6. Magnan S. Social determinants of health 101
for health care: five plus five. National Acade-
my of Medicine discussion paper. Published
October 9, 2017. doi:10.31478/201710c
7. Healthy People 2030. What are social determi-
nants of health? Accessed January 4, 2022.
https://health.gov/healthypeople/objec-
tives-and-data/social-determinants-health
8. Centers for Disease Control and Prevention.
Dialysis safety: audit tools and checklists. Last
reviewed September 25, 2017. Accessed
January 3, 2022. https://www.cdc.gov/dialysis/
prevention-tools/audit-tools.html
9. Bear RA, Stockie S. Patient engagement and
patient-centred care in the management of
advanced chronic kidney disease and chronic
kidney failure. Can J Kidney Health Dis.
2014;1:24. doi:10.1186/s40697-014-0024-7
Additional Resources
St. Peter W, Solid C. Outpatient IV antibiotic use in
the U.S. hemodialysis population, 1995 to 2007. US
Renal Data System. Accessed January 4, 2022.
https://render.usrds.org/2009/pres/06U_asn09_
antibiotic_use.pdf
Apata I. Chapter 14: Managing multidrug-resistant
organisms in outpatient dialysis facilities. In:
Nephrologists Transforming Dialysis Safety
(NTDS): A Curriculum to Achieve Zero Preventable
Infections. American Society of Nephrology.
Accessed January 4, 2022. https://www.asn-online.
org/ntds/olm.aspx
American Society of Nephrology Nephrologists
Transforming Dialysis Safety. Targeting zero
infections: MDROs and antimicrobial stewardship
in the dialysis facility (webinar). Published
52 | Section 8: Safety Culture and Quality Improvement in Dialysis

September 27, 2017. Accessed January 4, 2022.

