A Checklist for Dialysis

Posted on by CDC's Safe Healthcare Blog
Staff volunteers demonstrate the use of scrub-the-hub protocol checklist
Staff volunteers demonstrate the use of scrub-the-hub protocol checklist

Guest Author – Gemma Downham, MPH
Infection Prevention Epidemiologist,
AtlantiCare Regional Medical Center

We have all heard about the heroic feat of
Captain “Sully” Sullenberger when he performed
an emergency landing of a passenger jet on the Hudson River in 2009. It was amazing that no
lives were lost during that potentially disastrous situation. Checklists, which have been used for decades in the airline industry, were said to have helped Captain Sully and his co-pilot run through tasks to attempt to restart the engines—and when all else failed, perform an emergency landing.

Dr. Atul Gawande, professor of surgery at Harvard Medical School and bestselling author, has advocated in his book, The Checklist Manifesto, for the use of checklists in medicine to improve patient outcomes in surgery, prevent infections, etc., by reducing the potential for human error. So, when one of the nurses in our dialysis unit asked for a checklist for putting catheterized patients on and off the dialysis machines, I was both delighted (and overwhelmed.) Where to start?

Luckily, the CDC Dialysis BSI Prevention Collaborative had just devised a new scrub-the-hub protocol and published it on the website in checklist format. We held an in-service with “Dialysis Dan” (our simulation dummy with a catheter), and staff volunteers demonstrated use of the scrub-the-hub protocol checklist. We went through each step so that everyone knew the proper order for disinfection of the catheter limbs and hubs, and how to prevent contamination of the catheter ends after disinfection. Staff feedback indicated that the checklist was useful as dialysis turnover can feel very rushed, and it’s not easy to remember all of the steps. Further, we have recently welcomed new staff members to our unit, and the checklist has proven helpful for orienting them on the proper steps for aseptic catheter connection and disconnection. We even keep laminated copies of the protocol checklist on the dialysis station clipboards to which staff can refer.

In our next blog, Dr. Priti Patel will discuss how these checklists and tools are protecting dialysis patients. In the meantime, tell us what novel strategies you are using to protect your patients? How have checklists or other tools assisted you in providing better patient care?

Posted on by CDC's Safe Healthcare Blog

5 comments on “A Checklist for Dialysis”

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    Thanks for your comment. We agree with Dee that using antiseptic solution on nonsterile gauze (by pouring or soaking) is not the best approach to disinfecting open catheter hubs. Outbreaks have been associated with multi-use containers of antiseptic solution that have been diluted or handled inappropriately. In addition, non-sterile gauze can be contaminated with bacteria that might not be eliminated by applying an antiseptic. A recent outbreak possibly associated with nonsterile alcohol swabs that were contaminated with Bacillus is one illustration of this point. Facilities should use sterile antiseptic pads to disinfect catheter hubs. Dee also highlighted that there are several steps of the Scrub-the-Hub protocol that lack complete detail on exactly how they should be performed– e.g., how long do you have to scrub and in what direction? The answers to some of these questions are unknown because of a lack of data to help define the precise steps involved in this process. The most important parts however, are to remove debris (e.g., dried blood) by scrubbing the hub with friction and to disinfect the hub of the catheter after removing the dead-end cap. These two essential steps are specified in the protocol.

    The information about dialysis is very useful and i got more information and awareness about that.The CDC info is very useful.

    We monitor and track BSIs on our unit with help from a CNS and the ID dept. Our CNS took containers and mounted them to the wall in every patient room to keep alcohol preps, dead enders, and tubing change stickers in. So it’s all right there at our fingertips. They did random audits and presented it at clinical practice to spread the word. We’ve been using the containers for over a year now and our BSI rates declined dramatically. I believe the CNS wrote her project up and presented it at the January NDNQI conference.

    I was surprized to see the CDC scrub the hub campaign. My problem with it is that it did not give any detail to how the scrub would be accomplished without contaminating the open end of the catheter. As you well know, the catheter cleaning technique in the dialysis facility is a clean technique. Observations of catheter cleaning using this process, usually reflect the “clean” disinfectant soaked material being dragged over the sterile opening of the open CVC lines. I was always taught that nothing that is not sterile and fragment free should be used over a sterile port. I am open to any comments and suggestions…

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Page last reviewed: August 16, 2012
Page last updated: August 16, 2012