02.06 - Dialysis
Section: UTMB On-line Documentation
Subject: Infection Control & Healthcare Epidemiology Policies and Procedures
Topic:
02.06 - Dialysis
02.06 ¨C Policy
12.11.18- Revised
1977 - Author
02.06 - Dialysis
Purpose
To outline infection control guidelines for the practice of hemodialysis and
peritoneal dialysis at UTMB
Audience
All those who participate in the hemodialysis and peritoneal dialysis
procedures
Employees
?
Universal Precautions shall be followed when providing care to all
patients.
?
Eating and drinking shall be confined to designated areas.
?
Personnel shall comply with the Employee Health Center guidelines for
their areas.
?
Suspected or known exposure to or acquisition of a communicable
disease shall be reported to the Department of Infection Control &
Healthcare Epidemiology or the Employee Health Center. All needle
sticks shall be reported to the Employee Health Center.
?
Personal protective equipment (PPE) shall be worn for initiating and
discontinuing hemodialysis and anytime exposure to body fluids is
anticipated. If clothing becomes soiled by blood and/or body fluids, it
shall be changed immediately.
?
During the dialysis procedure, gloves shall be worn when touching or
manipulating the patient¡¯s fistula, shunt or intravenous catheter IV
tubing, or any patient¡¯s body fluids (i.e., vomitus, stool, urine, blood).
Gloves shall also be worn when touching the dialysis machine (i.e.,
knobs, buttons, tubing, clamps, changing transducers or cleaning the
machine).
?
Hand hygiene shall be performed before and after each patient contact
and after removal of gloves (see policy: Hand hygiene for All Hospital
Employees).
?
Healthcare workers shall wash hands, don gloves and refrain from
touching environmental surfaces prior to giving injections.
?
All ancillary personnel who interact with patients but do not provide
hands on patient care (i.e., social workers, teachers, and dietitians)
shall wash their hands when entering and leaving the dialysis area.
?
All cuts and lacerations shall be covered with a waterproof dressing
(i.e., Op-Site).
?
Blood and other specimens such as peritoneal fluid shall be handled
with care using Universal Precautions.
?
Linen shall be handled appropriately (see policy: Guidelines for
Page 1 of 10
Section: UTMB On-line Documentation
Subject: Infection Control & Healthcare Epidemiology Policies and Procedures
Topic:
02.06 ¨C Policy
12.11.18- Revised
1977 - Author
02.06 - Dialysis
Handling Linen).
Environment
Equipment
?
The environment shall be thoroughly cleaned between each
treatment and as necessary for spills of blood and body fluids.
?
Waste receptacles shall not be overfilled.
?
Dialysate and the water used to prepare the dialysate shall be
cultured at least once a month according to the nursing service
policy on Water Quality for Hemodialysis.
?
The following standards shall be followed for dialysis fluid.
Microbiologic and Endotoxin Standards for Hemodialysis Fluids
Type of Fluid
Microbial count
(CFU/ml)
Microbial Count
(CFU/ml)
Action Level
Endotoxin Count
(EU/ml)
Endotoxin Count
(EU/ml) Action
Level
Water used
to prepare
dialysiate
< 200
50
................
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