https://www.asn-online.org/ntds/event.aspx?ID=4

American Society of Nephrology. Patient engage-

ment. Kidney News. 2017;9(5):6-8. https://www.
kidneynews.org/view/journals/kidney-news/9/5/
article-p6_5.xml
 53 | Section 9: Emergency Preparedness
SECTION 9:
EMERGENCY PREPAREDNESS
IN THE DIALYSIS SETTING
“All emergencies are local.”
—FORMER FEDERAL EMERGENCY MANAGEMENT AGENCY DEPUTY ADMINISTRATOR RICHARD SERINO, NOVEMBER 14, 2011
Emergencies and disasters come in many forms,
including natural, human-made, and new/emerging
diseases. Although the federal and state govern-
ments have processes and procedures in place to
assist with emergent situations, it is the responsi-
bility of individual healthcare entities to prepare
themselves to protect their patients and staff.
Regulatory Requirements
Dialysis facilities are required by federal and, in
some cases, state regulations to have plans in
place to address how dialysis services will be
provided in the event of an emergency or disaster.
These plans should include ensuring that their
patients know where to seek information regard-
ing the facility’s operations, where to go to get
care should the facility be closed due to the
emergency or disaster, and who to call to get
updated information. The dialysis facility is also
responsible for ongoing training for their patients
and staff regarding emergency planning and
procedures in their local area.
The Centers for Medicare & Medicaid Services
(CMS) regulations require numerous emergency
preparedness activities for compliance as part of
the conditions for coverage for dialysis providers.
Refer to the CMS Emergency Preparedness Rule
for the regulatory requirements.1
Resources
Training
CMS has created an online Emergency Prepared-
ness Basic Training course,2 which may help
dialysis providers gain proficiency with the federal
rules.
Planning
The following organizations and agencies offer
emergency and disaster preparedness resources
that dialysis providers can leverage as they
develop or review their emergency plans, policies,
and procedures:
• Kidney Community Emergency Response
Coalition3
• CMS4
• US Department of Health and Human Services
Assistant Secretary for Preparedness and
Response Technical Resources, Assistance
Center, and Information Exchange (ASPR/
TRACIE)5
• Centers for Disease Control and Prevention
(CDC)6
Many individual dialysis organizations also provide
emergency preparedness resources for providers
in their system or network. For the most current
information, please refer to the individual organi-
zation’s website.
 54 | Section 9: Emergency Preparedness
Infection Prevention and
Control
Infection prevention and control after an emergen-
cy or disaster are of great concern and may be
complicated by the potential lack of resources,
such as power and water, and by interruptions
in supply chains. The CDC provides excellent
resources to guide dialysis providers after an
emergency.7
Outbreaks and Emerging Infections
As emerging infections are identified in the United
States, dialysis facilities must be prepared to
prevent their introduction into and transmission
within the facility. Examples of recent emerging
infections include severe acute respiratory syndrome
(SARS), Zika virus, Ebola, and, most recently,
SARS-CoV-2 (COVID-19). It is essential for dialysis
providers to address the possibility of emerging
infections in their emergency preparedness plans.
The evolving SARS-CoV-2 pandemic has led to
specific challenges within outpatient dialysis
facilities across the United States. Some of these
challenges include the conjugate nature of the
dialysis setting and the immunocompromised
status of individuals with chronic kidney disease.
The CDC has developed interim Guidance for
Infection Prevention and Control Recommenda-
tions for Patients with Suspected or Confirmed
COVID-19 in Outpatient Hemodialysis Facilities.8
The outpatient dialysis setting poses unique
challenges for containing the transmission of
infections. Beginning in the waiting room, patients
are most likely in direct contact with each other
prior to their dialysis treatment. Generally, dialysis
stations are close together, staff care for multiple
patients at one time, and patients with renal
disease are immunocompromised. In addition, in
most cases, patient assessment may not occur
until the patient has passed through the waiting
room, has crossed through the dialysis facility, and
is sitting in their dialysis station; as a result, a
contagious patient could potentially infect many
people along their path.
Dialysis providers must employ a process to
mitigate harm to their patients and staff from
potential infection transmission within their
organizations. One option for dialysis facilities is to
look to the innovations in public health, including
resources developed during the Ebola outbreak in
2014. Koening has described a process that helps
providers identify, isolate, and inform others about
a potential emergent infection:9
• Identify using screening methods applicable to
the suspected infection; fever screening may not
be enough in all cases. Examine all potential
exposures, physical signs, and symptoms.
• Isolate potentially infected persons until a
diagnosis is made or the person is cleared.
Ensure the efficient use of personal protective
equipment and hand hygiene.
• Inform local authorities (health department), the
medical director, supervisors, staff, and any
emergency personnel who may assist in the
situation to prevent additional transmission.
Emerging infections may have varied and evolving
features, and each type of potential infection will
need to be investigated individually for appropriate
interventions. It is essential to ensure that processes
are put in place prior to a disaster or outbreak to
protect patients and staff. Medical directors and
infection preventionists need to prepare their
dialysis facilities for the next emerging threat by
having a plan in place for spatial separation of
patients, communication plans with public health
and other local healthcare facilities, and emergency
staffing (as staff may be unable or afraid to come
into work), as well as coordination with local
disease experts.10,11 These plans should be used
along with specific facility activities required by
CMS emergency preparedness regulations.12
References
1. Centers for Medicare & Medicaid Services.
Emergency preparedness rule. Last updated
December 1, 2021. Accessed January 4, 2022.
https://www.cms.gov/Medicare/Provider-En-
rollment-and-Certification/SurveyCertEmerg-
Prep/Emergency-Prep-Rule
 55 | Section 9: Emergency Preparedness

