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Infection control practices in Canadian hemodialysis units.

Lam-Li, D., Newman, A., & the CHICA-Dialysis Interest Group. (2005, Fall). A survey of infection control practices in hemodialysis units in Canada. Canadian Journal of Infection Control, 20(3), 118-136.

Reviewed by Marsha Wood, BN, RN, MN, CNeph(C), Specialty Nurse Practitioner Nephrology, Capital District Health Authority, Halifax, NS, and Sheila MacDonald, RN, BN, CIC, Manager Infection Control, Capital District Health Authority, Halifax, NS

The number of people receiving hemodialysis treatments in Canada has increased over the last several years. The rate of incident renal replacement therapy rose 41% in Canada, from 1995 to 2004 (Canadian Institute for Health Information, 2006). At the end of 2004, there were 18,827 patients on dialysis (CIHI, 2006). People receiving chronic hemodialysis are at high risk for infection. High volumes of patients, dialysis equipment, invasive procedures to access the vascular system for long periods of time and compromised immune systems are some of the contributing factors for this increased risk. This increased risk for transmission of infection in our dialysis units warrants infection control practice based on the best available evidence.

This study was undertaken by a group of Canadian infection control practitioners in 2004 to examine infection control practices in Canadian hemodialysis units and was published in the Canadian Journal of Infection Control, 2005. The impetus for the study was the recognition of a paucity of Canadian guidelines to direct infection control practices in Canadian hemodialysis units where greater than 12,000 people received dialysis treatments in greater than 100 dialysis programs.

Guidelines set forth by the Canadian Society of Nephrology and the Kidney Foundation of Canada address only prevention of clinical infection and not prevention of infection transmission. American-based guidelines addressing the prevention of transmission of infections among chronic hemodialysis patients were released by the Centers for Disease Control and Prevention in 2001 (CDC, 2001). Since no Canadian equivalent existed, these American-based guidelines are largely accepted throughout the Canadian dialysis community.

The purpose of the study was to examine the infection control practices surrounding some infection control issues in Canadian hemodialysis units, assess adherence to the American-based guidelines and to determine the usefulness of existing Canadian-based guidelines.

The authors used a questionnaire survey based on questions that were posted by the Community and Hospital Infection Control Association of Canada Dialysis Interest Group. Questions were grouped under subject headings, and the survey was reviewed by infection control practitioners, two nephrology nurse instructors and a dialysis machine technical coordinator. The survey was rather lengthy, however, the intent was to capture as much relevant information as possible. The surveys were sent to all 108 Canadian health care facilities that provide hemodialysis and were listed in the 2004 Canadian Health Institute Directory. The name of the dialysis program and contact information was requested on the survey. The survey was e-mailed to infection control practitioners associated with specific hemodialysis programs. If no infection control practitioner could be identified, the survey was sent to the manager of the hemodialysis program. The survey was also posted on the Community and Hospital Infection Control Association of Canada website to allow infection control practitioners associated with small dialysis units and satellite units to respond. Participants had four weeks to complete and return the survey. A reminder was also sent via e-mail to those who had not yet participated. The survey return rate was very good at 44%.

Survey responses were received from 44% of Canadian dialysis units. Fifty-one per cent of responses were from in-centre units, 6.7% from pediatric units and 36% were from community-based satellite units. The survey elicited responses regarding the following areas of infection control practice: unit design, utilization of arteriovenous access type, carriage of MRSA, VRE, HBV and HCV, tuberculosis, influenzae and pneumonoccal immunization, infection precautions for patients with selected infections, infection surveillance, antibiotic utilization, antiseptic agents, hemodialysis access management, cleaning and disinfection, water treatment and hemodialysis waste.

The survey provides a fairly extensive description of infection control practices across Canada at a single point in time. The data are arranged into tables for easier visualization. The descriptive data demonstrated that there is little consistency among hemodialysis units regarding infection control practices, for example, the screening of patients for MRSA or VRE, screening for tuberculosis, or the use of antiseptic agents for central catheter or fistula care. Other areas of inconsistency include the lack of a single denominator for the calculation of infection rates for blood stream infection surveillance, a common infection in hemodialysis patients. Comparison among centres is difficult when data collection and infection rate calculation are inconsistent across different sites.

Generally, this article provides a good description of various practices in dialysis units across Canada. The study authors acknowledge that open-ended questions made it difficult to do extensive statistical analysis of the data. The review authors believe that this work is an important initial step in helping the dialysis community understand some of the current issues in infection control practices in Canadian dialysis units. The article clearly demonstrates that practice is varied, and highlights the need for the development of Canadian guidelines to assist in establishing some consistency among hospital-based and community-based programs. The survey results should stimulate many areas for further research around Canadian dialysis unit infection control practices and development of guidelines. Since this study was published, the Canadian Society of Nephrology (2005) released recommendations for the prevention of transmission of blood borne pathogens in hemodialysis patients. This demonstrates a growing interest in providing best infection control practices to protect our dialysis population. It also opens the door for dialogue and collaborative work to be done by the many health professionals involved in the care of people receiving dialysis in Canada.


Canadian Institute for Health Information. (2006). Treatment of end-stage organ failure in Canada, 1995 to 2004 (2006 Annual Report). Ottawa: Author. Retrieved from

Canadian Society of Nephrology. (2005, March). Recommendations from the ad hoc committee on the prevention of transmission of blood-borne pathogens in hemodialysis patients. Retrieved from

Centers for Disease Control and Prevention. (2001). Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR, 50(No. RR-5). Retrieved from
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Article Details
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Title Annotation:Research review
Author:Wood, Marsha
Publication:CANNT Journal
Article Type:Survey
Geographic Code:1CANA
Date:Apr 1, 2007
Previous Article:Good things come in threes: a review of three Canadian nephrology websites.
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