| Abstract|| |
In the developing world, the prevalence of Hepatitis C Virus (HCV) infection in the hemodialysis (HD) units is high. Poor adherence to infection control measures is considered the main predisposing factor. In Tripoli's HD units, the prevalence of HCV is high although isolation of HCV positive patients is routinely practiced. In this short questionnaire study, the degree of adherence of our HD nurses, to the infection control measures was examined. The study was conducted in May 2004; sixty responses were collected from nurses working in the three main HD units in Tripoli. When compared with nurses working in other HD units with low HCV infection prevalence, it was found that our nurses' adherence to the standard infection control measures was poorer (p<0.001). The other significant problems found were irregular supply of some of the essentials needed for HD, and understaffing of the units (p = 0.000l). HD is a financially expensive way of treatment, especially in the developing world. HCV infection adds to its costs as well as to the patients' suffering. We need to pay more attention to the application of the simple infection control measures in our dialysis units.
|How to cite this article:|
Buargub MA. The General Application of Standard Health Precautions in Tripoli Hemodialysis Units. Saudi J Kidney Dis Transpl 2005;16:201-5
|How to cite this URL:|
Buargub MA. The General Application of Standard Health Precautions in Tripoli Hemodialysis Units. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2020 Aug 11];16:201-5. Available from: http://www.sjkdt.org/text.asp?2005/16/2/201/32942
| Introduction|| |
The prevalence of hepatitis C virus (HCV) infection in hemodialysis (HD) patients is high, especially, in the developing world,  adding to the morbidity, mortality and costs of medical care.
To combat this problem, different measures have been undertaken world-wide, including publishing of guidelines like the Center for Diseases Control (CDC) recommendations for HD units. 
In our HD centers at Tripoli, the prevalence of HCV infection is high and estimated to be between 40-90%, inspite of segregation and universal use of dedicated machines for HCV positive patients.
Non-adherence to universal infection control precautions is considered the most important independent risk factor contributing to the high prevalence of HCV in the developing countries. 
Al-Ghamdi published their data recently  which prompted us to conduct this short pilot study in the three main chronic HD units in Tripoli. The aim was to compare the standards of infection control in our units with that in the units with low HCV prevalence.
| Method|| |
A questionnaire similar to the one used in Al-Ghamdi's paper was distributed to the nurses working in the three main units of HD in Tripoli in May 2004.
The questionnaire examined the nurses' sources of knowledge, patient isolation practice, infection control measures and nurses' experience and interest in their job.
Sixty answers were received; they were compared with the answers from the low prevalence units in Al-Ghamdi's study which was used as the control group.
| Statistical Analysis|| |
Statistical significance was assessed using the chi-square test when the difference between the two groups was assessed, and using the Z-statistic when comparing between means. P was considered as significant if < 0.05 and highly significant if < 0.001.
| Results|| |
A total of sixty responses were collected from nurses working at the three HD centers in Tripoli (Al-Shat, Tajoura and 2 nd of March HD centers). [Table - 1] shows the source of the nurses' education. When asked about their sources of HCV-related education, 35 out of 60 (58%) stated that they depended on the information they had before their graduation, 11 (18%) stated that they had their information from the doctors working at the HD units while 14 others (23%) indicated that they had no clear source of information. When this result was compared with the control group there was no statistical difference between the two groups.
[Table - 2] shows the isolation policies in the three units. In all three units, there was a universal (100%) use of dedicated machines for HCV-positive patients. Separate wards for HCV-positive patients were used by 71% of the responders. Statistically, this was highly significant (P <0.001) when compared with the control group.
HCV-positive patients were used by 71% of the responders. Statistically, this was highly significant (P <0.001) when compared with the control group.
[Table - 3] shows the method(s) of disinfection used for the HD machine. In our units, only 16 out of 60 responders reported the use heat disinfection after each HD session compared with 34 of 34 in the control group. Twentysix used both chemical and heat disinfection according to the manufactures' guidelines, and 11 stated that disinfection depended on the availability of the machines' specific sterilizing solution.
[Table - 4] compares some of the health control measures followed in the HD units. In the units studied, only 20 out of 60 responders (33%) cleaned the surface of the machine after each HD session while 23 out of 60 (38%) cleaned the table and the chair after each HD session. When compared with the control group this was highly significant (P <0.001).The rest of responders either never cleaned as a routine or cleaned only if they saw blood stains on the surface.
