Adherence to US Center for Disease Control and Prevention infection control guidelines in the haemodialysis care unit at Dar Al-Shifa Hospital in the Gaza Strip: a clinical audit

Abstract

BackgroundInfection is the most common cause of admission to hospital and the second most common cause of mortality in patients requiring renal haemodialysis, who have an increased risk of infection due to frequent use of intravenous cannulas or catheters. This audit aimed to assess current clinical practice at a dialysis unit in the Gaza Strip by use of the US Center for Disease Control and Prevention's guidelines for asepsis when dealing with haemodialysis catheters. MethodsA clinical audit was done at the haemodialysis unit of the Dar Al-Shifa Hospital. Data were collected in four categories: first, haemodialysis catheter connection and disconnection; second, haemodialysis catheter exit site care; third, dialysis station routine disinfection; and fourth, haemodialysis injectable medication preparation and administration. There was no overlap between the four groups. A data collection sheet was adopted from US Center for Disease Control and Prevention guidelines and data were collected prospectively between April and November, 2018, through direct observation of care by ML. FindingsThe total number of patients seen was 250, and the total number of dialysis station routine disinfection sessions observed was 20. In the first category of data (haemodialysis catheter connection and disconnection; n=100 patients), adherence to hand hygiene by the health-care professional was observed in the care of 3 (3%) patients, and adherence to the use of gloves by the health-care professional was seen with 14 (14%) patients. With 74 (74%) of the patients, catheters were connected aseptically from blood lines, and for 58 (58%) patients, catheters were disconnected aseptically from blood lines. After catheter disconnection, adherence to catheter clamping and cap removal was seen for 98 (98%) patients, but only for 34 (34%) patients were catheters attached to new caps aseptically during disconnection. In the second category (catheter exit site care; n=50 patients), adherence to hand hygiene by the health-care professional was seen for the care of one (2%) patient, adherence to the use of gloves was seen for one (2%) patient, and application of skin antiseptics and of antimicrobial ointments was not observed. Moreover, for 35 (70%) patients, procedures were done with no direct contact with the catheter exit site, and for 40 (80%) patients, dressings were applied aseptically. In the third category (dialysis station routine disinfection; n=20 sessions), the adherence to guidelines for catheter disconnection and removal of used blood tubes and dialysers from the machine, disposal in a leak-proof container, and confirmation of patient exit from the dialysis station before beginning routine disinfection of the dialysis station was 100%. However, adherence to confirmation that no visible blood or other contaminants remained on surfaces and that the priming bucket had been emptied was 0%. Additionally, adherence to application of disinfectants to all surfaces in the dialysis station after the patient had left the station was observed after the care of 18 (90%) patients, and adherence to the use of gloves and hand hygiene by the health-care professional was seen after the care of six (3%) patients. In the fourth category (haemodialysis injectable medication preparation and administration; n=100 patients), adherence to the use of new needles and syringes, preparing medications aseptically, and safely discarding vials in the sharp box was done for 100 (100%) patients. During administration, adherence to aseptic attachment of syringes and administration of medication was observed for the care of 80 (80%) patients, and adherence to aseptic disposal was observed for the care of 100 (100%) patients. However, there was no adherence to the use of gloves and hand hygiene. InterpretationHealth-care staff at Dar Al-Shifa Hospital showed good adherence to guidelines in some aspects of care, such as in preparation and administration of medications and in the cleaning of dialysis machine surfaces and stations, but poor adherence to hand hygiene, use of gloves, and application of aseptic dressings was poor. Poor adherence to safety of care can negatively affect overall health outcomes for patients requiring haemodialysis. We recommend staff training on the aseptic aspects of care during and after haemodialysis, and re-audits for the evaluation of the desired optimal outcomes.