| Abstract|| |
Hepatitis C Virus (HCV) infection constitutes a major health issue in many hemodialysis (HD) units all over the world, including Saudi Arabia. Despite the isolation policy practiced in many dialysis units, the prevalence is still high. Current literature does not support isolation policy and actually points to the role of health care providers in transmitting the disease. This study has been conducted in a questionnaire format to investigate the nurses' knowledge about HCV and their practice inside the HD units. Structured questionnaires were distributed among 36 nurses in units with high prevalence for HCV (Group I) and 34 nurses in units with low prevalence (Group II). Comparison was made between the two groups. In both groups, 54% of nurses received their HCV education by nurse educator, 13% by physicians, 10% by both and 23% had no targeted education. There is no statistical difference in the providers of education between the two groups. Most nurses in both groups isolate patients on the line of HCV serostatus. The difference was observed in the method of isolation and the use of dedicated machines. Twenty-five nurses (69%) of group I practice ward isolation while 16 nurses (47%) of group II use this practice (P = .04). Twenty-five nurses (69%) of group I reported using HCV-dedicated machines in comparison to only seven nurses (20.5%) of group II (P = .001). All nurses in group II cleaned the machine surfaces and HD tables after each patient, while only 58% of nurses in group I did so after each patient, 39% at the end of the day and three percent never cleaned the surfaces (P <. 001). The number of dialysis patients cared for by a single nurse at a time in group I was 3.4 while in group II, it was 1.7 (P < .001). A mean of 2.5 gloves per patient were used by nurses from group I in contrast to eight gloves per patient used by those from group II (P > .003). In conclusion, HCV infection in high prevalence units is probably related to poor application of standard health precautions and that isolation does not prevent spread of the disease inside HD units. Improving the nurse: patient ratio and encouraging the liberal use of gloves, together with well implemented policies and practices, will result in a better control of HCV transmission in dialysis units.
Keywords: HCV, Hemodialysis, Isolation, Nurse.
|How to cite this article:|
Al-Ghamdi SM. Nurses' Knowledge and Practice in Hemodialysis Units: Comparison between Nurses in Units with High and Low Prevalence of Hepatitis C Virus Infection. Saudi J Kidney Dis Transpl 2004;15:34-40
|How to cite this URL:|
Al-Ghamdi SM. Nurses' Knowledge and Practice in Hemodialysis Units: Comparison between Nurses in Units with High and Low Prevalence of Hepatitis C Virus Infection. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Jan 23];15:34-40. Available from: http://www.sjkdt.org/text.asp?2004/15/1/34/32963
| Introduction|| |
Hepatitis C Virus (HCV) infection is considered one of the major health problems in a significant numbers of Saudi dialysis population.  The prevalence in different geographical locations was reported in 1995 to be ranging from 42-87%. ,,,, Despite the increasing awareness and the isolation policy practiced by most dialysis units in Saudi Arabia, the prevalence is still high.  Some units have significantly managed to decrease the prevalence to less than 20%, (personal communication) while the majority of units still suffer from ever increasing number of anti-HCV positive patients.  The Centre for Diseases Control (CDC) has published guidelines to deal with HCV infection in the dialysis population.  The major focus in most of this report points to the importance of applying the Standard Precautions by the health-care providers, together with special emphasis on disinfection policies and measures to prevent crosscontamination. This study was conducted in order to investigate the nurses' knowledge and awareness of HCV infection and to document their practice in relation to the application of the standard health precautions and CDC guidelines. The nurses' knowledge and practice were compared between units with high and low prevalence for HCV infection.
| Material and Methods|| |
Structured questionnaires were distributed to the nurses in six dialysis units in the Western and Southern districts of Saudi Arabia. Three units with high prevalence of HCV (73%) and three units with low prevalence (20%) were pre-selected. The questionnaire was designed to examine prior nurses' education regarding HCV, knowledge about HCV transmission, and their views of physician's involvement in HCV prevention.
HCV-related education is defined as any lecture, seminar or one to one mentoring, concerning the route of transmission and methods for effective prevention of HCV infection.
The questionnaire also examines the isolation policy, methods of disinfection and finally, the application of Standard Precautions. The nurses were requested to answer the questionnaires all at once without consulting with each other. They were requested not to go back to correct their answers. The nurses' answers were entered and analyzed by the SPSS-10. Comparison was made between nurses' responses of both groups. When appropriate, Chi-square or T test for the means was used and significance is considered if two-tailed P value is < .05.
| Results|| |
A total number of 70 questionnaires were distributed in the morning shift of the six dialysis units. The questionnaires were collected at the end of the shift with 100% response rate. [Table - 1] depicts the provider of education to nurses concerning HCV infection and prevention. In both groups, 54% of nurses received their HCV education by a senior nurse or nurse educator, 13% by physicians, 10% by both while 23% had no targeted education.
There was no statistical difference in the provider of education between both groups (P =.83).
