The Yellow Peril - Hepatitis C Spreading in Dialysis Units

By Peter Laird, MD

In Anna’s recent report, we learned of the shocking reason why her DaVita dialysis unit was suddenly shut down after discovering unsanitary conditions which may have contributed to the spread of hepatitis C in an unfortunate dialysis patient. As a physician dedicated longstanding to hand washing to protect my patients, my family and myself, I have been personally horrified by the lack of application to this basic protection that many nurses, technicians and even patients pay little attention to. 

I am fortunate to dialyze incenter at a Fresenius Medical Care (FMC) unit which now has the third highest FMC patient outcomes in this nation.  I have dialyzed at a wonderful DaVita unit in Littleton Colorado, as well as superb DaVita units in Illinois and Pennsylvania that were well organized and well run with alert and healthy appearing patients.  I have also dialyzed at a major university hospital as well as small town units in remote northern states.  Without exception, no matter how well the units are organized, I have personally observed poor hand washing practices by individual technicians and nurses in every unit I have been in. Fortunately, I have also observed many professionals that share my own dedication to hand washing.

Ignaz Semmelweis was one of the first physicians to recognize the importance of hand washing. In 1847 he worked to prevent disease among women during childbirth. He found a simple, inexpensive solution and was outraged that it was not widely and thouroughly implemented:

While employed as assistant to the professor of the maternity clinic at the Vienna General Hospital in Austria in 1847, Semmelweis introduced hand washing with chlorinated lime solutions for interns who had performed autopsies. This immediately reduced the incidence of fatal puerperal fever from about 10 percent (range 5-30 percent) to about 1-2 percent.

Semmelweis was outraged by the indifference of the medical profession and began writing open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers. His contemporaries, including his wife, believed he was losing his mind and he was in 1865 committed to an asylum (mental institution). Semmelweis died there only 14 days later, possibly after being severely beaten by guards.

Over one hundred and fifty years after Semmelweis stood against the indifference of the medical profession, demanding they adhere to sound sanitary practices, I am sadly shocked to note that even in the best dialysis units in America, I am routinely frightened by individual dialysis nurses, technicians and physicians who approach me with unclean hands and unchanged gloves. The issue seen in Anna’s unit in New York is only the proverbial tip of the iceberg. Failure to adhere to simple sanitary practices, practices that prevent nosocomial transmissions, are rampant across this nation. I have personally observed this during the last 18 months as a physician receiving incenter hemodialysis.

In fact, I have been routinely considered a difficult patient simply for asking that all health care professionals that care for me wash their hands and change their gloves before approaching me or my machine. The grave of Ignaz Semmelweis must tremble daily with each patient harmed by health care professionals failing to observe the most simple and basic (and inexpensive) health care protection ever observed by any physician at any time: simply wash your hands in between each patient.   

Physicians that control hemodialysis units are ultimately responsible for all allied health care providers that they supervise. I have personally observed dried blood on chairs, contaminated priming buckets, technicians that do not wash their hands or even use gloves in between multiple patients, shoddy cleaning practices of patient care stations, nurses touching trash cans and then doing “sterile” procedures on patients with catheters, filthy blood pressure cuffs, multiple use of medication vials at the patient’s stations and tape picked up off of the floor and then used on patients. As a patient still at risk of nosocomial and iatrogenic infections, I plead directly to my health care colleagues to step up and implement the recommendations of the CDC and most especially honor the memory of Dr. Semmelweis. 

I never expected to be sitting in a dialysis chair at the mercy of other physicians, nurses and technicians who ignore the single most important step in my dialysis care by not washing their hands and changing their gloves in between each patient. I implore all allied health care providers to step up and wash your hands, my life is literally in your hands whether they are clean or contaminated: 

Also it was not unusual to find staff taking care of susceptible and infected patients in the same shift. Additionally, they did not routinely discard gloves after use. This practice may facilitate the dissemination of HCV between hemodialysis patients, since HCV RNA was found on the hands of dialysis personnel (Alfurayh et al. 2000).

Unfortunately, there are many of you that will likewise someday sit beside me crippled not only by chronic kidney disease, but perhaps also by hepatis C and other nosocomial infections passed on to you by the same lack of attention to a simple but effective method of preventing these infections. Please, wash your hands my friends and colleagues, my health and well being rest in your hands. I pray that they are clean.

Comments

[Anonymous]

I caught an antibiotic resistant bug during a long hospital stay and after it was found I was put in isolation and everyone who entered my room had to gown up and use gloves. Except one doctor came to my isolation room and examined me with bare hands! I was too shocked to say anything to him. The infection control officer who was very nice said I should have said something and should also have reported the doctor to her. This was years ago and I was a very afraid patient back then. Now I would say something. My neph. washes his hands between each patient and changes gloves when he is in the unit and staff seemed to follow his example but it's been a while. I go back on dialysis in a few weeks and I will be more vigilant this time. Thanks for this piece.

[Roberta Mikles, RN, Patient Advocate]

Perhaps, if more patients were educated, to those effective infection control practices that will be implemented by staff, then, patients can let staff know when there is a noted ineffective practice i.e. not washing hands between patients, not washing hands prior to and after gloving procedures. One main component of this scenario is that staff recognize, understand and accept that it is okay for a patient to bring to their attention that practice that might place the patient in potential or actual harm's way. Considering infection remains the number two cause of death, and as this NY facility demonstrates-----there remain problems within the dialysis community. One certainly has to ask what is wrong with this picture that the most basic procedures are not being conducted? Although there are internal controls e.g. QA/PI programs, staff must first be familiar with all infection control practices. Additionally, the mindset that dialysis patients are prone to infections must also be changed to we can prevent such with proper techniques. A culture within the dialysis unit must allow for one staff to bring to another staff's attention that they are conducting inappropriate techniques. Perhaps a patient who has acquired a preventable infection, that has resulted in a lengthy hospitalization, and rehab, with a decline in their quality of life, should present what it is like to be a patient, during staff orientation. Maybe this will hit home. "treat the patient as you would want yourself or a loved one treated" And, again, perhaps Medicare should consider dialysis facilities as they do hospitals and withhold Medicare reimbursement dollars $$$$$$$$$$ for certain preventable events. It is unfortunate that so many patients have been labeled as 'difficult', etc., when, in fact, they are just trying to keep themselves safe, as Dr. Laird mentioned in his post. Let's pull this team together and include patients and recognize their role in patient safety. Roberta Mikles, RN, Patient Advocate RMiklesRN@aol.com

[Zach Richter]

It's quite rare these days to hear the hemo nurses and PTs talk of the phrase, "aseptic techniques."