HemoDoc, From Doctor to Patient

The Genius of Stuart Mott: Solving Buttonhole Infections

By Peter Laird, MD

Buttonhole cannulation is an underutilized resource in the hemodialysis setting that recently has come into further question due to studies showing higher rates of infection than standard cannulation techniques. I have long believed that proper hygiene and disinfection can circumvent this higher infection risk leading me to conclude that it simply may be a failure of infection control techniques rather than a failure with buttonhole methodology itself.  Recently, Stuart Mott addressed these issues and developed a new approach and technique that may prove to be the solution to this problem of higher infection rates with the constant site techniques.

Milestone has been reached in buttonhole infections

1. At the end of June 2012 a milestone was reached with 4 000, cannulation of buttonholes. This projected was started in June of 2009 with just two patients and a lot of doters noted at the time. In January of 2010 two more patients where add as a resulted of the first two. No infections and buttonhole integrity remained in tactated.The use of shower scrubbers were initially used but in the summer of 2010 while getting more shower scrubbers at the local Wal-Mart I notice the exfoliating facial buffs. When first trying them out I notice a result that was far better than the shower scrubbers. Faster cleaning and better cleaning of the buttonhole site. The removal of dead skin as well as the oil around the site leads me to believe that his technique was the way to go. Immedelty after using the exfoliating facial buffers the scab remove became the key to the elimination of the infections problem. All the scab material was removed from the buttonhole site and only in rare occasions was there any scab left. What is left is the buttonhole plug. This is removed by using the pickers that come with the needles. 
2. The use of the technique is as followed.  Non-sterile, clean gloves. Cut the pad in half for longer use. You will notice after 30 to 40 uses the pad becomes compacted, it time to use the other half
3. Place the exfoliating facial pad under hot water for 30 to 45 seconds to warm and moisten the pad prior to applying to skin.
4. Apply one to two drops of antibacterial soap to the pad.  Using your fingers spread the soap around on the pad to provide even distribution of the soap.
5. Using a circular motion, the staff or patient scrubs the buttonhole site/scab in a circular motion using moderate pressure approximately 10-12 times.
6.  using a clean paper towel dry the site and throw the paper towel away , don’t use water to rise the site off.
7. Examine site to determine if all scab material around buttonhole site is removed.
8. If scab material remains in the buttonhole track, remove using a sterile needle that is provided in the needle kit.
9. Betadine will be utilized to cleanse buttonhole site immediately prior to cannulation with fistula needles.

Air dry exfoliating pad during treatment by placing pad on top of the dialysis machine.

The lecturer on this infection of buttonholes is limited with in formation. But with this in mind the lowest reported was 0.16 per thousand cannulation(Doss, Schiller, & Moran, 2008; Marticorena et al., 2006, 2009; van Loon, Goovaerts, Kessels, van der Sande, & Tordoir, 2009; Verhallen, Kooistra, & Van Jaarsveld, 2007).  The Mott method for cleaning buttonholes  use somewhat different approach in that it cleans the whole area and not just the area around the buttonhole.

Since February a multiply content approach using this technique is in play, Australia, Canada and Europe are in different phase of getting this approved. The outcomes will be written about in the next year.

Stuart and his team has achieved an incridible 4000 buttonhole cannulations withour a single infection using this novel technique. Stuart is now engaged in an international, multi-center study to validate his initial observations in a study now commencing. Should the initial results Stuart obtained in his home unit be duplicated with a significant reduction in infections, one of the biggest considerations against using buttonhole cannulation will evaporate.

Buttonhole cannulation in my opinion should be the standard of care using Touch Cannulation to eliminate the variance between multiple cannulators. With these preliminary results, Stuart may single handedly be on course to solve the remaining issues that prevent universal acceptance of constant site cannulation which is known to reduce aneurysm development. The results of this ongoing study will hopefully confirm and promote a standard process for scab removal. With over 4000 infection free scab removals and cannulations, it is certainly a process that demands further study.

Dialysis Related Infections: Peritoneal Dialysis Poses more Dangers

By Peter Laird, MD

Every patient with ESRD by law is required to have education at the start of treatment on all of the differing options of renal replacement therapy including in-center conventional hemodialysis, in-center nocturnal hemodialysis, home hemodialysis either short daily, nocturnal and standard, peritoneal dialysis and renal transplantation options.  Each modality carries with it a unique set of risks and benefits that fit the lifestyle choices of individual patients.  One of the major risks of renal replacement therapy no matter the choice are serious infections often requiring hospitalization to treat. The second leading cause of death in dialysis patients is infection causing approximately 15% of all deaths, second only to cardiovascular related deaths. 

