Challenges to Infection Control of Hep C, B and HIV

Challenges to Infection Control of Hep C, B and HIV Infection control and cross contamination prevention are imperative to ensuring high quality patient care and quality of life for all patients. In the hemodialysis clinics and hospital units where patients are in end stage renal disease the prevention of infection is of utmost concern as it is directly correlated to lowered morbidity and mortality rates. Blood borne pathogens and bacteria are transmitted through poor infection control practices and lack of cross contamination prevention procedures. To understand the importance of infection control and cross contamination prevention, it is first imperative to understand the risks and consequences of infection transmittal in the hemodialysis unit. The hemodialysis unit is unique in that the procedure allows pathogens to enter the body through access sites, injection sites, and catheterization, all of which increase risk of infection for already ill patients. The following explores the most common concerns in infection transmittal as He patitis C and B, HIV, and common bacteria found in hemodialysis patients. This is followed by an exploration of methods in infection control, focusing on the procedures of cleaning, sterilization, and disinfection. An examination of staff education and training procedures that impact infection control and patient care follows. The research concludes with a summary and commentary. Research has often compared the incidences of HCV infections in hemodialysis and peritoneal dialysis in patients, finding that patients undergoing clinical bloodstream invasive hemodialysis procedures have three times higher rates of HCV infections (Horl et al 2004). This is reflective of nosocomial transmission of HCV within the clinical dialysis setting (Horl et al 2004). HCV is transmitted through cross-contamination, occurring through blood, shared cannulas, and equipment, and blood transfusions (Horl et al 2004 p 1390). A comparison of the outcome of hepatitis virus-positive and -negative kidney transplant and hemodialysis patients involved 384 kidney transplant patients (67 HBsAg positive, 39 anti-HCV positive, 278 hepatitis negative), transplanted between 1987 and 2001, and 403 hemodialysis patients (128 HBsAg positive, 83 anti-HCV positive, 192 hepatitis negative) who had started hemodialysis and were referred to the kidney transplant waiting list during the same period (Visn ja et al 2008). Comparison of the groups survival rates, adjusted for patient age, showed that all kidney transplant patients survived longer than hemodialysis patients (p Thirty-two outpatient hemodialysis providers in the United States voluntarily reported 3699 adverse events to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) during 2006 (Klevens et al 2008). Among the 599 isolates reported, 461 (77%) represented access-associated blood stream infections in patients with central lines, and 138 (23%) were in patients with fistulas or grafts (Klevens et al 2008). The microorganisms most frequently identified were common skin contaminants (e.g., coagulase-negative staphylococci) (Klevens et al 2008). Hepatitis C (HCV) among maintenance hemodialysis patients has limited data on the incidence and prevalence. According to Bennett, Brachman and Jarvis (2007 p 360): In 2002, 63% of dialysis centers tested patients for anti-HCV, and 11.5% reported having (symbol) 1 patient who became anti-HCV positive in 2002. The incidence rate in 2002 was 0.34% among centers that tested for anti-HCV, the prevalence of anti-HCV among patients was 7y.8%, a decrease of 25.7% since 1995. In the facilities that tested, the reported incidence was 0.34% and the prevalence3 was 7.8%. Only 11.5% of dialysis facilities reported newly acquired HCV infection among their patients. The most efficient transmission of HCV is through direct percutaneous exposure to blood, central to the epidemiology of HCV transmission is the infected patient (Bennett, Brachman and Jarvis 2007 p 360). Staff members in hemodialysis clinics have similar rates of infection as other healthcare workers, between 1-2% (Bennett, Brachman and Jarvis 2007). The risk factors of HCV infection in hemodialysis clinics include blood transfusion from unscreened donors and the number of years the patient has undergone hemodialysis treatment (Bennett, Brachman and Jarvis 2007). The years of hemodialysis treatment is an independent risk factor that is strongly associated with high HCV infection rates, where the time of hemodialysis treatment increases the prevalence of HCV infection (Bennett, Brachman and Jarvis 2007). Patients undergoing hemodialysis