Making Dialysis Safer for Patients: Bloodstream Infections, Wall Boxes, and Lessons Learned

>> Hello and welcome to today’s Tune In To Safe Healthcare Webinar: Making Dialysis Safer for Patients: Bloodstream Infections, Wall Boxes and Lessons Learned, hosted by the Centers for Disease Control and Prevention My name is Lauren Moccia, and I am the coordinator for the Making Dialysis Safer for Patients Coalition This webinar is part of a series of infection control related webinars that CDC hosts, along with a variety of external partners and experts We thank you for tuning in today Before we get started, we have the following disclaimers to show And the following disclosures This webinar is accredited for physicians, nurses, pharmacists, dialysis technicians, certified health educators, public health professionals and other health professionals The next two slides show the accreditation statements for the continuing education Instructions for obtaining continuing education will be provided at the end of the webinar I would now like to introduce our speakers for today Our first speaker is Dr. Shannon Novosad Shannon is a medical officer with Dialysis Safety Team in the Division of Healthcare Quality Promotion, DHQP, at the Centers for Disease Control and Prevention Dr. Novosad received her medical degree from the University of Alabama at Birmingham In 2015, Dr. Novosad came to CDC as an epidemic intelligence service officer assigned to DHQP, where she investigated outbreaks in healthcare settings Her areas of concentration include prevention of central line-associated bloodstream infections, and increasing the safety of patients on dialysis Our next speaker today is Kristen VanAllen Kristen is an infection preventionist with DaVita, who has worked in dialysis for over 13 years, and has served as an in-center hemodialysis nurse, a clinical coordinator and a facility administrator before taking on the role of infection preventionist Kristen received a BSN from Regis University in Denver, Colorado, and an MSN from Western Governors University She has a certification in infection control, and a certification in nephrology nursing Our last speaker today is Robert Allen Whitney, IV Robert is the senior manager of biomedical services with DaVita He has a degree in electronic engineering, and currently oversees DaVita Technical Support and Quality Managers He has 30 years of experience in the biomedical industry, and has been with DaVita for eight years I would now like to turn it over to Dr. Novosad to begin today’s presentation >> Thank you As you all can tell by the title of this webinar, we’re going to be discussing bloodstream infections, wall boxes and lessons learned I’m going to spend the bulk of my time discussing an outbreak investigation of gram-negative bloodstream infections associated with wall boxes But first I’m going to discuss briefly the risks of water and plumbing in the healthcare setting, as this is critical to understanding the risk associated with wall boxes And then I will touch on some infection prevention and control measures we developed using the lessons learned from this outbreak investigation As a disclaimer, I will often use the word “water” when I am referring not only to water, but plumbing systems as a whole Meaning every use of water in the healthcare setting from the tap to the drains and even toilets where waste is emptied These wet environments support microbial growth, and serve as a source of pathogens, and potentially healthcare associated infections, or HAIs Tap water meets stringent safety standards in the United States, but it’s not sterile Certain numbers and types of bacteria and other microbes may be present when water leaves the tap For typical household uses, such as washing, bathing, drinking and food preparation, these microbes rarely pose a serious health risk In contrast, in healthcare settings the way we use water are more varied, and patients might be more vulnerable to infection There are particular microorganisms or pathogens that are associated with water Many or most of these pathogens are environmental organisms, and found in water under normal circumstances, and not necessarily contaminants of water Although, we frequently do refer to them as contaminants These include a wide variety of pathogens from gram-negative bacilli, gram-positive bacilli, fungi and free-living amoeba And I’ve already mentioned the risk to the general population is low Though, some special populations do exist, such as persons with cystic fibrosis, immune suppression and pre-existing lung damage Listed here on this slide are just a few of the water-associated pathogens that we see including Legionella, the group of pathogens known as non-fermenters, which includes Pseudomonas aeruginosa and Burkholderia cepacia complex Another group of pathogens the non-fecal coliforms These include Enterobacter, Klebsiella and Serratia species,

the non-tuberculous mycobacteria, and even fungi, such as Aspergillus Certain conditions within healthcare plumbing systems can even encourage microbial growth Meaning those opportunistic or environmental pathogens can multiply Some system issues that can lead to pathogen multiplication include disruptions and/or pressure drops, loss of disinfection residuals, renovations and the age and design of the system Altogether, this can lead to dangerously high levels of potential pathogens Pathogens that are present in water in plumbing have certain properties that make them hard to eradicate, including thermal tolerance, survival and growth under low oxygen conditions and slow growth These microorganisms also have a tendency to associate with and stick to surfaces These adherent organisms can initiate and develop biofilms A biofilm is an assemblage of microbial cells that become associated with or stick to a surface, and then are enclosed within a complex matrix of extracellular polymers, mostly polysaccharides and