Vascular Access-Related Infections: Definitions, Incidence Rates and and Risk Factors

Hemodialysis is associated with a high risk of morbidity and mortality, often caused by infections. Infections account for approximately 15% of all deaths in this patient population (the second leading cause after cardiovascular events) and for about one-fifth of admissions. Approximately one-fourth of infection-related admissions are caused by dialysis-associated peritonitis or vascular access infection that may lead to such significant complications as endocarditis or death.

A recent study by Jean-Philippe Lafrance, MD, of the University of Montreal revealed a surprising finding that peritoneal dialysis patients are at much higher risk of a serious infection requiring hospitalization than hemodialysis patients with access related infections. As recently reported in Renal Urology News, peritoneal dialysis patients had a 51% increased risk of hospitalization from infections compared to a similar hemodialysis control group:

Hospitalization Risk for Infections Higher with PD

Twenty-one percent of the PD patients had been hospitalized once in the previous year (not counting the hospitalization during which dialysis was initiated) compared with 16% of the matched HD patients. PD patients were also more likely than HD patients to have two or more and three or more hospitalizations (8% vs. 5% and 8% vs. 3%, respectively).

PD was associated with a nearly 2.9-fold higher risk compared to HD of hospitalization due to dialysis-related infections, a twofold increased risk of other hospitalizations due to other infections, including a 1.6-fold higher risk of hospitalization due to abdominal infections. However, PD also was associated with 70% and 40% lower probabilities of being hospitalized for septicemia or pneumonia, respectively.

In a previous retrospective cohort study of 168 patients initiating outpatient dialysis (71 on PD and 97 on HD), researchers at Sunnybrook Health Sciences Centre in Toronto found that patients who initiate outpatient PD do not have a significantly increased risk of infection-related hospitalization compared with patients who initiate outpatient HD, according to a report published in Peritoneal Dialysis International (2011;31:440-449). The study, however, showed that patients starting outpatient treatment on PD were significantly more likely than those starting on HD to be hospitalized for peritonitis.

The risks of peritoneal dialysis vs. hemodialysis must be assessed and weighed against the intended benefits  of PD which includes ease of use, independence, greater mobility, fewer dietary restrictions, preservation of residual renal function and no need for vascular access. Researchers need to evaluate and develop further strategies to prevent PD related infections to maximize the benefits of this treatment option that many patients prefer over hemodialysis. The quest for the perfect renal replacement treatment options continues unabated but remains still in the future. 

For patients initiating dialysis, adherence to proper technique can further diminish infection risks but cannot eliminate them completely no matter how diligent and careful the practitioner is. Infection is a reality that all that have ESRD must consider and design their technique with that sobering thought in mind. Many patients have successfully avoided any infection for years, but with the nature of chronic kidney disease and poor immune function, we shall always be at higher risk that the general population. Certainly it is true however that we can do much better than we do today most often by failing to promote and practice safe and proper infection control techniques. Sadly, one of the greatest failures found during state and CMS inspections is improper hand hygiene and infection control. We can and must do better. Proper technique does lend optimism to infection avoidance as many patients doing self care can testify.

Choosing which modality is best for any given patient comes down to personal preference in many instances. The goals of therapy should not only be ease of use but consider all aspects especially in reguard to survival and avoiding hospitalizations. Despite the many benefits of PD, the infection risk is and has been one of the most difficult issues to resolve.

Clostridium difficile Infections Spreading Throughout Health Care Facilities

By Peter Laird, MD

Infectious diseases around the world are becoming more common and prevalent due in large part to the lax hand hygiene standards among health care professionals. One serious infection on the rise throughout America is Clostridium difficile (C. Diff) that causes diarrhea and other serious complications. It is an insidious organism that is easily passed from objects and staff who fail to wash their hands. Sadly, proper hand hygiene and judicious use of bleach on points of contact essentially limits all risks from this growing pathogen that is now becoming resistant to all antibiotics:

Making Health Care Safer: Stopping C. difficile Infections

People getting medical care can catch serious infections called health care-associated infections (HAI). While most types of HAIs are declining, one – caused by the germ, C.difficile – remains at historically high levels.C. difficile causes diarrhea linked to 14,000 American deaths each year. Those most at risk are people, especially older adults, who take antibiotics and also get medical care. When a person takes antibiotics, good germs that protect against infection are destroyed for several months. During this time, patients can get sick from C.difficile picked up from contaminated surfaces or spread from a health care provider's hands. About 25% of difficile infections first show symptoms in hospital patients; 75% first show in nursing home patients or in people recently cared for in doctors' offices and clinics.