2. Centers for Medicare & Medicaid Services 8. Centers for Disease Control and Prevention.
Quality, Safety, & Education Portal. Emergency Interim additional guidance for infection
preparedness basic training. Accessed January prevention and control recommendations for
4, 2022. https://qsep.cms.gov/pubs/ClassInfor- patients with suspected or confirmed
mation.aspx?cid=0CMSEmPrep_ONL COVID-19 in outpatient hemodialysis facilities.
Updated December 17, 2020. Accessed
3. Kidney Community Emergency Response
January 4, 2022. https://www.cdc.gov/corona-
Coalition. Accessed January 4, 2022. https://
virus/2019-ncov/hcp/dialysis.html
www.kcercoalition.com
9. Koenig KL. Identify, isolate, inform: a
4. Centers for Medicare & Medicaid Services
3-pronged approach to management of public
Quality, Safety & Oversight Group. Emergency
health emergencies. Disaster Med Public
preparedness. Last updated December 1, 2021.
Health Prep. 2015;9(1):86-87. doi:10.1017/
Accessed January 4, 2022. https://www.cms.
dmp.2014.125
gov/Medicare/Provider-Enrollment-and-Certi-
fication/SurveyCertEmergPrep 10. Gorman G. Chapter 16: Preparedness for
emergency threats. In: Nephrologists Trans-
5. US Department of Health and Human Services
forming Dialysis Safety (NTDS): A Curriculum
Assistant Secretary for Preparedness and
to Achieve Zero Preventable Infections.
Response. Technical Resources, Assistance
American Society of Nephrology. Accessed
Center, and Information Exchange. Accessed
January 4, 2022. https://www.asn-online.org/
January 4, 2022. https://asprtracie.hhs.gov
ntds/olm.aspx
6. Centers for Disease Control and Prevention.
11. American Society of Nephrology. COVID-19
Dialysis after a disaster. Last reviewed April 27,
toolkit for nephrology clinicians: preparing for
2015. Accessed January 4, 2022. https://www.
a surge. Accessed January 4, 2022. https://
cdc.gov/disasters/dialysis.html
www.asn-online.org/covid-19/toolkit
7. Centers for Disease Control and Prevention.
12. Centers for Medicare & Medicaid Services.
Infection control after a disaster. Last reviewed
Emergency preparedness for dialysis facilities:
September 5, 2017. Accessed January 4, 2022.
a guide for chronic dialysis facilities. Accessed
https://www.cdc.gov/disasters/infectioncon-
January 4, 2022. https://www.cms.gov/
trol.html
medicare/end-stage-renal-disease/esrdnet-
workorganizations/downloads/emergencypre-
parednessforfacilities2.pdf
 56 | Section 10: Peritoneal Dialysis
SECTION 10:
PERITONEAL DIALYSIS
Peritoneal dialysis (PD) is the most common home
dialysis therapy in the United States. In addition, it
is increasingly being used in acute care as an
alternative to hemodialysis for patients with acute
kidney injury (AKI).1,2 PD uses the membrane that
lines the abdominal cavity (peritoneum) for
diffusion and removal of toxins, electrolytes, and
excess fluids from the body. It requires the inser-
tion of a catheter into the abdominal cavity for
repeated infusion and drainage of dialysate.
Dialysate
PD dialysate is commercially available premixed,
and the solution is sterile. Prior to use, the bags
should be inspected for cracks and leaks, as well as
particulate matter within the solution. The expira-
tion date should also be checked. If the dialysate is
expired or contains particulates, or the bag is
damaged, the dialysate should not be administered.
A dry heating method such as a warming cabinet
or heating pad is often used to warm dialysate
prior to infusion.
There are different types of PD therapy available,
and they may require either intermittent or
continuous presence of dialysate in the abdomen.
Dialysate may be transferred either manually or
with a machine.
Home Peritoneal Dialysis
Home PD offers a great deal of flexibility and
control for dialysis patients because the treatments
may be administered in any location where aseptic
technique can be maintained. PD is completed
through a series of exchanges, which is the
process for filling and draining the abdominal
cavity for prescribed periods at prescribed intervals.
Continuous ambulatory peritoneal dialysis (CAPD)
is done without the use of machines. Exchanges
occur via the catheter, with gravity used to assist
with the instillation and drainage of the dialysate.
While the dialysate dwells within the abdomen, the
patient may go about their normal daily activities.
Automated peritoneal dialysis (APD) is done at
home using a machine called a cycler. APD is
similar to CAPD, except APD exchanges are made
via the cycler machine throughout the night while
the patient sleeps.
Infectious Complications
Peritonitis is one of the most common infections in
PD patients because of the presence of a catheter
in the normally sterile abdominal cavity. Signs and
symptoms of peritonitis in a PD patient include
abdominal pain, fever, cloudy dialysate, or a
positive Gram stain/culture of dialysate. PD
patients who experience repeated or severe
peritonitis may need to be permanently switched
to hemodialysis.
Other common infections include exit-site infections,
which may present with redness, tenderness, or
drainage at the exit site, and subcutaneous tunnel
infections, which will present with similar signs and
symptoms in the subcutaneous tissue.
Most infections associated with PD are due to
catheter placement and maintenance. Research
indicates that the risk for PD-associated infections
does not differ significantly with various catheter
designs.3
Because the patient or caregiver is the primary
administrator of the peritoneal catheter after
placement, it is important to educate them about
aseptic technique and proper exchange of dialysate,
as well as how to monitor for infection. Patients
 57 | Section 10: Peritoneal Dialysis

and caregivers should be instructed to contact
their provider at the first sign of infection.
Facilities should monitor rates of peritonitis to
inform infection prevention activities. The Interna-
tional Society for Peritoneal Dialysis has definitions
for peritonitis that can be adapted for surveillance
at the facility.4 Table 10.1 reviews strategies for
infection prevention in patients receiving PD.3-5