proteins that facilitate adhesion and provide a structural matrix The solid liquid interface between a surface and an aqueous medium, such as water or blood, provide an ideal environment for the attachment and growth of microorganisms These biofilms are difficult to remove, and may become irreversibly associated with a surface, such as a pipe or sink drain It is inevitable that biofilms will form in most water systems In the healthcare facility environment, biofilms may be found in the potable water supply, piping, hot water tanks, air conditioning cooling towers, or in sinks, sink traps, aerators or showerheads Biofilms, especially in water systems, are not present as a continuous slime or film, but are more often scanty and heterogeneous in nature The slide here shows a picture of the many ways that water can be used in the healthcare setting, and illustrates there are many possible avenues for patient exposure to water And where water can potentially lead to infections in patients from the patient rooms with sinks and showers to operating rooms, dialysis units, wastewater facilities and even lobbies where fountains or other decorative water features may be present, food services where water is used to prepare food, and the water treatment facility where the water is treated prior to circulating through the facility And there are other settings that are not shown in this schematic, such as the pharmacy where water can be introduced during the preparation of medications Given all of this, it’s not surprising that a number of outbreaks associated with water exposure have occurred in the healthcare setting This slide shows just a sample with different exposures across multiple settings, including an outbreak of non-tuberculous mycobacteria or in abscessus infections in pediatric dental patients associated with water exposure during procedures, another outbreak of NTM linked to humidifiers used during LASIK surgery in an outpatient clinic, and an outbreak of Pseudomonas associated with tap water in neonatal intensive care unit And similarly, in the dialysis setting, numerous outbreaks have been associated with water exposure, including an outbreak Serratia associated with contamination of injectable medications, and one of many outbreaks associated with introduction of pathogens during reprocessing of human dialyzers Now I’ll move to discussing the outbreak associated with wall boxes Gram-negative bacteria are an uncommon cause of bloodstream infections in hemodialysis patients, as a majority of bloodstream infections are due to gram-positive organisms, such as Staphylococcus However, as previously mentioned, gram-negative BSIs have been linked to water sources in this setting, including preparation of medications close to sinks, introduction of water into reused dialyzers, and incomplete disinfection of these dialyzers Here on this slide, we see our dialysis station, which as you all know consists of many parts in close proximity The arrow here shows one particular part of the dialysis station that we’re talking about today And this is the wall box They are sources of water located in a station that have not previously been investigated as a source of gram-negative bloodstream infections While boxes contain several connections that allow the dialysis machine to hook up to the water supply, as well as the acid and bicarbonate concentrates, as indicated here by the blue arrows In addition, waste lines from the dialysis machine can connect, and the waste can empty into the sanitary or municipal sewer system CDC first came aware of this outbreak via an algorithm used

to detect clusters and infections or outbreaks using data reported to the National Healthcare Safety Network, or NHSN, which is the largest healthcare associated infection surveillance system in the U.S. This algorithm detected a cluster of gram-negative bloodstream infections at a single facility CDC subsequently consulted with the state health department, where we found that three outpatient hemodialysis facilities, which we’ll refer to as A, B and C, each had large clusters of gram-negative bloodstream infections A number of different gram-negative organisms were identified, including Serratia marcescens, Pseudomonas aeruginosa and Enterobacter cloacae A common point source, such as a contaminated product, was considered possible as all three facilities were owned by the same company, and located in close geographic proximity In October 2016, an on-site investigation was initiated A variety of activities occurred, including a case-control investigation, infection control assessments using standardized CDC tools that included audits of CVC care, injection medication handling and hand hygiene Environmental samples were collected, and included swabs from multiple areas, such as sinks, dialysis stations, including prime buckets, counters adjacent to medication preparation areas, and in pods where infections occurred and wall boxes In addition, water samples were collected from sinks in the patient care areas and reverse osmosis tanks Pulsed-field gel electrophoresis, or PFGE, as well as whole genome sequencing, were used to compare patient and environmental isolates when organisms were the same A case was at least one gram-negative organisms isolated from blood during July 1st, 2015 to November 30th, 2016 in a hemodialysis patient treated at facility A, B or C. Case finding included review of facility electronic medical records, as well as queries of infection control staff at area hospitals A case-control investigation was conducted at facilities A and B, which were the centers with the greatest number of cases Each case was matched to one control on facility and symptom onset date And controls were excluded if in the two weeks prior they had evidence of infection In addition, we completed facility infection control assessments using some of the standardized tools we have developed at CDC, and included