As the armaments against infectious disease are rendered ineffective from resistance, returning to simple and capable cleaning measures is once again at the forefront of our defenses against these agents. The specter of disease in this case is not only a danger to patients, but to health care professionals as well. At some point, the realization that health care workers who fail to protect their patients by proper hand hygiene and environmental cleaning of patient rooms will also place themselves at risk as well as their families with these easily transmitted pathogen. Once again, it is not a high tech solution that shall reduce this spread, but only simply following basic hygiene guidelines first championed by Ignaz Simmelweis over a hundred and fifty years ago. It seems his discovery is still ignored today, all to our great demise.

The MP3 Study: Mupirocin Tops Polysporin for PD Infection Prophylaxis

By Peter Laird, MD

Patients undergoing peritoneal dialysis (PD) are prone to peritonitis as well as exit site infections (ESI) from various organisms. Unfortunately, PD related infections is one of the limiting factors in the effectiveness of peritoneal dialysis with most patients experiencing at least one episode of peritonitis annually. The most common pathogens are those that grow on the skin called gram positive bacteria. These are bacteria that stain dark when placed in Gram's dark stain. The most virulent skin organism in these infections is Staph Aureus which many people carry in there nose. Several prior studies have shown that Mupirocin (Bactroban) is an effective antibiotic for preventing ESI and peritonitis in PD patients. The MP³ Study compared Polysporin triple anibiotic (P³) to Mupirocin:

A Randomized Controlled Trial Comparing Mupirocin and Polysporin Triple Ointments in Peritoneal Dialysis Patients: The MP³ Study

Results Seventy-five of 201 randomized patients experienced a primary outcome event (51 peritonitis episodes, 24 ESIs). No difference was seen in the time to first event for P³ (13.2 months; 95% confidence interval, 11.9–14.5) and mupirocin (14.0 months; 95% confidence interval, 12.7–15.4) (P=0.41). Twice as many patients reported redness at the exit site in the P³ group (14 versus 6, P=0.10). Over the complete study period, a higher rate per year of fungal ESIs was seen in patients using P³ (0.07 versus 0.01; P=0.02) with a corresponding increase in fungal peritonitis (0.04 versus 0.00, respectively; P<0.05).

Conclusions This study shows that P³ is not superior to mupirocin in the prophylaxis of PD-related infections. Colonization of the exit site with fungal organisms is of concern and warrants further study. As such, the use of P³ over mupirocin is not advocated in the prophylaxis of PD-related infections.

There are many techniques useful in mitigating the risk of infection including careful hand washing, wear gloves when changing bandages, check the tubing for any signs of cracks daily as well as observing any redness or discharge from the PD tunnel, and avoiding hot tubs and public pools. Placing antibiotic creams are effective. When compared to Polysporin, Mupirocin is more effective at preventing PD related infections.

Harbor-UCLA Infection Control Deficiencies: A Climate of Disregard

By Peter Laird, MD

Harbor-UCLA medical center made headline news recently for severe public health infection control issues cited in a 55 page report. (here, here)  Reading though this lengthy report reveals a climate of disregard for basic infection control procedures that affected every aspect of medical care throughout the entire hospital. The Federal government responding to these serious deficiencies with a threat of withdrawing Medicare funds should the hospital fail to correct the outcomes of the report. Hospital officials responded to local news blaming the deficicies on the age of the building:

Inspectors: Harbor-UCLA Hospital Unsanitary

Harbor-UCLA executive Delvecchio Finley said the hospital has addressed all the concerns raised by inspectors, according to the Times. Nevertheless, Finley told the Times, issues continue to arise because of the age of the hospital, which was built in 1963.

"It's an old building," he told the newspaper's Anna Gorman. "Because of that, there are certain challenges."

However, despite the fact that some of the deficiencies were related to the infrastructure needs of the hospital, many more were blatant failures to adhere to simple hygiene standards expected of health care professionals. My medical training at Boston City Hospital was in a building over 100 years old, but I learned to wash my hands and scrub properly for surgical procedures, a task that I took seriously not only for the prevention of nosocomial spread of disease to my patients, but also to my own family when my work was completed.  Infection control begins with an attitude of professionalism understanding hygiene standards and caring enough to take the time to perform them with each and every patient, every time.

