One of the unique aspects of being a nephrologist is that a fair number of us become medical directors of dialysis units. The skills and knowledge to be an effective medical director are unique from those required for individual patient care. I know in my fellowship there was no training on how to be an effective medical director and the boards had few questions on it. The skills and knowledge are acquired casually with little formal teaching. In February of this year CJASN began a new series about being a medical director to provide a more rigorous back ground and infrastructure for this important skill set. NephJC is going to look at one article in this series. This stuff is important.
Take a look at the introduction to the series by Drs. Provenzano and Hymes
Medical directors no longer practice in isolation but are integral members of the larger team of renal providers and are empowered by data and tools to drive improved renal outcomes. In this issue of CJASN, we begin a series on the role of the dialysis facility medical director. This series brings together content and experiential experts to provide a broad-based practical compendium for all medical directors, both experienced as well as novice. This series will serve as a reference and repository of the expertise of our colleagues, many of whom have helped build and shape the field of nephrology.
This NephJC took place on Tuesday, April 14, at 9 PM EDT and Wednesday, April 15, at 8 PM GMT
"hospitalizations for infection have increased 43% since 1993, although the overall hospitalization rate and total hospital days have declined" Wow.
One of the roles of a dialysis unit's medical director is infection prevention.
The mechanism for this is setting up an evidence-based quality assessment and performance improvement (QAPI) system.
Preventing infection in the dialysis unit can be divided into two realms:
- Patient-Related Issues
- Facility-Related Issues
Too many patients still initiate dialysis with a catheter. Part of the reason for this is the fear that early access will result in too many people being unnecessarily burdened by access surgery that they won't use because they never progress to dialysis or die prior to needing dialysis (I guess those are kind of the same thing). This comes from the lack of certainty regardng the future need of dialysis based solely on an estimated GFR. One way to increase certainty is to use a risk estimating formula, like the one validated by Levey et al. An online version of this calculator is available here.
If patients do start dialysis with a catheter, medical directors need to ensure that they are moved forward to get an AV access with expediency. This should be done with a tool like the one developed for Fistula First. The article suggests using pathways published at the ESRD National Coordinating Center.
Scrub the Hub and other access issues
This is a CDC and CID recommendation to reduce the risk of catheter associated infection. It is a procedure to clean the catheter and then handle it in an aseptic manner to reduce the risk of contamination. One of the key steps is after cleaning the catheter to let the hub drug before considering the job complete. If catheter infection rates are high, the medical director should review and reinforce proper catheter handling.
Care of fistula and grafts
To prevent infection patients need to be educated on taking care of their accesses. The CDC publishes 6 Tips for Preventing Dialysis Infections. This should be taught to patients.
The CDC website provides these materials, along with Spanish versions. Medical directors need to know how accesses are cleaned, assessed and maintained in their units to prevent and track infections
Immunization and Screening
Consideration should be given to screening for hepatitis B and hepatitis C. Patients that convert should trigger a root cause analysis and reported. Hepatitis B vaccine is recommended for all dialysis patients and dialysis unit employees.
Patients should be screened for TB at least once and additionally if they are exposed.
All dialysis patients should receive the flu vaccine. Tetravalent and high dose vaccines may provide more protection. Flu vaccine is estimated to reduce the risk of death by 50%. The authors recommend that medical directors speak with all patients who refuses the vaccine and try to persuade them to receive it. Employees of the unit should be encouraged, or mandated, to be vaccinated against influenza.
The pneumonia vaccine is recommended for all dialysis patients, in fact the CDC recommends both the traditional adult PPSV23 vaccine and since 2010 the PCV13 pneumococcal vaccine (Prenvar).
Medical directors need to take the lead to make sure effective hand washing is being done in the clinic. Staff should be taught the correct method and audits should be done to assure compliance with these systems.
Cleaning and disinfecting is a basic procedure to prevent infection. Televisions, chairs and dialysis machines all need to be cleaned and disinfected.
Multi drug resistant organisms (MDRO)
The rate of MRSA infection in dialysis patients is 100 times higher than the general public. Most of this transmission is person-to-person. Dialysis units have limited ability to isolate patients but increased precautions should be used:
- Put infected patients in corners or on the ends to minimize adjacent stations
Medical directors should be familiar with isolation protocols for hepatitis B. Incident patients without yet a negative result should not be dialyzed in the isolation room, but extra precautions should be used. Though Hepatitis C does not require isolation, chorussing patients with hepatitis C into a single area or shift has been shown to reduce seroconversion.