observations of central venous catheter care, injection medication handling and hand hygiene For patient isolates, identification and confirmation were performed using [inaudible] For environmental isolates, including the swabs and water samples, they were processed in methods to isolate the target organisms, specifically the gram-negative organisms of interest were used And as mentioned previously, PFGE and whole genome sequencing were used to compare samples when the same organism was present Shown here is an epidemic curve color-coded by facility As you can see, cases started as early as spring of 2015 The y-axis shows the number of cases, while the x-axis indicates a date of positive blood culture Each facility is shown in a different color, A in blue, B in orange and C in gray The box indicates the time of our investigation period, which was referenced earlier, when I introduced the case definition The arrow shows when the on-site investigation started Visually, this shows that this was a prolonged outbreak spanning over a year, with a large number of infections at each facility Shown on this slide and the next couple of slides are characteristics of the 58 cases These include a large number of gram-negative organisms isolated The most common being the Serratia marcescens, Pseudomonas aeruginosa and Enterobacter cloacae Twenty-eight percent had greater than one gram-negative organism isolated And when looking at outcomes, over 80 percent were hospitalized The median length of hospitalization was eight days And one patient died within two weeks of positive blood culture Fifty-eight cases occurred in 51 patients, where you’ll see the denominator is only 51 on this slide Shown here is the distribution of cases across facilities So for A, B and C, you can see again that a majority of cases occurred in facility A and B. And then moving on to dialysis treatment characteristics, the majority of cases of dialyzed after the first shift,

so meaning the second and third shift Fifty-five percent dialyzed Tuesday, Thursday and Saturday, while around 41 percent dialyzed Monday, Wednesday, Friday Only one underwent nocturnal dialysis And greater than 85 percent had a central venous catheter for dialysis access While more than 50 percent had greater than three staff involved in a single treatment session Moving on to the results of the case control investigation When looking at time on hemodialysis, more time on hemodialysis was protective So more than 26 months had lower odds of infection And then looking at some specific dialysis treatment risks in the case control investigation So dialyzing after first shift was associated with greater odds of infection And having a central venous catheter was, again, associated with higher odds of infection And then, finally, more staff in each dialysis session So having greater than three staff in a single session associated with higher odds of infection The infection control assessments we observed multiple missed opportunities for hand hygiene And we did observe that supplies in medication preparation areas were found to be adjacent to sinks, as seen on the picture here You can see circled in the blue, very close to a sink without a splash guard in place So, again, highlighting the different avenues that water could be introduced in this investigation We observed multiple times of inadequate aseptic technique during CVC care, and manipulation of CVCs and other vascular access sites after staff had touched the wall boxes Other practices we looked at for potential introduction of water include dialyzer reuse So shown again here on the slide is the epidemic curve But we added in arrows that shows when dialyzer reuse stopped at each facility So you can see that all the facilities had been reprocessing their dialyzers But facility A and C stopped right as the outbreak began And facility B stopped the following spring We had numerous opportunities to observe the wall boxes, where we saw that water and other liquid often drained into the basin, and frequently pooled there, as indicated by the arrows There is actually some water here in these pictures It’s just difficult to see against the white plastic of the wall box And then here on this slide, again, pictures that we took during the investigation But the hose there where the arrows are pointing, those are the air gaps in which frequently wastewater would bubble up through these holes And, again, contributed to the basins being frequently wet with visible pools of water or other liquids Interviews with staff revealed significant issues with wall boxes that were first noticed around early 2016, which included foul odors and clogged drains There were further reports that staff were not consistently performing hand hygiene after touching connections of the wall boxes So, for example, you can see on top image the waste line has been unhooked from the connection, and there’s visible sediment clogging the line In the bottom, there’s foam filling up the basin of the wall box We collected 43 samples from facilities A, B and C. Numerous gram-negative organisms were covered from the environment, as illustrated in the table here, including the three most common outbreak pathogens: Serratia, Pseudomonas and Enterobacter Every wall box sampled at all three facilities had at least one of these three organisms But in contrast, water samples of other surfaces and sinks rarely contained these three most common organisms We found no patient isolates were related across facilities by PFGE And because of these results, a single source among facilities was thought to be less likely However, a patient isolate was found to be related to a wall box isolate within a single facility, as illustrated by the PFGE shown on this slide Whole genome sequencing confirmed no related patient isolates across facilities, but again confirmed there was related isolates within facilities, and again confirmed the PFGE findings of the related wall box in patient isolates within the single facility, facility C. In addition, in another facility, a patient isolate was found to be related to a wall box isolate, further strengthening the association between wall boxes and patient infections Our lab findings were interpreted in conjunction with our epidemiologic investigation, infection control observations and staff interviews