The inspectors focused mainly on the surgical and in-patient areas, but they also found serious procedural errors in the dialysis unit including failure to respect patient privacy, improper chloramine testing, failure to test for endotoxins since 2007, no policy and procedure for endotoxin testing and no policy for notification by the water utility for changes in chloromine concentrations. All of these irregularities place patients at risk each time they undergo hemodialysis in this unit.

Canada promotes a new climate of infection control through their Stop! Clean Your Hands Day annual promotion. Thousands of patients die each year by the lack of attention to simple and basic concepts by the people they trust with helping and curing their illnesses. Over a hundred and fifty years since Ignaz Semmelweis first showed the benefits of washing your hands between patients, it remains one of the most serious health care issues today. Dr. Semmelweis was ridiculed, insulted and castigated for his suggestions that doctors were causing the deaths of the obstetrical patients attended shortly after they performed autopsies. The fact that Canada has to remind healthcare professionals about the most basic infection control procedure demonstrates the remarkable personal and collective failure of doctors, nurese, lab techs and all of the people employed throughout this industry.

The ghost of Dr. Semmelweis haunts the halls of every hospital throughout the world with the knowledge that many health care professional are still the cause of death to thousands of patients entrusted in their care through a lack of personal handwashing. Until the health care industry develops an attitude of infection control at every level, there remains little hope that this climate of disregard shall ever end. 

Dialysis Patients May be at Higher Risk for Listeria Food Poisoning

By Peter Laird, MD

The news over the last month chronicles the still increasing death toll from a deadly bacteria called Listeria Monocytogenes. The culprit in this attack stems from cantaloupe at a farm in Colorado (here).  There are now over 28 confirmed deaths since the outbreak of listeriosis became evident in the middle of August. Listeria is one of the most feared bacteria due to its unique method of invading other cells, it is rocket powered: 

The gram-positive bacterium Listeria monocytogenes is the causative agent of listeriosis, a
severe food-borne infection characterised by abortion, septicaemia, or meningoencephalitis. L. monocytogenes causes outbreaks of febrile gastroenteritis and accounts for up to 10% of community-acquired bacterial meningitis in humans. It is the primary cause of central nervous system infection in domestic ruminants. Listeriosis has one of the highest hospitalisation (90%) and mortality rates of all food-borne infections.

Dialysis patients may be at an increased risk of this infection according to prior studies. In one study from 1984, patients on hemodialysis who received multiple blood transfusions causing elevated iron uptake had several cases of Listeria compared to dialysis patients who had not received blood transfusions. 

Listeriosis in patients with long-term hemodialysis and transfusional iron overlaod

Over a four-year interval, four cases of Listeria monocytogenes bacteremia were observed among a population of 127 patients undergoing long-term hemodialysis. None had an underlying malignancy or were recently receiving immunosuppressive medications. A search for a predisposing factor suggested a relationship to transfusional iron overload. Although still a rare infection, the possibility of listeriosis must be kept in mind by physicians caring for patients undergoing hemodialysis, particularly those requiring blood transfusions.

This may be more relevant today now that EPO recommendations are to increase the reliance of blood transfusions in chronic hemodialysis patients who are not candidates for transplant (here). Another population that may be at risk is the peritoneal dialysis patients. There have been several outbreaks of Listeriosis from contaminated PD solutions documented over the years.

Listeria Monocytogenes Peritonitis in a Peritoneal Dialysis Patient with Severe Heart Failure

Listeria monocytogenes has rarely been reported to cause peritonitis in peritoneal dialysis (PD) patients. Listeriosis is usually a severe disease with a mortality rate of 20 to 40% in humans despite early antibiotic treatment. In this report we present the first case in Greece of peritonitis caused by L. monocytogenes, in a chronic PD patient with severe cardiac failure. The patient received prolonged antibiotic therapy with vancomycin and netilmicin which resulted in peritonitis resolution. Unfortunately however, the listeria infection caused decompensation of the patient’s cardiac failure and led to his death, despite appropriate antibiotic treatment. When peritoneal fluid cultures yield gram positive rods in an immune-compromised patient or on a patient with severe underlying diseases who regularly consumes dairy products, the clinical suspicion of this rare infection must be immediately evaluated. Listeriosis can be fatal despite effective antibiotic therapy, since it affects patients with severe underlying pathologies.

