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Dialysis Turn
Over
Special Edition
March 11, 2009
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Welcome to this special edition of
Dialysis Turn Over, a
dedicated dialysis management newsletter. We hope to keep you
informed of breaking news of importance to dialysis
administrators.
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Dialysis Unit Closed After
Hepatitis C Outbreak
A
The state survey found multiple deficiencies in
infection control practice, including the
following:
The unit did not obtain confirmatory
testing for anti-HCV positive results, inform patients of their change in
HCV infection status, or report HCV seroconversions to the local health
department.
The unit did not provide patients
with medical evaluation related to HCV
infection.
Contrary to CDC recommendations,
monthly alanine aminotransferase (ALT) levels were not obtained from
>90% of HCV-susceptible patients, and anti-HCV testing, although
conducted on most patients, was performed at intervals ranging from once
per month to once per 2 years rather than semiannually.
Inadequate cleaning and disinfection
practices were observed during site visits in July and August 2008.
·
A single bleach-soaked gauze
pad was used to clean a patient's entire dialysis station, including
dialysis machine surfaces and ancillary patient equipment (e.g., blood
pressure cuff and shared computer monitor and keyboard).
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Visible blood remained on
dialysis chairs, dialysis machine surfaces, and the surrounding floor
between patient treatments.
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The bleach solution used to
clean machines was prepared and stored improperly, and staff members did
not allow sufficient contact time between surfaces and bleach.
Direct care staff members failed to
don gloves with every patient encounter, change gloves between patients,
or perform hand hygiene after contact with patients and soiled surfaces.
Many of the direct care staff members
were unaware of the hemodialysis unit's written infection control
policies, including those pertaining to cleaning and disinfection.
The surveyors made multiple visits over the summer
of 2008. The infection control problems were not
corrected.
This infection control disaster could well have
been prevented if the unit had self-surveyed. Failure to do so
resulted in at least nine HCV seroconversions since 2001, the loss of
license and closure of the unit, requiring the transfer of 162 patients,
and a hefty fine, not to mention whatever subsequent lawsuits may
follow.
Do you think that self-surveying might have
averted this disaster?
For the full CDC Mortality and Morbidity Weekly
Report,
click
here.
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Thank you for
your business, Judith Filangeri
The opinions expressed herein are those of
the author alone |