Many potential water sources were identified, but did not contain the target organisms However, targeted environmental sampling and comparison of isolates using PFGE and whole genome sequencing helped to reveal an indistinguishable patient and wall box isolate in the same facility, and confirm a previously unrecognized source of infections Central venous catheters and increased staff involved with care were identified as risk factors, and support of general infection control breaches while dialyzing later in the day potentially indicated environmental contamination contributing to the infections But by themselves, these risk factors were unable to point to the source of infection Infection control assessments showed wall boxes could be a potential source of water, that they were malfunctioning and also providing mechanisms, such as poor hand hygiene, of which organisms can move from the wall box to the patient during central venous catheter care The facilities had already started implementing control measures We recommended that the affected facilities to decrease the risk of infections from the wall boxes they needed to continue to focus on two areas One, improve infection control practices, specifically central venous catheter care and hand hygiene; and to continue a routine wall box disinfection and declogging regimen So why is this important? There are greater than 6,500 outpatient hemodialysis facilities, and wall boxes are present in every facility We felt we needed to explore design aspects and disinfection protocols to decrease the contamination in the dialysis station wall boxes, and raise awareness amongst centers of this newly recognized source of infections So this led us to develop a list of infection control and prevention issues that we thought would apply widely to wall boxes from facilities across the country I’m going to first list out the issues, and they’re here on this slide, that we typically see associated with wall boxes And then we’ll dive a bit deeper into each one of these issues First, is that staff may lack awareness of infectious risks associated with wall boxes, and necessary infection prevention and control measures Two, wall boxes are part of the immediate patient care environment, and are considered contaminated or dirty Three, wall boxes contain drains that are predisposed to the development of biofilms Four, wall box drains may become clogged, and splashing and foaming at the wall box may occur And, finally, biofilms and wall box drains may contain opportunistic pathogens that can cause HAIs, or healthcare associated infections So, again, to dive a little bit deeper into number one, which is that staff may lack awareness of infectious risk associated with wall boxes and necessary infection prevention and control measures So, first, after hearing the presentation today, if you’re not already doing so, I hope you’ll all go back to your facilities and educate staff on the risks associated with wall boxes, and the practices to prevent wall box related infections, which we’re going to discuss One of the most important things you can do is perform hand hygiene after coming into contact with a wall box or any of its components This should be regularly reinforced and assessed to make sure compliance remains high Number two, that wall boxes are part of the immediate care environment, and are considered contaminated or dirty There are a lot of steps and strategies associated with this issue So they’ve broken down across a few slides But usually, as we always do, we’ll start with the policy Each facility should develop policies about the specific frequency and methods for wall box surface disinfection And then in regards to the actual cleaning of the wall box, the wall box should be disinfected at least daily Ideally at the end of the day after all patients have dialyzed cleaning and disinfection may be needed more frequently And cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during other patient care activities I’m going to go back to the slide before it, actually I forgot the two things there But be sure, as usual, to follow the manufacturer’s label instructions for proper dilution, preparation, contact time and use And suggestions for disinfection — disinfected selections are described within CDC’s notes for clinical managers Which you guys have probably seen before And then, finally, I mentioned there’s a lot for number two You should use an Environmental Protection Agency, or EPA, registered disinfectant And it should be applied to all surfaces of the wall box and any attached hoses Ensure high touch surfaces, such as the connections, are disinfected Wipes or other supplies used to disinfect the wall box should be discarded after use, and not used to disinfect other surfaces in the station So, for example, a wipe used on the wall box shouldn’t next be used on the — on the chair