Listeria is a lethal pathogen that rears its head in many different settings and is difficult to treat and at times difficult to diagnose due to its similar features to other "gram positive" bacteria. With its unique mode of rocket powered propulsion, it is not only a deadly invader, it is one of the marvels of God's creation. Truly, there is nothing new under the sun as Solomon stated over 3000 years ago.

Taking Hemodialysis Home Safely

By Peter Laird, MD

Home hemodialysis is undergoing a renaissance in the United Stated with over 5000 patients now utilizing this flexible and convenient therapy in the comfort of their own homes. Safety in the home dialysis environment is a diverse topic with patients having varying skill levels coupled with no standardized training programs. Nevertheless, there are many common safety elements when applied uniformly that will assure the best outcomes and reduction of complications.

Patient safety in the home begins with an attitude towards safety. When a pilot steps into the cockpit of a plane or a surgeon into the operating theatre, there is an expectation of safety as the first and highest priority.  Likewise, the home dialysis patient needs to adopt this same reliance on safety first. However, since it is also the place where we live, patients face a difficult compromise between basic living quarters and tending our own dialysis unit. The first step is to have a separate, dedicated space for dialysis and supplies when possible.  Supplies should be inspected upon delivery for damage and loss of integrity, discarding any that are compromised. The storage area should minimize exposure to sunlight, moisture, dust and extreme temperature fluctuations.  Pets and young children should not enter the supply area. 

The daily dialysis session starts with proper setup of the equipment and inspection of all supplies. Crimped bloodlines can lead to hemolysis which can be life threatening. Patients need to examine all prepackaged dialysate for discoloration of the fluid and check for proper prescription. The artificial kidney should not contain any cracks and you should only use supplies that have not expired or had any external damage to the protective coverings. Always check for any leaks of the cartridge or bloodlines prior to starting dialysis while the machine is priming. Review all machine settings to assure that they are correct.

All dialysis machines monitor for internal system failures during the priming session and any alarms should be addressed prior to hooking up. The operators instruction manual must be within easy reach at all times as well as phone numbers for technical support of your specific machine. If there are any unusual sounds or obvious dysfunction of the machine, notify the technical support staff before proceeding with your dialysis session. Inspect all connections to make sure none are loose.  Assure that the proper lines are open or closed depending on the system used with all caps in place Lastly, keep emergency supplies for disconnecting the blood lines in the event of an emergency within easy reach including scissors, hemostats, needle nosed pliers as well as a telephone to call for emergency medical attention.

Infection Prevention:

Infection control in the home setting originates with healthful living and general cleanliness. Pathogens abound in un-kept homes especially staphylococcus bacteria that can live on exposed living surfaces for several days. Routine hand washing is the anchor to safe performance of dialysis in the home. Unfortunately, proper hand hygiene is also one of the most ignored tasks leaving home dialysis patients at increased risk.  Johns Hopkins revolutionized infection control in the intensive care unit several years ago by developing a “bundled” checklist for central line insertion and after care. This same attention to basic hygiene principles could mitigate many of the common infectious complications associated with hemodialysis.

• Shower or wash access site just before the session begins.
• Employ diligent hand hygiene from a combination of hand washing and use of alcohol gels during the different steps of home hemodialysis.
• Wear gloves and facemasks at all times when inserting needles, hooking up bloodlines and disconnecting at the end of a dialysis session.
• Use sterile bandages instead of communal supplies from multi-use dispensers that are easily contaminated.
• Disinfect cannulation sites preferentially with chlorhexidine instead of iodine if not allergic to chlorhexidine.
• Avoid long-term catheter access and utilize fistulas when possible which significantly reduce all cause complications.

Many patients on home hemodialysis access their fistulas using the constant site cannulation technique also known as buttonhole cannulation. There are several benefits to buttonhole cannulation including reduction in aneurysm formation, reduced pain with needle insertion and significant reduction in infiltration with cannulation. However, recent studies reveal an increased risk of access site infections with buttonhole cannulation versus rope ladder cannulation techniques, especially in the setting of in-center dialysis units.  Proper technique may mitigate these infections:

• Wash arm and disinfect site with an antimicrobial agent before picking scabs.
• Consider single use, sterile disposable tweezers for each buttonhole site instead of reusable metal tweezers that are difficult to disinfect.
• Soften scabs prior to removal with alcohol gel or pads covered by warm compresses for several minutes.
• Avoid using sterile needles to pick scabs since they can increase tissue damage that then serves as a nidus for infection.
• Re-prep buttonhole sites with an antimicrobial agent before cannulation.