Table 10.1. I nfection Prevention Strategies for Peritoneal Dialysis Patients

Strategy Method Notes

Prophylaxis • Administer a single-dose
antibiotic immediately
before catheter insertion.
Surgical insertion • Place catheter in an • A minimally invasive approach results in higher
approach accessible location for the 1-year catheter survival rate and less-frequent
patient; consider dominant catheter migration, compared to laparotomy.3
hand. • No significant differences in the rate of
• Avoid placing catheter in peritonitis or exit-site infections were observed
skin folds and at the when laparoscopy was compared with
beltline. standard laparotomy or when subcutaneous
catheter insertion was used.3
MRSA screening • Routinely screen PD • Nasal carriers of S. aureus have an increased
patients for risk of exit-site infections and peritonitis.3
Staphylococcus aureus. • If nasal carriage of S. aureus is found in PD
patients, nasal application of mupirocin is
recommended.4
Antimicrobial ointment • Use a topical application • This is recommended for all patients.
of antibiotic on the
catheter exit site.
Prophylactic antifungal • Monitor PD program’s
history of fungal peritonitis
and decide whether an
antifungal with antibiotic
protocol would be
beneficial, particularly for
patients taking prolonged
or frequent courses of
antibiotics.
Patient education and • Provide continuing • Teach back methods can help ensure
compliance5 education on proper understanding.
catheter and exit-site care
for patients.
• Instruct patients in hand
hygiene, and the difference
between clean and sterile.
• Instruct patients about the
various ways that bacteria
may enter the abdominal
cavity.
• Document and reinforce
education at each
encounter.

Abbreviations: MRSA, methicillin-resistant Staphylococcus aureus; PD, peritoneal dialysis.

 58 | Section 10: Peritoneal Dialysis

Acute Peritoneal Dialysis asepsis during the PD procedure, including

connection, disconnection, and PD catheter care,
Acute PD may be the best option for a critically ill can help prevent peritonitis.
patient with AKI (Table 10.2).6,7 Strict adherence to

Table 10.2. S
 pecial Considerations for Acute Peritoneal Dialysis

Topic Description
Indications and • Indications: AKI if patient is hemodynamically unstable or experiencing
contraindications coagulopathy, or if HD and CRRT are not available.6
• Contraindications: Abdominal surgery, severe respiratory failure, pleural-
peritoneal fistula, rapidly rising potassium, intra-abdominal sepsis, or
abdominal wall cellulitis.6
Complications • Compared with HD or hemofiltration patients, patients receiving acute PD
are at increased risk for:
– Peritonitis
– Mechanical complications
– Protein loss
– Hyperglycemia
Access • The PD catheter, typically placed in surgery, provides access.
• Asepsis during catheter insertion and care is critical to prevent peritonitis.
• There is a risk of mechanical issues with PD catheters.
• Safety of handling and disposal of effluent should be assessed.
Staffing • Expertise is required to manage acute PD.
COVID-19 • Acute PD may be especially useful during the COVID-19 pandemic because it
may reduce strain on HD and CRRT resources in critical care.
Other • Compared with HD and CRRT, acute PD uses fewer consumables and
therefore is a less costly procedure.

Abbreviations: AKI, acute kidney injury; CRRT, continuous renal replacement therapy; HD, hemodialysis; PD, peritoneal
dialysis.

References
1. Cullis B, Al-Hwiesh A, Kilonzo K, et al. ISPD
guidelines for peritoneal dialysis in acute
kidney injury: 2020 update (adults). Perit Dial
Int. 2021;41(1):15-31.
doi:10.1177/0896860820970834
2. Chen W, Caplin N, El Shamy O, et al. Use of
peritoneal dialysis for acute kidney injury
during the COVID-19 pandemic in New York
City: a multicenter observational study. Kidney
Int. 2021;100(1):2-5. doi:10.1016/j.
kint.2021.04.017
3. Kitterer D, Latus J, Alscher M, Kimmel M.
Causative organisms and recommended
treatment options. In: Ekart R, ed. Some
Special Problems In Peritoneal Dialysis. Rijeka,
Croatia: SPI Global; 2016:95-110.
4. Szeto CC, Li PK, Johnson DW, et al. ISPD
catheter-related infection recommendations:
2017 update. Perit Dial Int. 2017;37(2):141-154.
doi:10.3747/pdi.2016.00120
5. Figueiredo AE, Bernardini J, Bowes E, et al. A
syllabus for teaching peritoneal dialysis to
 59 | Section 10: Peritoneal Dialysis

patients and caregivers. Perit Dial Int.