And then, finally, more than one disinfectant wipe or application may be needed to ensure that all wall box surfaces are visibly wet For issue number three, wall boxes contain drains that are predisposed to the development of biofilms To help with this issue, your facility should consider having practices in place that decrease the rate of biofilm formation, and use these as preventative measures on a routine schedule for drains and traps Examples include using drain cleaners, drain gels or enzymatic cleaners And as stated before, chemicals should not be mixed, and follow the product instructions for use Issue number four, wall box drains may become clogged, and splashing and foaming may occur There are a few things that could be done to fix or help decrease this issue include — including utilizing the services of a qualified plumber to help remove clogs If the clogs persist or start happening more frequently, you may need to modify how often that plumber comes to work on the drain And a final strategy could be to use a different type of wall box There are many different types And an ideal wall box will separate dirty the waste line and drain from the clean, the acid bicarbonate and RO water supply connections, and/or relocate or reconfigure the air gap if foaming or splashing is persistent And then, finally, issue number five, biofilms in the wall box drains may contain opportunistic pathogens that can cause HAIs So for this, conducting routine surveillance, for example, monthly for HAIs including bloodstream infections, and regularly reviewing the results, can give you a hint that there may be problems occurring at your wall boxes Blood cultures positive for gram-negative organisms commonly found in water-related biofilms should prompt investigation into possible reservoirs in the patient environment, including wall boxes And you can always contact local or state public health authorities to help investigate potential wall box related infections and clusters Further, we identified some design features and other wall box attributes that may contribute to the likelihood that you will notice issues with your wall boxes, including smells, clogging and foaming, or that wall boxes will lead to patient infections through contamination of healthcare personnel hands or the environment Robert Whitney will discuss some of these features in more detail These include separation of clean and dirty Meaning dirty the waste line and drain from clean Again, the acid bicarbonate in our water supply connection areas Splash at your wall box For example, we saw in some of our visits that water or other liquids that actually splashed from the wall box out to some of the other equipment in the station, you could see evidence of this as it dried [inaudible] depending on how your p-trap is configured, it could mean that there’s a larger risk of the contamination from organisms And, again, the air gaps similar to the p-traps can contribute to how likely your wall box is to have some of the problems with the foaming and splashing and such So some take-home messages Wall boxes are a source of pathogens that can result in infection Hand hygiene should be performed after coming in contact with the wall box, or any of its components Environmental surface disinfection procedures should include the wall boxes They need to be regularly cleaned and disinfected at least daily And obvious wall box dysfunction should be addressed immediately, including splashing and foaming and clogged drains On the CDC website we have some of this information available, including kind of the list of infection prevention and control issues and suggested strategies, as you can see here And we recently published a description of this outbreak in AJKD as well And now I’ll turn it over to Kristin >> All right Let me share my screen Oh, there we go Okay. Hi, everyone My name is Kristen Van Allen And I’m going to be talking to you guys about how we increased our infection prevention strategies in order to reduce the risk of wall box contamination And then I’m going to turn it over to Robert Whitney to present the biomed portion So once the outbreak had occurred, we were faced with the challenge of how to prevent it from happening again in order to keep our patients safe We needed to take the knowledge gained from the investigation, and determine what changes needed to be made, and how to best make them So not only did we need to make the changes, but we also needed

to make them stick in over 25 — in 2,500 in center clinics We also continue to evaluate the policies and process, and make adjustments as necessary So, first, I’m going to explain the infrastructure we have here at DaVita as it relates to infection prevention So I work as an infection preventionist, or IP And our department consists of nine IPs who are all nurses And we are all either certified in infection control, or we are in the process of obtaining this certification We each cover approximately 350-plus clinics And we are responsible for educating the field on infection related subjects And we also do infection surveillance, and assist facilities with responding to their infections So after the outbreak, we developed a workgroup consisting of several infection preventionists in order to figure out how to best proceed Not only did we know that we needed to make some policy changes in order to ensure patient safety, but we had to figure out how to respond to gram-negative infections as they occurred in order to detect any potential clusters before they resulted in an outbreak So we came up with a plan that resulted in several changes, including, one, revisions to our existing infection control policy; two, field education, we wanted our teammates to absorb the new learnings and understand the why behind the policy changes, so they were more invested; three, we developed tools for the field, these were to help spot problems early on and prevent BSIs or outbreaks from occurring again; and then four, we also developed a response process and tools to respond to infections as they occurred So let’s start by reviewing the policy changes that we made So, first, to make immediate changes to teammate practices, we updated the existing infection control policy to be more clear around certain practices We made the following changes So we revised the station disinfection process to include disinfection of the wall box in the machine drain and water lines We added a statement that spray bottles should not be used to clean the wall boxes We added specific language to state to remove gloves, perform hand hygiene and