Preventing Dialysis Emergencies:

Cafazzo, et al, in 2009(1) noted that the fear of a catastrophic event is one of the most important patient-perceived barriers to home hemodialysis.  Air embolism and exsanguination from venous needle dislodgement are the most serious immediate medical emergencies that can occur during hemodialysis, albeit rarely documented.  With the popularity of nocturnal home hemodialysis, venous needle dislodgement gains even more importance to prevent since many home nocturnal dialysis patients sleep alone. Unfortunately, venous needle dislodgement remains the most common cause of preventable death in the dialysis unit and is a serious risk for the home hemodialysis patient.

The FDA recently approved the Redsense monitor to detect blood loss during hemodialysis. Many home hemodialysis patients have used bed wetting monitors to protect against undetected venous needle dislodgement in an off label use that is not recommended.  Nocturnal hemodialysis patients especially need to utilize an approved moisture alarm device during each session in addition to the usual precautions:

• Tape the bloodlines securely before initiating dialysis.
• Keep bloodlines and needle insertion sites visible at all times. Never cover with blankets or clothing.
• Never tape bloodlines to chairs, tables or other objects that could cause the venous needle to dislodge.
• Utilize FDA approved moisture detectors and test frequently to make sure the device is functioning properly.
• Never disable pressure alarms designed to detect a sudden change of pressure from venous needle dislodgement.
• Never cut the dialysis needle lines during emergencies, you will bleed to death. Clamp and cut above the dialysis needle lines. 

Air embolism during hemodialysis occurs when atmospheric gas is introduced into the venous system. As little as 20 ml of air can be fatal when introduced directly into the blood system. Modern home hemodialysis machines all detect small amounts of air and automatically shut down the machine. One of the most common risks for venous air embolism is an empty IV saline bag during rapid infusions for cramps and during the final rinse-back especially if bypassing the machine in a manual rinse-back maneuver.  Careful attention observing saline levels will prevent this error. If a saline bag runs dry and introduces air, remove all introduced air in the line before proceeding with any further saline infusion. If the lines cannot be cleared, abort any further infusions since the air can be fatal or cause severe complications. Long-term exposure to even small levels of air bubbles can cause significant clinical effects from micro-bubbles, which can be reduced by up to 75% with careful priming.

Dialysis patients utilizing catheter-based treatments are at the highest risk of venous air embolism since any air is introduced directly into the central blood vessels immediately. Assuring that the catheter is clamped securely before connecting or disconnecting bloodlines limits the risk of venous air embolism. However, a venous catheter crack or disconnection that goes unnoticed can be rapidly fatal. Safely measures to prevent air embolism include:

• Use the vascular catheter only for hemodialysis access.
• Keep all bloodlines visible during dialysis at all times.
• Monitor for cracks, tears or breaks of the catheter hub and Luer lock disconnection during hemodialysis.
• Replace saline bags before they become empty.
• Suspect air embolism if the patient complains of shortness of breath or has any unusual symptoms during or immediately after a hemodialysis session.

Preparing for Non-medical Emergencies:

All home hemodialysis patients should prepare for local disasters including adverse weather, home fires, earthquakes and epidemics. In addition, during the hot summer months, loss of electricity is a common disruption during dialysis. Patients need to understand manual rinse-back procedures and should have emergency lighting available if dialyzing at night. Emergency preparedness includes keeping supplies available for food, water and shelter in the event of a local disaster as well as having available travel arrangements if they must evacuate the area. There are several basic measures of emergency preparedness that all home dialysis patients need to adapt to their own specific situations. 

• Keep personal medical information available and consider medical alert bracelets. Keep basic proof of ID and insurance information on hand as well as credit cards and banking information.
• Register your home with water and power companies to increase priority restoration in times of emergency.
• Have flashlights, batteries, medications, emergency food and water supplies and cell phones charged.
• Know the phone number to the backup dialysis unit you are assigned.
• Prepare an emergency dialysis supply kit filled with tape, masks, needles, syringes, heparin, saline, gloves, hand sanitizers, betadine and medications.
• Trash bags for waste disposal.
• Bleach to decontaminate equipment if using the portable NxStage System One and related supplies.
• Keep a three-day emergency diet on hand in case you are not able to re-establish your dialysis routine in that time.