2016;36(6):592-605. doi:10.3747/
pdi.2015.00277
6. Cullis B, Abdelraheem M, Abrahams G, et al.
Peritoneal dialysis for acute kidney injury. Perit
Dial Int. 2014;34(5):494-517. doi:10.3747%2Fp-
di.2013.00222
7. Srivatana V, Aggarwal V, Finkelstein FO,
Naljayan M, Crabtree JH, Perl J. Peritoneal
dialysis for acute kidney injury treatment in
the United States: brought to you by the
COVID-19 pandemic. Kidney360.
2020;1(5):410-415. doi:10.34067/
KID.0002152020
 60 | Section 11: Infection Prevention Considerations for Special Populations

SECTION 11:
INFECTION PREVENTION CONSIDERATIONS
FOR SPECIAL POPULATIONS

Pediatric Patients Because the number of pediatric-only HD centers

is small, travel distance prohibits many patients
In 2019, approximately 13 million children in the from receiving care at one of these centers. Many
United States were treated for chronic kidney hemodialysis centers dialyze only 1 or 2 pediatric
disease (CKD).1 Kidney transplant is the ideal patients in addition to their adult patients. Approx-
therapy for pediatric patients with G5 (CKD stage imately 75 US dialysis centers perform HD for 3 or
5). (See Section 1, Table 1.2 for information on CKD more children.2
staging.) While awaiting a transplant, hemodialysis
Like other patients, pediatric patients may change
(HD) or a peritoneal dialysis (PD) modality (con-
treatment modality (e.g., from PD to HD) or return
tinuous ambulatory peritoneal dialysis [CAPD] or
to in-center HD after a kidney transplant failure.
continuous cycler-assisted peritoneal dialysis
Table 11.1 describes some infection prevention and
[CCPD]) may be initiated. Many patients receive
control considerations for pediatric patients
dialysis at home, most commonly PD; however,
receiving in-center dialysis.3-9
significant training and certain basic setup require-
ments are necessary to perform dialysis procedures
safely in the home, so in-center dialysis is an option.

Table 11.1. Special Considerations for Pediatric In-Center Hemodialysis

Topic Description
Vascular access • Catheter access presents higher risk for infection than fistula or graft
access.3,4
• Skin is fragile, and skin integrity can be easily disrupted by frequent
exposure to dressings and antiseptics.5
• Children may pull at or manipulate external devices such as catheters.
• Small caliber vasculature can create flow and functional issues for
dialysis catheters.
• Vein preservation is critical for supporting a lifetime of kidney
replacement therapy.
• It may be technically difficult to create a fistula for small children or
infants.
• Venipuncture pain can be a barrier to having a fistula or graft.
Dialysis water and equipment • Due to risk of hypovolemia, the child’s size is considered in the
selection of extracorporeal components.
Care environment • Pediatric care team members (e.g., child social worker, child
psychologist, school support person, play therapist) will need relevant
infection prevention and control education.
 61 | Section 11: Infection Prevention Considerations for Special Populations

Topic Description
Linen, waste, environmental • If toys, electronic devices, or other objects given for diversional
hygiene activity are used by multiple patients, they must be cleaned and
disinfected between uses.
Staffing • Regular adult dialysis staff may not have pediatric nursing experience.
Disease origin • The underlying cause of CKD in pediatric patients is typically an
acquired or congenital condition.6
Patient outcomes • Best survival rates occur with transplantation. The patient’s age at
initiation of dialysis will affect survival rate.7,8
• Multiple hospitalizations and multiple kidney transplants are not
uncommon.
• Physical growth is poor.
Vaccinations • Recommended vaccines include those recommended for CKD and
kidney dialysis patients as well as the childhood vaccines.9

Abbreviation: CKD, chronic kidney disease.