for less than five years have a 12% chance of infection, while patients receiving dialysis for more than 5 years have a 37% chance of infection (Bennett, Brachman and Jarvis 2007). Dialysis related HCV outbreak research is indicative that HCV transmission occurs due to inadequate infection control practices of supplies and machinery (Bennett, Brachman and Jarvis 2007). During hemodialysis, monitors such as the venous pressure monitor is used to as a protective system against external blood loss, wh ere blood may leak through clamps on infusion lines (Horl et al 2004). Pressure of the leak is sense through an air-filled tube that connects the venous bubble to the monitor, which senses the pressure of the blood flow; however blood losses up to 40 ml/min may be undetectable by the sensor equipment (Horl et al 2004). Cross-contamination during invasive practices occurs when blood enters the air-filled tube and contacts the monitoring machinery where the pressure protectors are inserted into the line or connective areas (Horl et al 2004). Hydrophobic and impermeable flexible membranes used may become wetted with blood, and thus pressure changes are not transmitted to the sensor and the monitor itself does not function accordingly, indicating that cross contamination may have occurred (Horl et al 2004). The CDC reported three outbreaks of HCV infection from 1999-2000 for patients in chronic hemodialysis centers (Bennett, Brachman and Jarvis 2007). Cross contamination opportunities were the common indicator of infection, where observations of cross contamination included: Equipment and supplies that were not disinfected between patient use (Bennett, Brachman and Jarvis 2007 p 360). Use of common medication carts to prepare and distribute medications at patient stations (Bennett, Brachman and Jarvis 2007 p 360). Sharing of multidose vials, which were placed at patients stations on the top of the hemodialysis machine (Bennett, Brachman and Jarvis 2007 p 360). Contaminated priming buckets that were not routinely changed or cleaned and disinfected between patients (Bennett, Brachman and Jarvis 2007 p 360). Machines surfaces that were not routinely cleaned and disinfected between patients (Bennett, Brachman and Jarvis 2007 p 360). Blood spills that were not cleaned up promptly (Bennett, Brachman and Jarvis 2007 p 360). The sharing of multidose vials or injectable medications has been a source of high cross contamination. According to Finelli (et al 2002 p 58: â€Å"In 2002, 52.8% of centers reported that medications from multidose vials were drawn into syringes in preparation for patient administration in a dedicated medication room or an area separate from the treatment area, 24.6% reported that medications were prepared on a medication cart or a medication area within the treatment area, 3.7% at the dialysis station, and 18.9% in other areas. In 2002, the incidence of HBV infection was significantly higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area compared to a dedicated medication room (Table 13). However, the incidence of HCV infection was not significantly different by location where injectable medications were prepared. The incidence of HBV results are of particular concern because all medications, supplies, and equipment for HBsAg-positive patients should be dedicated for their use and not used by HBV-susceptible patients. Outbreaks of HBV infection have occurred when multipledose medication vials were available in the treatment area and used for both infected and susceptible patients, although isolation procedures for HBsAg-positive patients were in place for equipment and other supplies. To avoid contamination in the general hemodialysis population, medications should be prepared in a centralized area separate from the treatment area, and supplies and equipment should be shared only if they are disinfected between patients.† Furthermore, in dialysis centers where multiple infections clustered around timeframe a common exposure event is suggested as being likely due to supply carts moved from station to station which carried clean supplies and blood contaminated items such as biohazard containers, sharps disposal containers, and other containers contaminated or used to contain patients blood (Bennett, Brachman and Jarvis 2007). Due to the cross contamination opportunities and incidences, it is recommended that routine testing of hemodialysis patients for anti-HCV occur on admission and reoccur every six months (Bennett, Brachman and Jarvis 2007). HIV patients often undergo hemodialysis over other options of dialysis therapy when they are in advanced stages of the disease, as hemodialysis has lowered incidences of