All home hemodialysis patients need to spend time developing their own individual emergency preparedness plan and implement that plan upon completion of their dialysis-training program. Fortunately, there are several excellent resources available online.  Those that I find helpful include: 

• Home Dialysis Central:  Disaster Planning for PD and Home HD (http://www.homedialysis.org/article/life_at_home/disaster_planning_for_pd_and_home_hd)
• KCER: Kidney Community Emergency Response Coalition (http://www.kcercoalition.com/resources.htm)
• National Kidney Foundation: Planning for Emergencies (http://www.kidney.org/atoz/pdf/DisasterBrochure.pdf) 

Water Safety:

Dialysis patients require large amounts of water to perform dialysis making water safety one of the most important elements of a dialysis safety program. There are currently two FDA approved systems for home dialysis that utilize different processes to prepare the cleansing dialysate, the Fresenius [email protected] dialysis machine and the NxStage System One. The first step for all home hemodialysis patients is to have their tap water analyzed to make sure it adheres to basic water purity for drinking water and does not contain certain heavy metals such as arsenic, other elements or excessive bacteria. Dialysis patients are exposed to higher levels of water each week through their treatments than normal drinking making even small levels of contaminants that are tolerated in drinking water dangerous for the home dialysis patient.  Patients should diligently follow the prescribed water testing schedules that your home dialysis trainer sets up.

The Fresenius [email protected] dialysis machine relies on technology used in conventional in-center dialysis units with a reverse osmosis machine that removes most chemicals and metals from the water.  However, it does not remove chlorine and chloramines used by city water systems to purify drinking water or all of the bacteria and their breakdown products called endotoxins. Activated charcoal filters remove the chlorine before the RO system processes the water. Bacteria and endotoxins are removed by specials microfilters.

Patients learn how to test and maintain these systems during the extended training for home dialysis. The key element of water safety is to maintain accurate records and correctly perform all maintenance on schedule. Daily testing for chloramines is a necessary task to prevent serious adverse effects during dialysis.  Many patients find daily maintenance of the water systems the most difficult part of home hemodialysis when dialyzing with the standard RO process.

The NxStage System One utilizes ultrapure dialysate that is either pre-packaged in ready to use bags or from the PureFlow SL machine that takes tap water, purifies it with a multi-step process and combines this purified water with sterile dialysate concentrate making 60L of dialysate with each batch. Patients must test daily for chloramines and maintain scheduled testing of the water quality for metals and bacteria levels to ensure safety. Water safety in dialysis is one of the most technically complex aspects of dialysis care in the home requiring close communication with the supporting dialysis unit and continued testing and maintenance of all equipment in conjunction with professional oversight by qualified technicians.

Dialysis Waste Disposal:

Dialysis waste includes used needles, syringes, bandages, bloodlines, artificial kidneys and other biohazards. Proper waste disposal completes the circle started with proper infection control practices in the home hemodialysis setting. One of the greatest safety hazards is proper disposal of used needles that become a biohazard risk to care takers, family members and waste management personnel.  Each state has their own guidelines and regulations on proper disposal of all home medical wastes in conjunction with the environmental protection agency (EPA). Patients should enquire from their supporting dialysis unit how to dispose of these wastes safely and in compliance with state, local and federal regulations.  Needle safety starts first with a standard sharps disposal container in the home environment that is kept safely away from children and other members of the household.  

Fall Prevention:

Many hemodialysis patients have several co-morbid conditions and restricted mobility that places them at higher risk of death or injury from falls in the house. In addition, hemodialysis with high ultrafiltration rates increases the risk of falling from low blood pressure during and immediately after finishing a dialysis session. Adhering to low sodium diets and carefully monitoring for excess intradialytic weight gain is part of home dialysis safety. For patients with congestive heart failure and other cardio-pulmonary diseases that increase fluid retention, physicians and patients should consider daily, nocturnal home hemodialysis that minimizes the amount of fluid removed with each session and in addition removes the fluid slowly over a longer period of time. Many studies reveal less intradialytic hypotension and normalization of blood pressure with this approach making the risk of falling less likely.

Lastly, care partners should be able to perform basic emergency procedures such as placing the hypotensive patient in reverse trendelenberg, give a rapid saline bolus also being able to change the IV bag safely, have emergency numbers available as well as basic medical information to give to the responding paramedics. Hemodialysis in the early pioneering days of dialysis was by necessity a home-based therapy. Today we are rediscovering the benefits of dialyzing in the comfort and safety of the home environment with significantly improved mortality and a lower burden of complications than conventional in-center hemodialysis. As America continues to expand this needed home therapy, home dialysis training programs need to instill basic safety guidelines into the routine practice of dialysis in the home. Patients considering home hemodialysis need to embrace the responsibility of their own treatments and at the same time know that they shall enjoy the benefits of increased freedom to travel and an improved quality of life.