Notable Pediatric Infection Risks Environment

Like adults, pediatric CKD patients are at risk for
infection due to their compromised immune
systems, frequent exposure to hospital settings,
and vascular access. Catheter access infections
have been well described.3,4
It is of the utmost importance to preserve pediat-
ric vasculature because patients may require renal
replacement therapy for their lifetime. The ideal
vascular access for children is a surgically created
fistula or graft; however, in small children or
infants, creation of arteriovenous access in a
small-caliber vein may be technically challenging.
In addition, skin integrity at the catheter exit site
may become compromised due to the child’s
sensitive or fragile skin, leading to increased
infection risk. Skin can become red, broken, or
irritated from regular and frequent exposure to
skin antiseptics or adhesives during dressing
changes.5
Children are at risk from community-acquired
illnesses and should be offered recommended
vaccines.5,9
Care environment factors (such as patient place-
ment, sharps containers, personal protective
equipment, and storage of low- or intermediate-
level cleaning and disinfection products) are the
same as for adult HD. Machine care and water
system maintenance are also the same as for
adult HD.4
The pediatric environment may include a play-
room, or it may offer objects for diversional
activities such as books, electronic devices, or
toys. It is best to use disposable items or restrict
items to a single patient’s use. If diversionary items
are touched by multiple persons, they (like other
objects) should be cleaned and disinfected
between users.4
Finally, expect increased visitor traffic because of
the presence of parents or family. Infection pre-
vention policies must be effectively communicated
to visitors.
Pediatric Care Team
The pediatric care team may include a child social
worker, child psychologist, play therapist, or other
specialized team members. These individuals likely
do not perform invasive procedures, but they will
 62 | Section 11: Infection Prevention Considerations for Special Populations
need infection prevention strategies relevant for
their work with the patients in the dialysis center.
Kidney Transplant Recipients
Kidney transplant is the treatment of choice for
patients with CKD. Transplant recipients will have
markedly decreased mortality as compared to
patients on HD. However, dialysis is often still
required in patients who are awaiting transplant,
or after transplant if the kidney does not efficiently
work immediately. Additionally, transplant patients
may re-enter the HD setting if the new kidney graft
fails or is rejected by the host immune system.
Patients who receive a kidney transplant should
be closely monitored for signs and symptoms of
infection and provided adequate education to
reduce their infection risk. Transplant recipients
are prescribed immunosuppressant medications to
prevent rejection of the kidney allograft, but these
drugs may interfere with their natural immunity,
making patients more susceptible to infections.
To combat this altered immunity, most patients are
prescribed antibacterial, antiviral, and antifungal
medications to prevent contracting harmful
infections.
Among all infections, viruses are considered the
most common because of their abundance,
infectivity, and latency ability. Well-known viral
infections in kidney transplant patients include
herpes simplex virus, varicella zoster virus, Epstein-
Barr virus, cytomegalovirus, hepatitis B virus, BK
polyomavirus, and adenovirus.10
References
1. US Renal Data System. 2019 USRDS annual
data report: epidemiology of kidney disease in
the United States. National Institute of Diabe-
tes and Digestive and Kidney Diseases.
Accessed January 5, 2022. https://www.usrds.
org/media/2371/2019-executive-summary.pdf
2. Centers for Medicare & Medicaid Services.
Dialysis Facility Compare, Data Set: Dialysis
Facility-Facility Listing, Column AR. Last
updated September 17, 2020. Accessed
January 5, 2022. https://data.medicare.gov/
data/archives/dialysis-facility-compare
3. Nguyen DB, Arduino MJ, Patel PR. Hemodialy-
sis-associated infections. In Chronic Kidney
Disease, Dialysis, and Transplantation, 4th ed.
Philadelphia, PA: Elsevier; 2019:389-410.e8. doi:
10.1016%2FB978-0-323-52978-5.00025-2
