CCHT Infection Control 2 — Questions and Answers
Question 1: What is the recommended hand hygiene technique after removing gloves following patient care in a hemodialysis unit?
- Gloves provide complete protection; hand hygiene is optional after removal
- Wash hands with soap and water or use alcohol-based hand rub immediately after glove removal (Correct answer)
- Only wash hands if gloves visibly tore during use
- Sanitize gloves and remove them over the sink
Correct answer: Wash hands with soap and water or use alcohol-based hand rub immediately after glove removal
Hands must be washed or sanitized immediately after removing gloves because gloves can have micro-tears and removal itself can contaminate hands.
Gloves do not provide complete barrier protection as they can have microscopic punctures or tears, and the act of removing them can transfer contamination to hands. CDC and APIC guidelines require hand hygiene after every glove removal. Alcohol-based hand rub (60% alcohol or more) is acceptable unless hands are visibly soiled or after known exposure to C. difficile or norovirus, which require soap and water.
Question 2: A new patient has been identified as hepatitis C positive. What infection control precautions should be implemented in the hemodialysis unit?
- Isolate the patient in a separate room with dedicated equipment
- Follow standard precautions only; HCV is not transmitted by casual contact in dialysis
- Cohort the patient with other HCV-positive patients and use dedicated machines (Correct answer)
- Refuse treatment until the patient completes antiviral therapy
Correct answer: Cohort the patient with other HCV-positive patients and use dedicated machines
CDC recommends cohorting HCV-positive patients in a dedicated area or machine due to hemodialysis-specific transmission risks, in addition to standard precautions.
Although HCV is not transmitted by casual contact, hemodialysis units have documented HCV outbreaks due to contaminated equipment, shared supplies, or injection practices. CDC HCV guidelines for dialysis units recommend: dedicating equipment (blood pressure cuffs, tourniquets, clamps) to HCV-positive patients, cohorting them in a designated area or using dedicated machines, performing HCV testing every 6 months, and reinforcing strict infection control.
Question 3: What is the most common source of catheter-related bloodstream infections (CRBSI) in hemodialysis patients?
- Contaminated dialysate water
- Contamination of catheter hubs during connection/disconnection procedures (Correct answer)
- Skin flora migrating through the insertion site
- Infected dialyzer membranes
Correct answer: Contamination of catheter hubs during connection/disconnection procedures
The majority of CRBSIs originate from contamination of catheter hubs during the frequent connection and disconnection required for hemodialysis.
Hemodialysis CVCs are manipulated 3 times per week, creating repeated opportunities for intraluminal contamination. Each connection/disconnection event exposes the catheter hub to environmental pathogens. Skin organisms (Staphylococcus aureus, coagulase-negative staph) colonize hubs and migrate intraluminally. Prevention includes strict aseptic technique, chlorhexidine-impregnated caps, antimicrobial ointment at exit sites, and minimizing catheter manipulations.
Question 4: What is the proper technique for disinfecting the skin before needle insertion for arteriovenous fistula cannulation?
- Wipe with a single alcohol swab in one direction
- Apply chlorhexidine gluconate in a circular motion and allow to dry completely before needling (Correct answer)
- Use povidone-iodine spray without rubbing
- No disinfection needed if the patient recently showered
Correct answer: Apply chlorhexidine gluconate in a circular motion and allow to dry completely before needling
Chlorhexidine gluconate applied with friction and allowed to air dry provides the most effective skin antisepsis before cannulation, reducing infection risk.
KDOQI and CDC guidelines recommend chlorhexidine gluconate (2% CHG) as the preferred skin antiseptic for vascular access cannulation. Apply with friction for 30 seconds, then allow to dry completely (30 to 60 seconds) before needling. Drying is essential as wet CHG is less effective. Povidone-iodine (10%) is an acceptable alternative but also requires drying. Patients should also wash the fistula arm with soap and water before arriving for treatment.
Question 5: What action should be taken if a hemodialysis staff member receives a needlestick injury from a used dialysis needle?
- Complete the treatment first, then report the injury at the end of the shift
- Immediately wash the wound, report to supervisor, complete an incident report, and seek post-exposure evaluation (Correct answer)
- Apply antibiotic ointment and continue working without reporting if vaccinated against hepatitis B
- No action needed if the source patient is known to be HIV negative
Correct answer: Immediately wash the wound, report to supervisor, complete an incident report, and seek post-exposure evaluation
Needlestick injuries require immediate wound care, incident reporting, and medical evaluation for post-exposure prophylaxis (PEP) potential regardless of known source patient status.
Immediate steps: (1) Wash wound thoroughly with soap and water for at least 15 minutes, (2) Report to supervisor immediately, (3) Complete occupational incident/exposure report, (4) Identify source patient and obtain consent for bloodborne pathogen testing (HIV, HBV, HCV), (5) Seek medical evaluation within 2 hours for HIV PEP consideration (most effective if started within 72 hours), (6) Baseline testing of the exposed worker.
Question 6: During a hemodialysis treatment, the technician notices that the dialysate has a cloudy appearance. What is the most appropriate action?
- Continue treatment since cloudiness is normal from concentrate mixing
- Stop treatment, do not return blood, and report to the charge nurse and biomedical staff (Correct answer)
- Add more concentrate to clear the cloudiness
- Increase the dialysate flow rate to clear the cloudiness
Correct answer: Stop treatment, do not return blood, and report to the charge nurse and biomedical staff
Cloudy dialysate is abnormal and may indicate contamination, bacterial growth, or incorrect concentrate mixing; treatment must be stopped immediately.
Normal dialysate is clear and colorless. Cloudiness can indicate bacterial contamination, endotoxin contamination, precipitation of calcium-phosphate or bicarbonate salts (from incorrect proportioning), or dialyzer blood leak. Any of these can be harmful to the patient. The treatment must be stopped, the dialyzer and lines must not be returned to the patient, and the machine must be taken out of service for investigation and disinfection.
CCHT Infection Control 2
What is the recommended hand hygiene technique after removing gloves following patient care in a hemodialysis unit?