A total of 16 (26%) stated that the gloves were located next to the machines compared with 100% in the control group (P<0.001). Only 38 (60%) stated that there was a free supply of gloves. However, 50 out of the 60 also mentioned that on occasions, the supply was quite limited. The mean number of gloves used by the nurse for each patient was 3.1 compared with eight in the control group which again was highly significant (P<0.0001). In addition, it was noticed that hand washing between patients was not routinely practiced in the study group
[Table - 5] shows a comparison of other risk factors for HCV transmission. There was no difference between the two groups regarding the nurses' duration of experience in HD units. However, the mean number of patients dialyzed by each nurse at one time was 4.9 in our groups compared with only 1.7 in the control group. Statistically, this was highly significant (P 0.0001) and it indicates a low personnel/ patient ratio
Additional information about the nurses' interest in their job and their main complaints is shown in [Table - 6]. We found that 51% of the nurses were not satisfied with their job, and that their main complaints were low salaries (75%), lack of promotions (95%) and the fear of acquiring viral infections (95%).
| Discussion|| |
The mechanisms responsible for transmission of HCV among HD patients are not entirely clear. Blood transfusion is no longer considered a major risk, and attention has focused on intra-dialytic procedures and environment.  Thus, HCV transmission from patient to patient can occur through contaminated HD equipment or through contaminated environment like nurses' hands, tables, chairs, clamps, doorknobs, blood pressure apparatus, tourniquet, multidose vials, etc. , To minimize this risk, it is essential to adhere to the standard infection control measures according to the international guidelines. In addition, regular serologic testing, active surveillance, training and education of the staff is required. 
The special precautions required in dialysis units include wearing disposable gloves when caring for patients or touching the patient's equipment at the dialysis station, removing gloves and washing hands between patients, cleaning and disinfecting the dialysis station (chair, bed, table and machine) between patients. 
In Al-Ghamdi's paper it was shown that the higher prevalence rate in the studied units was probably caused by the poorer application of standard health control measures. Since there was a problem in finding low prevalence units in Tripoli for comparison, it was decided to use the lower prevalence units in Al-Ghamdi's study as our control group. This was based on the observation that the two groups come from somewhat similar population in regards to social, cultural and general educational background.
The results of this study are in support of the original study, and the significant findings are as follows:
First: 23% of the nurses had no clear source of information regarding HCV virus infection and most of them used the knowledge they had before their graduation. The participation of doctors in nurses' education was poor (18%). Also, there was no continuous targeted educational program.
Second: Use of dedicated machines for HCVPositive patients is a routine in our units, although clinically, it did not have a significant protective effect. Thus, in the presence of high HCV prevalence, the risk of HCV transmission is not reduced by patient segregation. 
Third: Important deviations in standard infection control measures were found including;
a) Problems with HD machine disinfection. Although nurses did follow the manufactures' guidelines, to use both heat and chemical disinfection after each use, there were occasions when the machines' specific sterilizing solution was not available and the nurses had to use saline rinse only between patients.
b) Only 33-38% of the nurses routinely cleaned the surface of the machines, tables and the chairs between patients. Thus, the majority either never did the cleaning, or did so only if they saw blood stains on the surface.
c) 60% of nurses stated that gloves were freely supplied in their units, but, 83% stated that there were occasions when the supply was quite limited. Gloves were located in a central position in 73% of cases and not next to the HD machine, the latter serving as an important reminder for the nurses to change the gloves between patients.
d) The mean number of gloves used by each nurse for each patient was low when compared with the control group.
Fourth: The mean number of patients dialyzed by a nurse during each shift was high, 4.9 compared to 1.7 in the control group. This is an important indicator of understaffing which is considered as a surrogate marker of poor quality health care. 
Finally: We found that 51% of the nurses were not satisfied with their job because of several reasons including, fears of getting infected, low income and lack of promotions.
| Conclusion|| |
In Al-Ghamdi's study the HCV virus prevalence was higher in the HD units with poorer application of the standard health precautions. The results in our HD units were in support of this finding.
It is vital to do the following to reduce the transmission of HCV among the HD patients.
a) Implement continuous educating programs directed to nurses, doctors and patients in the HD units.
b) Monitor strictly and regularly the standards of hygiene and the infection control policies in the HD units.
c) Ensure continuous uninterrupted medical supplies.
d) Solve the problems of understaffing and encourage the medical staff to become more interested in their job by solving their problems and duly recognizing their efforts.
| References|| |
|1.||Fehr T, Ambuhl PM. Chronic hepatitis virus infections in patients on renal replacement therapy. Nephrol Dial Transplant 2004; 19:1049-53. |
|2.||Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis 3 rd edition, Philadelphia, Lippincott Williams&Wilkins 2001. 502503. |
|3.||Huraib SO. Hepatitis C in Dialysis Patients. Saudi J Kidney Dis Transplant 2003; 14(4):42-450. |
|4.||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 Transplant 2004; 15(l):34-40. |
|5.||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 Kidney Dis 2001;37:1004-10. [PUBMED] |
|6.||Froio N, Nicastri E, Comandini UV, et al. Contamination by hepatitis B and C viruses in the dialysis setting. Am J Kidney Dis 2003;42:546-50. [PUBMED] [FULLTEXT]|
|7.||Meyers CM, Seeff LB, Stehman-Breen CO, Hoofnagle JH. Hepatitis C and renal disease: an update. Am J Kidney Dis 2003; 42:631-57. [PUBMED] [FULLTEXT]|
Mahdia A Buargub
Medical Department, Tripoli Central Hospital, P.O. Box 83478, Tripoli
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]