4. Centers for Disease Control and Prevention.
Dialysis safety: guidelines, recommendations
and resources. Last reviewed November 17,
2017. Accessed January 5, 2022. https://www.
cdc.gov/dialysis/guidelines/index.html
5. West K, Nyquist AC, Bair T, Berg W, Spencer S.
Pediatrics. In APIC Text Online. Published 2014.
Accessed January 5, 2022. https://text.apic.
org/toc/infection-prevention-for-special-
ty-care-populations/pediatrics
6. National Institute of Diabetes and Digestive
and Kidney Diseases. Kidney disease in
children. Last reviewed March 2014. Accessed
January 5, 2022. https://www.niddk.nih.gov/
health-information/kidney-disease/children
7. North American Pediatric Renal Trials and
Collaborative Studies. 2011 annual dialysis
report. Accessed January 5, 2022. https://
naprtcs.org/system/files/2011_Annual_Dialy-
sis_Report.pdf
8. Samuel S, Tonelli M, Foster B, et al. Survival in
pediatric dialysis and transplant patients. Clin
J Am Soc Nephrol. 2011;6(5):1094-1099.
doi:10.2215/CJN.04920610
9. Centers for Disease Control and Prevention.
Guidelines for vaccinating kidney dialysis
patients and patients with chronic kidney
disease. Published 2012. Accessed January 5,
2022. https://www.cdc.gov/dialysis/PDFs/
Vaccinating_Dialysis_patients_and_patients_
dec2012.pdf
10. Vanichanan J, Udomkarnjananun S, Avihingsa-
non Y, Jutivorakool K. Common viral infections
in kidney transplant recipients. Kidney Res Clin
Pract. 2018;37(4):323-337. doi:10.23876/j.
krcp.18.0063
 63 | Section 12: Bringing It All Together
SECTION 12:
BRINGING IT ALL TOGETHER:
IMPLEMENTATION STRATEGIES
Dialysis is a life-saving intervention for persons
with end-stage kidney disease (ESKD). Significant
improvements have been made in the dialysis
process over the past several decades, which has
resulted in increased survivability for patients on
dialysis. Despite these improvements, infection
continues to be a major cause of morbidity and
mortality in the ESKD patient population. Over the
past 2 decades, several agencies and work groups
have published guidelines to help reduce the risk
of infection in the dialysis setting. However,
research has shown that these interventions are
not uniformly implemented or followed in dialysis
facilities.1 Use of an organized framework such as
the Agency for Healthcare Research and Quality
Safety Program for End-stage Renal Disease
Facilities Toolkit2 can help dialysis programs
prevent healthcare-associated infections (HAIs)
through attention to the culture of safety. It is
important to have a comprehensive, unit-based
safety culture in place to not only improve practice
but also modify the beliefs and attitudes in the
unit to effect real change.
The 4Es
Many of the infection prevention techniques
discussed in this guide can be organized under the
concepts known as the 4Es—engage, educate,
execute, and evaluate3—which collectively form an
effective model for implementing quality improve-
ment initiatives and evaluating effectiveness. Using
the 4Es method to implement the strategies
contained in this guide can help to build an
effective and sustainable infection prevention
program.
Engage
During this stage, key stakeholders are engaged to
actively support quality improvement initiatives
and goals through sharing data and practice gaps.
Strategies include:
• Gaining the support of senior leadership
• Identifying unit champions
• Using multidisciplinary teams
• Adopting evidence-based practices
• Focusing on the culture of safety
Educate
This next phase includes education about practic-
es shown to prevent infection in the dialysis
population. Strategies include:
• Aligning infection prevention education for all
levels of staff
• Assessing staff competency on hire and annually
• Providing one-on-one education when a gap is
identified
• Educating staff about the science of safety
• Educating patients and caregivers about infec-
tion prevention
Execute
This phase focuses on removing barriers and
improving adherence to evidence-based practices
to reduce the risk of infection in the dialysis
setting. Strategies include:
• Differentiating target interventions between
special populations
• Using standardized checklists for catheter
connections, disconnection, exit-site care,
station cleaning, and medication administration
• Using information technology innovations to
 64 | Section 12: Bringing It All Together