put on new gloves, if necessary, after working in the wall box We addressed machine handling during transport to state that the drain and water line should not be draped or placed in the prime bucket in order to avoid contamination from the lines or dripping water And then we also added a statement to the infection control policy that teammates should report certain red flags to the biomed and FA that they see in the wall box, such as broken connectors or possible drain patency issues So, next, we worked on some education for the field We didn’t want to just make these drastic changes to the infection control policy, and leave it at that Sometimes new policy changes take a while to stick And if people don’t understand the why behind them, they may be less likely to comply Therefore, we decided to develop a Web Ex course that detailed the policy changes, and the why behind the change We sent this recording out to all of our infection managers that worked at the facility level And we asked them to share the information with our teammates We also sent it out to the managers of clinical services who are the nursing specialists that work with our clinics for them to review And we distributed it to our biomed teammates So we wanted to hit on several things in this education And we included the following Gram-negative pathogenicity, why are we so concerned about gram-negative bacteria We included the fact that they can be highly resistant to antibiotics Why the CVC is a risk factor in our patients The different methods of transmission And the common reservoirs in the clinic that might harbor these types of bacteria We also discuss cross contamination, so how this can occur during our normal workflow, and ways we might not have thought about in the past We educated the team on red flags in our wall boxes, so what should we be looking for to spot problems early on And Shannon covered a lot of those in her slides And then we also discussed the environmental services or housekeeping as an important part of the equation So then to take it a step further, and be a little more proactive, we updated our infection control audits to assist with the adherence of these policy changes We audit infection control practices in our facility monthly And now the auditor is asked whether

or not these policy changes are complied with In addition, we also created a one-page tool that is designed to help the manager of clinical services, the biomed or, really, whoever wants to use this tool Look at the environment and teammate practices for potential risk factors This was so that we could take more of a proactive approach to ensure patient safety Any teammate can use this tool, and give feedback to the facility administrator in order to get problems resolved So at this point, we’ve addressed policy, we’ve educated the team, and we created a prevention tool However, as infection preventionists, we felt we needed to be proactive if we did see a gram-negative bloodstream infection occur in one of our facilities So over a series of several months, the workgroup met weekly in order to develop a process that would allow us to respond to each event that occurred So out of this workgroup came several tools, including a surveillance algorithm that assisted the infection preventionist with decision-making, a standard communication template to make the process easier This makes sure that the process is uniform and easy for the infection preventionist to execute We developed a patient clinical summary form to get more details on each patient We developed a facility-specific process audit to the modes of — I’m sorry — a facility process audit that was specific to the modes of transmission usually associated with these types of pathogens And then we created a standard form to assist facilities with holding governing body meetings In addition, this little visual at the bottom here is a standardized tracker that we created to assist the infection preventionist with keeping track of everything going on in their facilities, and that would allow us to detect clusters earlier So the process — for the process, first, we start off with the identification of a gram-negative BSI And we do look at both internal and external blood cultures, anything that’s reportable in NHSN So once the infection preventionist identifies a gram-negative bloodstream infection, we use the algorithm to determine the next step in regards to whether to jump to the full process, or just a request in clinical information first So we look at a surveillance — a facility surveillance history to determine if it’s the first gram-negative BSI in 90 days And if there is, we just send the clinical summary However, if the facility has a history of more than one gram-negative BSI, we’re going to escalate it a little sooner So if this is the first gram-negative, we send the email to the facility requesting that they complete the clinical summary on the patient So this clinical summary just has some basic questions that look for a source for the BSI So once this form is returned, the infection preventionist reviews it, and goes back to the process algorithm developed to determine the next steps If a source has been identified, and it is determined that the infection is from a wound or UTI or some other source not related to transmission in the facility, we do ask for supporting documentation, and we close the case out However, if the facility — I’m sorry — if the source is undetermined, we send the facility process audit which asks questions regarding teammate practices and the environment So examples of things that are on the audit include wall box cleaning, prime bucket cleaning and the status of the drain So when the facility process audit is returned, we review it and schedule a call to close the loop, and assign action items to the facility These action items might include holding an in-service with our teammates on station disinfection, or