[Table - 2] shows the nurses' knowledge on the mode of transmission of HCV among dialysis patients. They were asked to rank the mode of transmission to one as least likely and 10 as the most likely. In high prevalence units, nurses ranked blood transfusion (nine), and contaminated HD machines (seven) as highly responsible for HCV transmission. On the contrary, in low prevalence units, nurses ranked dialysis in other centres (7.8), nurse transmitting the virus from patient to patient (6.6), blood transfusion (six) and contaminated HD machines (six) as highly responsible for HCV transmission in the HD units. Nurses gave physicians intermediate rank of 5 to 6 in their concern regarding HCV infection and in their involvement in HCV prevention.
[Table - 3] describes the isolation practice and method of disinfection in units with high and low HCV prevalence. Twenty-five nurses (69%) in high prevalence units versus 20 (59%) in low prevalence units practice isolation of HCV positive from the negative patients (P = .35). The use of separate HCV positive wards and use of dedicated HCV positive machine is the prime mode of isolation practiced by 25 nurses in high prevalence units. In low prevalence units, four (12%) nurses practice shift isolation, 16 (47%) nurses practice ward isolation and 14 (41%) practice no isolation. All nurses in low prevalence units use heat disinfection after each patient and only one nurse in high prevalence unit uses such practice (P<. 001) Similarly, 28 nurses (78%) in high prevalence units use chemical disinfection after each treatment and none in the low prevalence units [Table - 3]. Seven nurses (19%) from high prevalence units only use saline rinse after each patient.
[Table - 4] outlines the difference between both groups in the application of the Standard Precautions and CDC guidelines. All nurses in low prevalence units clean the surface of machine after each patient, while only 21 nurses (58%) in high prevalence units clean after each patient, 14 (39%) clean the surface of the machine at the end of the day and one nurse (3%) does not clean the machine at all (P < .001). Similar to this is the cleaning of HD tables [Table - 4]
All nurses in low prevalence units describe glove box location to be next to dialysis machine while all nurses in high prevalence units point to central location of glove boxes (P <.001). Only one nurse in low prevalence units reports that patient ever asked her to change gloves before handling him, while 14 (39%) of nurses in high prevalence units had admitted patient asking them to change gloves (P < .001).
[Table - 5] outlines the various variables that might have some impact on HCV transmission among patients in high and low prevalence units. Nurses in high prevalence units dialyze 3.4 patients at a time, while nurses in low prevalence units dialyze 1.7 patients at a time (P = .001). Nurses from high prevalence units use 2.5 gloves per patient in contrast to eight gloves used by each nurse per patient in low prevalence units (P = .003).
| Discussion|| |
The CDC  has recommended a training and educational program for HD personnel before they begin working in the units. From this study, it was of interest to find that 23% of the nurses had no targeted formal education regarding this important health problem. Moreover, physicians had contributed to HCV-related education to only 23% of the nurses. This could explain the "intermediate rank of 5" for physicians' involvement in HCV-related education [Table - 2]. The two groups (high and low prevalence for HCV) did not have statistical difference regarding the provider of education or no education. This may suggest that education alone may not be the only factor for the difference in prevalence of HCV in these dialysis units. Evidently, monitoring and application of standard health precautions and CDC guidelines in high prevalence units are lacking.
The current literature does not consider dialysis machines to be responsible for transmitting the virus, although it indicates that inadequate application of Standard Precautions as primarily responsible for spread of the infection in HD units. ,,,,,, Although previous studies ,, have identified a correlation between HCV infection and the number of blood transfusions inside HD units, all transfused blood is presumably screened negative for HCV.
Thus, lack of proper and targeted education could explain nurses' perception about how HCV is transmitted. The role of a nurse in cross-transmission between patients was equally perceived by nurses in high and low prevalence units (5.8 and 6.6 respectively). Nurses in low prevalence units felt that patients may acquire the infection by undergoing dialysis in units with high prevalence for HCV. We had previously reported that dialysis in other centres is a potential risk factor for HCV transmission in Saudi dialysis units. 
Both groups practice patient isolation based on HCV sero-status. The only significant difference is that more nurses in high prevalence units use dedicated machines for HCV positive patients, a practice which is however, not supported by the current literature. ,,,, The current study failed to show significant protective effect of patient isolation or using dedicated machine. The most important finding is that 19% of nurses in high prevalence units use saline rinse after each treatment and they do not apply either chemical or heat disinfection. This is considered a breach of manufacturer's recommendation for machine disinfections. All nurses in low prevalence units apply heat disinfection after each treatment in contrast to high prevalence units, wherein 78% of nurses apply chemical disinfection after each treatment. This, however, may be related to the type of machine used in these units.
All nurses in low prevalence units clean the machine and table surfaces after each treatment, while only 58% of nurses in high prevalence units use this approach. This is a significant deviation from the CDC recommendations and may well be responsible for the high prevalence in those units.