simplify and standardize documentation tools to evaluate performance of hand hygiene,

• Participating in local, regional, or national
collaboratives such as the Centers for Disease
Control and Prevention (CDC) initiative Making
Dialysis Safer for Patients4
• Using order sets such as those used to stan-
dardize screening and immunization
Evaluate
This phase focuses on determining the effective-
ness of interventions and adherence to standards
using measurement and evaluation tools. Strate-
gies include:
• Reporting events to the National Healthcare
Safety Network5
• Integrating the dialysis-focused program into an
existing quality assessment and performance
improvement program
exit-site care, connection and disconnection of
dialysis lines, medication administration, and
station cleaning
• Providing performance feedback to leaders and
staff
• Establishing benchmarks for long-term compari-
sons
• Using outcome measures to shift or modify
prevention activities
Accountability
Accountability is essential to the prevention of
HAIs. Each member of the dialysis team has a
responsibility to ensure that evidence-based
prevention practices are in place and followed to
protect patients from avoidable harm (Table 12.1).

• Using direct observation of practice and audit

Table 12.1. Accountability of Healthcare Personnel in Preventing Healthcare-Associated Infections

(HAIs) in Dialysis

Role Responsibilities
Senior leadership • Ensure that the infection preventionist or designee is adequately trained
• Ensure that there are adequate resources for an effective infection prevention and
control program
• Provide the imperative for HAI prevention by making it an organizational priority
• Ensure all personnel are competent to perform their assigned duties
Unit leadership • Identify highly engaged staff and physicians to be champions of HAI prevention
• Hold personnel accountable for their practice
• Ensure that adequate training is provided on hire
• Periodically assess competence
Direct caregivers • Practice proper infection prevention and control principles at all times
• Engage patients and caregivers in techniques to prevent infection
Infection • Ensure that there is an active surveillance program in place to detect HAIs
preventionist/ • Analyze surveillance data and provide feedback to stakeholders
designee
• Ensure that evidence-based practices are incorporated into the infection
prevention and control program
• Evaluate effectiveness of infection prevention and control interventions
• Develop appropriate infection prevention and control education and training for
staff, patients, and caregivers
 65 | Section 12: Bringing It All Together
Multidisciplinary Teams and
Collaboration
There are numerous examples in the literature of
successful multidisciplinary team efforts in various
care settings to plan, develop, implement, and
evaluate the effectiveness of interventions to
prevent HAIs. The dialysis infection prevention
team, too, should be multidisciplinary to reflect the
nature of the care provided.
In the acute care setting, this team is often led by
a dedicated infection preventionist (IP) or a
hospital epidemiologist. Dialysis centers that are a
part of the hospital system will often benefit from
the advanced training and expertise of the IP
when building their infection prevention and
control program, although the IP may lack exper-
tise specific to dialysis.
In contrast, building an effective infection preven-
tion and control team at freestanding centers may
be more challenging. Dialysis settings that are not
a part of an acute care hospital may not have a
dedicated IP and instead may have a person
delegated to the role. This person will typically
lack advanced training and expertise in infection
prevention and control.
One of the principal aims of this guide is to
provide tools and resources for the non-IP who is
designated to lead the infection prevention and
control team so they can successfully build and
implement an effective program. Another principal
aim is to provide dialysis-specific infection preven-
tion and control techniques for the IP who is not
trained in dialysis. IPs are increasingly being
consulted for their expertise by centers or collabo-
rative projects aiming to improve practices and
outcomes in dialysis facilities. At times, IPs may
feel hesitant to participate in such initiatives
because they fear that a lack of dialysis-specific
knowledge is a hinderance. However, IPs are
essential members of the multidisciplinary team.
Read more about this collaborative and the tools it
developed in the Fall 2020 issue of Prevention
Strategist magazine.6
The following one testimonial from an IP
who joined a multidisciplinary dialysis team:
When I was
asked to
become the
liaison with
our outpatient
dialysis center,
I felt hesitant
due to a
knowledge
deficit. I reached out to fellow infection
preventionists (IPs) for guidance and was
brought into a collaborative that focuses
on standardizing practices in pediatric
dialysis. This collaborative is predominantly
attended by nephrologists and other
dialysis specialists. To inspire greater IP
presence, my colleagues and I created a
tool to help provide guidance for IPs in this
specialty area. Our development and
feedback group included dialysis leaders
and IPs from multiple hospitals across the
United States. We received input from this
group and successfully created a rounding
tool that is now used by both IPs and
dialysis staff. Although our initial goal was
to create a tool to inspire more involve-
ment by IPs in dialysis, our collaborative
effort with dialysis specialists created a
tool that can be used by their staff as well
as IPs. The greatest benefit this has is the
increased awareness and improved infec-
tion prevention practices in this high-risk
population of patients.
—J. Rindels, MBA, BSN, RN, CIC
References
1. Chenoweth CE, Hines SC, Hall KK, et al.
Variation in infection prevention practices in
dialysis facilities: results from the National
Opportunity to Improve Infection Control in
ESRD (end-stage renal disease) Project. Infect
 66 | Section 12: Bringing It All Together

Control Hosp Epidemiol. 2015;36(7):802-806.

doi:10.1017/ice.2015.55
2. Agency for Healthcare Research and Quality.
AHRQ Safety Program for End-Stage Renal
Disease Facilities—toolkit. Last reviewed
January 2015. Accessed January 5, 2022.
https://www.ahrq.gov/patient-safety/settings/
esrd/resource.html
3. Pronovost PJ, Berenholtz SM, Needham DM.
Translating evidence into practice: a model for
large scale knowledge translation. BMJ.
2008;337:a1714. doi:10.1136/bmj.a1714
4. Centers for Disease Control and Prevention.
Making Dialysis Safer For Patients Coalition.
Last reviewed February 14, 2020. Accessed
January 5, 2022. https://www.cdc.gov/dialysis/
coalition/index.html
5. Centers for Disease Control and Prevention.
National Healthcare Safety Network. Accessed
January 3, 2022. https://www.cdc.gov/nhsn/
index.html
6. Rindels J. Building bridges between IPC and
dialysis units. Prevention Strategist 2020;13(3).
https://rise.apic.org/web/apic/publications/
issue.aspx?issueId=prevention_strategist_
fall_2020&issueTitle=Prevention%20Strate-
gist—Fall%202020
1400 Crystal Drive, Suite 900
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