reaching out to the biomed to resolve any drain issues that are present in the facility They may include patient specific actions, such as patient education, as well as facility-level actions So the facility completes the actions that are assigned by the infection preventionist And a governing body is held And it’s documented in the quality assessment and performance improvement notes The IP continues to keep eyes on the facility using the tracker to ensure that we’re not seeing a cluster or a trend So as this process has evolved, we do continue to update the tools and forms based on feedback from both the teammates in the field and from the infection preventionist We are actually on version 25 of these tools We’ve also taken learnings from this process, and developed what we call homeroom lessons for staff education and competency We were able to develop specific homeroom lessons around topics such as wall box cleaning, station disinfection

and CVC kitting among others This process has allowed us to identify areas in our policies and procedures that may need clarification or vision in regards to infection control And we have also formed an infection preventionist workgroup that is specifically assigned to reviewing and updating these policies In addition, we were able to identify gaps in our current infection control audit We added a piece on housekeeping to ensure that these services were being performed appropriately by our vendors And, lastly, we have shared what we call case studies with other infection preventionists so that we can learn from each other So it’s difficult to quantify the impact of these changes alone, because there are so many confounding factors So I can’t give exact statistics But I can say that the facilities are letting me know when they have a gram-negative BSI now They’re actually filling out that form, and sending it to me, because they’re so hyper aware of these And our clinical services managers are bringing potential issues to our attention And we’re working very closely with biomed to get these resolved as quickly as possible So now I’m going to turn it over to Robert Whitney to address drain issues >> Thank you, Kristen And hello, everyone This is Robert Whitney What I’m going to be covering today is addressing dialysis drain issues from a biomed standpoint So what we’ve seen is issues in our facilities with clogs, foaming, odor and drain flies So to address these issues from a national team perspective, we put together an assessment to provide the frontline teammates with recommendations for what issue they’re having And what I’m going to share today is what that assessment looks like So first thing we are going to look at is the drain slope What we’re looking for here is a quarter inch per square foot drain slope So no process that we put in place is going to work if our drains are running uphill So if we do see that scenario where our drains are uphill, we’re going to ask the teammates at that point to work with a plumber to fix the issue Next, we’re going to look at foaming problems What we typically see here is foam buildup over our drain pipes And what we do to correct this is put two 45-degree angle fittings to change the velocity of flow So, for an example, it’s like pouring a coke into a glass If you pour it in the middle of the glass, it will foam up But if you pour it on the side, it doesn’t tend to foam as much And we’ve been successful with implementing that And, again, we’re going to ask the teammates to work with the plumber to get this action taken care of The next thing we’re going to look at is clogs We want to make sure that our water box’s floor drains are clear of any debris Things that we typically find is dialyzer caps, trash, saline caps and bloodline caps So any debris in our drains can play — can provide a place for protein buildup, and cause a clog So we want to ensure that any debris is removed from our drains before we move forward with the assessment After our drains are free of debris, we want to ask our teammates if they have any kind of protein buildup And what we’re going to be looking at is chase boxes, floor drains, chase drain lines, machine drain lines So all depending on where they’re having the issues to what our recommendations may be at this point Next slide, please The next thing that I want to address is odors We need to understand where the odors are coming from, whether it’s from our chase boxes, from our floor drains And then we can provide the proper recommendation to take care of the issue Then we want to look at air gaps We want to make sure we have sufficient air gaps And what we’re looking for here is one inch of air gap, or what local plumbing codes are requiring Next thing would be studor vents These are the vents in the drain lines themselves that allows proper drain flows So they actually dent your drain lines So it’s important that these are operating correctly What we’ve seen in the past is drain flies clogging up the vents, and preventing them from opening correctly And, again, a plumber may be necessary to get these studor vents replaced But if we do see them being clogged, we want to get them replaced as well The next thing is flies If there’s an infestation, we want them to contact an exterminator,