1) Patient-Perceived Barriers to the Adoption of Nocturnal Home Hemodialysis - CJASN (April 2009)(4) 784-789, Cafazzo et al

Hand Hygiene: Back to Basics Video from NEJM

By Peter Laird, MD

The NEJM has an excellent back to basics video on hand hygiene. This simple measure may save more lives than many of our high tech medical therapies combined. It is time, long past the time that the American medical establishment paid attention to this simple but effective infection control measure, most especially in the dialysis unit.

About the Procedure

Health-care associated infections are a threat to patient safety and the most common adverse events resulting from a stay in the hospital.1 Approximately 5 to 10% of hospitalized patients in the developed world acquire such infections, and the burden of disease is even higher in developing countries. Proper use of hand hygiene is a critical to the prevention of these infections, but compliance among health care workers is most often below 40%. . . . .

 http://www.nejm.org/doi/full/10.1056/NEJMvcm0903599?query=TOC

"Preventing Bloodstream Infections is not only Possible, It Should be Expected"

By Peter Laird, MD

The CDC recently announced the dramatic news that catheter based infections in the ICU's across America since 2011 are greatly reduced by the use of "Bundled" protocols of catheter insertion and preventive care saving over 1.8 billion in the last decade alone. One of the central factors to the success of the bundle is peer pressure from public reporting of each physicians outcomes.  

  

However, dialysis units have not shared this success despite the fact that bundled central lines in the ICU have been the standard of care for several years.

CDC: Too Many Infections in Dialysis Clincs

"Preventing bloodstream infections is not only possible, it should be expected,” said Thomas R. Frieden, MD, MPH, CDC director. “Meticulous insertion and care of the central line by all members of the clinical care team including doctors, nurses and others at the bedside is essential. The next step is to apply what we've learned from this to other healthcare settings and other healthcare-associated conditions, so that all patients are protected.”

The CDC is now targeting blood infections in the dialysis unit in the same manner as their program against cather associated infections in the ICU over the last several years.  The steps to prevent infections are quite simple and proven over hundreds of years beginning with the simple procedure of washing your hands before doing any patient care. Unfortunately, the record on hand washing in American dialysis units is abysmal.  

I am pleased to see this new focus on dialysis related infections which if implemented widely shall significantly reduce the pain and suffering of dialysis patients at the hands of those they trust with their lives simply because they don't care enough to wash their hands or change gloves between patients. As in many issues, simply taking the time to treat your patients in the same manner as you would expect is the beginning of professional health care. It is time to remember these simple truths.

STOP! Wash Your Hands

By Peter Laird, MD

Inadequate infection control practices remains the single largest preventable source of dialysis related complications by many reports. Sadly, the culture of overlooking basic hand washing, changing gloves and proper cleaning of the dialysis machine is prevalent in every dialysis unit I have dialyzed (9 in 7 different states).  The lessons learned in the ICU preventing blood borne infections with central line catheters by a simple check list where health care associated infections (HAI) have been essentially eliminated should become the model of care in dialysis units.

The World Health Organization (WHO) is now sponsoring the Clean Care is Safer Care initiative which promotes the annual wash your hands day events now ongoing in Canada, but apparently it has yet to catch on here in the United States.

STOP! Clean Your Hands Day

The Canadian Patient Safety Institute (CPSI) launched a national hand hygiene campaign in 2007 under the theme “STOP! Clean your hands”. CPSI is working on this initiative with the Community and Hospital Infection Control Association–Canada, the Canadian Council on Health Services Accreditation and the Public Health Agency of Canada.

A simply mental checklist is also available to remind health care workers when they must wash their hands to prevent HAI's from the WHO.  Simply applying these simple concepts could help prevent thousands of dialysis center acquired infections every year. It is time to put this life saving knowledge to work and change our cultures of death in our American dialysis centers.

My 5 Moments for Hand Hygiene

The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.

This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings.

This approach recommends health-care workers to clean their hands

• before touching a patient,
  
• before clean/aseptic procedures,
• after body fluid exposure/risk,
• after touching a patient, and
• after touching patient surroundings.