Glove-use and physical location of glove boxes were investigated. All nurses in low prevalence units indicated that the glove box is located next to dialysis machine while it is centrally located in high prevalence units. This explains why the number of glove use per patient is statistically higher in low prevalence units than high prevalence units (8 and 2.5 respectively). This is another indicator of loose application of standard health precautions in high prevalence units reinforcing the need for changing gloves when moving from one patient to another. Importantly, the number of patients dialyzed by each nurse is much higher in high prevalence units compared with low prevalence units (3.4 and 1.7 respectively). Thus, the workload may adversely affect the practice and create a favorable environment for loose application of Standard Health Precautions. In fact Petrosillo et al  had found that understaffing in dialysis setting increases the risk of HCV nosocomial transmission.
Finally, our results suggest a significant role for nursing practices in the prevalence of HCV. However, we cannot rule out other patient-related risk factors for such different prevalence in the different areas, though to the best of our knowledge the patient population studied were homogeneous in terms of the known risk factors for the prevalence of HCV.
In conclusion, transmission of HCV infection is probably related to poor application of standard health precautions and that isolation or use of dedicated machines by themselves may not control the spread of infection in HD units. Improving the nurse: patient ratio and encouraging liberal use of gloves, together with strict application of standard health precautions, will result in better control of HCV transmission in dialysis units.
| Acknowledgement|| |
The author sincerely thanks all nurses who participated in this survey. Special thanks to Dr. Linda Luna PhD, Dr. Abbas Zagnoon, MD, Dr. E. Ibrahim, MD for the critical review of this manuscript.
This study is supported by the King Faisal Specialist Hospital & Research Centre' Health Outreach Program. Jeddah Saudi Arabia
| References|| |
|1.||SCOT Data: Dialysis in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transplant 2001;12(3):421-34. |
|2.||Al-Muhanna FA. Hepatitis C virus among hemodialysis patients in the eastern region of Saudi Arabia. Saudi J Kid Dis Transplant 1995;6(2):125-7. |
|3.||Al Shohaib SS, Abdelaal MA, Zawawi TH, Abbas FM, Shaheen FAM, Amoah E. The prevalence of hepatitis C virus antibodies among hemodialysis patients in Jeddah area, Saudi Arabia 1995;6(2):128-31. |
|4.||Bernieh B, Allam M, Halepota A, Mohamed AO, Parkar J, Tabbakh A. Prevalence of hepatitis C virus antibodies in hemodialysis patients in Madinah Al Munawarah. Saudi J Kid Dis Transplant 1995;6(2):132-5. |
|5.||Shaheen FAM, Huraib SO, Al-Rashed et al. Prevalence of hepatitis C antibodies among hemodialysis patients in the western province of Saudi Arabia. Saudi J Kid Dis Transplant 1995; 6(2):136-9. |
|6.||Huraib S, Al Rashed R, Aldrees A, Aljefry M, Arif M, Al-Faleh FA. High prevalence of and risk factors for hepatitis C in haemodialysis patients in Saudi Arabia: a need for new dialysis strategies. Nephrol Dial Transplant 1995;10:470-4. |
|7.||Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep 2001; 50(RR05):1-43. |
|8.||Jadoul M. Transmission routes of HCV infection in dialysis. Nephrol Dial Transplant 1996; 11(Suppl 4):36-8. [PUBMED] |
|9.||de Lamballerie X, Olmer M, Bouchouareb D, Zandotti C, De Micco P. Nosocomial transmission of hepatitis C virus in haemodialysis patients. J Med Virol 1996;49:296-302. [PUBMED] |
|10.||Caramelo C, Navas S, Alberola ML, Bermejillo T, Reyero A, Carreno V. Evidence against transmission of hepatitis C virus through hemodialysis ultrafiltrate and peritoneal fluid. Nephron 1994 66(4):470-3. |
|11.||Manzini P, Amore A, Brunetto MR, et al. Is hepatitis C virus RNA detectable in dialysis ultrafiltrate? Nephron 1996; 72: 102-3. [PUBMED] |
|12.||Stuyver L, Claeys H, Wyseur A, et al. Hepatitis C virus in a haemodialysis unit: molecular evidence for nosocomial transmission. Kidney Int 1996;49:889-95. [PUBMED] |
|13.||McLaughlin KJ, Cameron SO, Good T, et al. Nosocomial transmission of hepatitis C virus within a British dialysis centre. Nephrol Dial Transplant 1997; 12:304-9 [PUBMED] [FULLTEXT]|
|14.||Forns X, Fernandez-Llama P, Pons M, et al. Incidence and risk factors of hepatitis C virus infection in a haemodialysis unit. Nephrol Dial Transplant 1997;12:736-40. |
|15.||Al-Ghamdi SM, Al-Harbi AS. Hepatitis C Virus serostatus in hemodialysis patients returning from holiday: another risk factor for HCV transmission. Saudi J Kidney Dis Transplant 2001; 12(1): 14-20. |
|16.||Petrosillo N, Gilli P, Serraino D, et al. Prevalence of infected patients and understaffing have a role in hepatitis C virus transmission in dialysis. Am J Kid Dis 2001;37(5):1004-10. |
Saeed MG Al-Ghamdi
Department of Medicine, King Faisal Specialist Hospital & Research Centre-Jeddah, P.O. Box 40047, Jeddah 21499
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]