and set up treatments to remove the flies And when they’re treating, they need to think about treating the entire facility, because if you treat one location, they will move to where you did not treat, places like old breakrooms, reuse rooms, or any room that you haven’t been in in quite a while they have a tendency to move to And we want to make sure that our kitchens are also addressed We don’t want to leave them out in this practice The next thing is machine drain hoses We want to ensure that there is no buildup in our machine drain lines If so, if we do find them with buildup, we want to replace them or clean them, whichever option works the best And we want to make sure that there’s no restriction in our drain lines, like quick disconnects, because this can provide a place for buildup as well in these connections And we want to make sure that our drain lines are free-flowing So that’s some of the things that I wanted to cover from our assessment And I want to thank you for your time on today’s call >> Thank you, Robert I want to thank all of our speakers today for their insight We do have a few minutes to go over some questions that came in So the first question I have is for Dr. Novosad Of all the interventions mentioned in today’s presentation, is there one you feel that is the most important takeaway, or the one thing we should be bringing back to our facility for training? >> I think — I mean, obviously, a lot of the things we talked about are of various importance, I think depending on, like, what exactly the wall boxes look like in a particular facility But I think the one thing that can really apply universally is the recommendation surrounding hand hygiene We didn’t get into a lot of details during the presentation We did mention, you know, that there were two different facilities where we found matching patient and wall box isolates And, in fact, in one of the facilities, we really didn’t notice much wall box dysfunction in that particular facility We did see the wetness that we talked about But we weren’t seeing the clogging or the foaming or any of the smells But, again, we’re still seeing patient infections that we thought were related to the wall boxes So I think hand hygiene is something that if universally practiced across all facilities in particular, you know, with some of the highlights after coming into contact with the wall boxes, that, you know, patient infections that could be happening without over a wall box dysfunction, you know, could be prevented >> Great. And one other question for you, Dr. Novosad is do we know the extent of how widespread this issue is of wall boxes causing infections in dialysis >> Um, no, that’s a great question But, no, we really don’t know how widespread this issue is You know, for example, in this investigation, we were able to define this association between wall boxes and these infections But, again, there was a really large number of infections across multiple facilities And while we, you know, can say that some of the infections were associated with wall boxes, we don’t know that all of the infections were So, again, even in this case, we can’t give an exact number, you know, or an extent of the wall boxes And we don’t know if this is occurring at, you know, a smaller level across, you know, many facilities across the country, or how many of the gram-negative infections we see are associated with wall boxes So, again, it’s something we suspect could be occurring, you know, more widespread But, you know, based on the information we have now, we’re not able to put an exact number on it >> Great. Thank you The next question I have is for Robert Have you ever observed just one symptom of biofilm formation, such as an odor with no foaming, or other visible issues? Or do you typically see multiple issues appear together? >> Well, I will say it is definitely a mix of issues out there We have seen where it’s been one issue But most of the time, what we’re seeing is multiple drain issues That’s why I think it’s so important to put in place a drain assessment, so you can ensure that you’re catching all of the facility’s issues that they may be having >> Great. Thank you, Robert And then we had one other question come in You mentioned having to remove any debris from drain lines that may have fallen into the line, such as dialyzer caps or other items What is the easiest way to remove these items? Or how do you go through that process? >> Well, I would ask the teammates to ensure that they’re wearing proper PPE before reaching into the drain lines But most of the time, we put on proper PPE, and reach in and just remove whatever debris there may be >> Great. Thank you >> Yes, ma’am >> Kristen, I have a question for you that came in How did the staff receive and react to the new education and training you put in place? Were they receptive? Or was there some pushback initially? >> No. Everyone was actually really receptive to it

It was — it’s actually really interesting information And I think it was kind of like, you know, a newly documented source And we all just want to keep our patients safe So they were happy to watch it, and learn more about how it happened >> Great. And then you mentioned that you asked the staff not to drape the lines into the prime buckets Can you expand more on what staff now do instead? >> Sure. We actually have them put a glove over the end of the line to avoid the water dripping on the floor, and like I said, into the prime bucket And then some facilities have actually worked with biomed to get hooks installed that can be easily cleaned, and will stay on the machines And they wrap up the drain lines on that Or the other alternative, they can still drape them on the IV poles But then we make sure that they’re not dripping water, and they’re certainly not dripping them in the prime bucket So the gloves on the ends really help >> Great. Thank you So moving on, to obtain continuing education for today’s presentation, you will need to visit the TCEO website at If not previously registered, you’ll need to complete a short registration process And then once logged in, you can utilize the Search Courses tab, and type in the keyword “WD2720-121019,” or you can search by the title of the webinar There is no code associated with this webinar So you should be prompted to then complete the continuing education assessment, the evaluation and post-test And you need to score at least 80 percent to receive the continuing education There are no fees for this continuing education credit So I want to thank everyone for joining today And I hope you enjoy the rest of your day