The AskASN Chat: Follow up FAQs

The AskASN Wrap Up 

We had a fabulous discussion on the various facets of being a dialysis center medical director, and the resources available from the ASN:Excellent Patient Care workgroup. 

Thanks to the ASN:EPC experts who helped prepare these FAQs:

Among the helpful resources brought up during the discussion were:


The following are some of the questions brought up for discussion, along with the answers form the ASN:EPC expert team. 

 Preventing Outpatient Dialysis Infections as a Team 

Do national regulations require dialysis to have a designated infection prevention (IP) specialist in the facility?

  • Despite what we might think, there is NO national regulation requiring outpatient dialysis facilities to have a designated IP role on staff in the facility, though individual state requirements may be different. 

  • Another exception to this may be outpatient dialysis facilities that are affiliated with hospitals. For those facilities, one of the hospital infection prevention specialists may cover the facility, but they are not typically present in the facility at any given time. Another exception is one of the large dialysis organizations (LDOs), which may have IPs assigned to large regions of the country, but not always to individual facilities. 

  • As nephrologists, we need to be aware of the dialysis staff present at the facility and that we may be working directly with the facility manager, charge nurse, or other front-line staff to address infection prevention and control issues or concerns. 

What can nephrologists do to assess infections?

  • Ask patient about symptoms of infection like fevers, chills, rigors or malaise

  • Examine to assess for localized erythema and cellulitis

  • Assess for an abscess or localized collection with an arteriovenous access

  • Assess for purulence at the exit site / tunnel for a tunneled central venous catheter

What should be done after an access infection in the dialysis unit?

Treat each infection as a QI opportunity. See what could have been done differently and work as a part of the team to implement educational workshops and perform periodic audits!

 Which empiric antibiotics should be used in the setting of suspected access infection?

Always use coverage for both gram positive and gram negative infections. Vancomycin and ceftazidime are good options but the choice will also depend on which antibiotics are available in the HD unit. Do not rule out using the occasional aminoglycoside (taking care when there is residual renal function). 


Section 2:  What a Nephrologist Needs to Know About Water Systems  

What is chloramine, why must we assure it is removed from dialysate, and what component of the water system removes it?

Chloramine is formed in the potable chlorinated water sources we use to compose hemodialysate. It is calculated by subtracting free chlorine from total chlorine. Chloramine can cause hemolytic anemia in an exposed hemodialysis patient, with complications of this RBC destruction. The 2 carbon tanks in series (primary and secondary) remove the chloramine, and the water exiting these tanks is tested regularly with chloramine test strips.

What is the purpose of the water system carbon filter, and what is the purpose of the RO membrane?

The carbon filter removes chloramine, and also endotoxin and organisms such as viruses and bacteria. The RO membrane removes 96% - 99% of all solutes

So what to do if there's a high level of chloramine?  Does the whole unit have to shut down?

There are usually 2 carbon tanks. If the first has chloramine escaping the effluent -- and the 2nd (scrubber) is chloramine-free, you can use the water to make dialysate for hours until the first tank is replaced. If chloramine is detected in water leaving the 2nd tank the unit has to shut down.

The specific sequence to follow in the event of breakthrough after Primary Carbon:  

  1. Testing for chlorine/chloramines at the sample port directly following the Secondary Carbon tank.

  2. Increase testing frequency (hourly) of the Secondary Carbon tank sample port.

  3. All carbon tanks have to be replaced or re-bedded with new carbon within 72 hours of breakthrough.

  4. If the chlorine/chloramine level exceeds the CMS limit, following the Secondary Carbon tank, then dialysis must stop.

What responsibility does the dialysis facility medical director have for the water system?

The medical director is ultimately responsible for the quality and safety of the water system and the hemodialysate it produces. Cultures and endotoxin sampling must be done before routine disinfection of the system, and the medical director is involved with the quality assessment and performance improvement (QAPI) activities monitoring the water system.

Figure from the Renal Fellow Network on Water Treatment 


Section 3:  Infection Prevention and Control at Outpatient Dialysis

How do I find the most up to date resources on dialysis infection control?

 A great starting point is the CDC dialysis safety homepage.  Just go to CDC.gov and type “dialysis” in the search bar. The Nephrologists Transforming Dialysis Safety (NTDS) and Making Dialysis Safer for Patients Coalition websites also have a wealth of curated information and resources.

What exactly are the CDC Core Interventions?

These are activities that have been proven to reduce hemodialysis bloodstream infections (BSI) including hand hygiene observations, CVC/vascular access care observations, patient education, and protocols for skin antisepsis and catheter hub disinfection. 

I know what an iPhone is….what is an ICAR?

ICAR stands for Infection Control Assessment and Response Tool.  From the CDC dialysis safety page, go to “Audit Tools and Checklists”.  You’ll find more at this link (PDF) a specific tool for HD facilities.  This can be used to identify gaps or issues in infection control that can be used for QAPI and active (not reactive) prevention of infections.

As medical director, who can help me in the dialysis facility with infection control?

While the Medicare Conditions for Coverage assigns oversight of infection control to the medical director, infection control is the SHARED responsibility of the entire dialysis facility.  This includes patients.  NTDS has created a special patient education tool called “LET’S RESET” that can be used to empower patients and staff to speak up and communicate more effectively as a team. Access all the ASN:EPC learning resources at this link. 

ICAR assessment is a pro-active way to introspect and implement changes in the dialysis units for better infection control practices.  How can I get an ICAR assessment for my dialysis unit?

Because it’s voluntary (and not regulatory or punitive), someone at the facility (or representative of the facility) must reach out to the State Health Department. Here’s the FAQ for a dialysis facility (PDF) in Virginia.  

If you are a medical director in Minnesota for example, this page would help you participate. Dialysis facilities are eligible. 

As medical director, you have authority under CfC to direct your facility to participate.  But remember it’s a TEAM you lead that can help you. Also, inviting the State health department proactively may be something you and your staff are new or unaccustomed to doing.

You should partner with your clinic manager and IDT to make sure they understand the ICAR’s purpose and utility first. You should get help from the appropriate dialysis organization administration so everyone is able to plan and coordinate efficiently for an ICAR.