protein loss and peritonitis (Henrich 2003). Hemodialysis is also preferred over CAPD for patience with cognitive motor dysfunction (Henrich 2003). However, concerns of transmission of HIV infection during hemodialysis in clinical dialysis units exist as patient to patient, patient to staff, and staff to patient risks of cross contamination (Henrich 2003). The risks of HIV transmission from patient to patient is extremely unlikely in dialysis units that conform to the practice guidelines recommended by the CDC† (Henrich 2003 p 341). The CDC examines that individual dialysis units had no HIV nosocomial transmissions for patients undergoing hemodialysis treatments in clinical settings (Henrich 2003). Furthermore, a study of multiple dialysis centers across the USA found no instances of HIV seroconversion over a 48 week period (Henrich 2003). Thus there is a negligible risk of HIV transmission, and therefore HIV patients do not require dedicated machines or isolation while undergoing hemodialysis when the clinicians follow the CDC guidelines (Henrich 2003). HIV has not been shown to be transmittable through hemodialysis machines as the pore size of dialyzer membrane is between 1 and 7 nm, and the HIV virus is 105 nm (Henrich 2003). The use of the same dialysis machine between HIV positive and negative patients is not correlated with the transmission of HIV in the clinical setting, provided that disinfection procedures for dialyzers and dialysis machines are followed for both non-HIV positive and HIV positive patien ts (Henrich 2003). It is important to note that when the disinfection and cross contamination procedures are ignored, HIV outbreaks in dialysis clinics can occur (Henrich 2003). This is represented by recent outbreaks of HIV in Columbia, Argentina, and Egypt hemodialysis clinics. In Columbia it was found that the transmission of HIV was due to the cross contamination of dialysis access needles and sharing of inadequately disinfected site access needles (Henrich 2003). In Argentina the cross use of filters and multidose heparin vials was shown to be the likeliest reason for the transmission of HIV (Henrich 2003). In Egypt, syringes were used for more than one patient, allowing the cross contamination to occur (Henrich 2003). While HIV patient to patient transmission has not occurred in Westernized clinics, it is imperative that adequate procedures for dialyzer and dialysis access devices are continuously utilized as a precautionary and preventative method (Henrich 2003). For healthcare workers, patient to staff transmission is a high concern. Interestingly, only one incidence of patient to staff HIV transmission has been recorded in the United States, which occurred through a needlestick injury (Henrich 2003). Yet risk still exists, where research statistics show reported incidences of 5 needlestick exposures and 28 skin and mucous membrane exposures for every 10,000 dialyses. (Henrich 2003 p 320) However, only one instance of HIV seroconversion due to patient to staff transmission has been reported by the CDC, but that should not diminish the risk that HIV transmission can occur, most likely due to needlestick injuries in hemodialysis clinics (in peritoneal dialysis, it may occur through improper handling of PD effluent) (Henrich 2003). Staff to patient transmission is also a concern. According to Henrich: To date, there have been no reports of transmission of HIV from a health care worker to a patient in a dialysis setting. There are other important issues in dialysis units that accept patients with HIV infection. Patients with HIV infection are prone to infection with myobacterium tuberculosis. In contrast to HIV, M. tuberculosis infection is an aerosol-transmitted infection, and, therefore, precautions to prevent the spread of this infection to other patients should be taken. Importantly, M. tuberculosis infections among HIV infected patients are often multidrug resistant. Nosocomial transmission of multidrug tuberculosis has been described. In addition to tuberculosis, HIV infected patients are at increased risk of other communicable infections. Appropriate precautions should be observed to protect other patients in the dialysis facility and the staff caring for these patients. (Henrich 2003 p 342). Nontuberculosis mycobacterial (NTM) infections are a concern for all hemodialysis patients, particularly in clinics that practice the reuse of dialysis machinery (Nissenson and Fine 2005). NTMs have a predilection to colonization in water utilized for hemodialyzer reprocessing, where the CDC examined 115 dialysis centers in 1988 (Nissenson and Fine 2005). NTM recovery from water was found in 83% of these centers and 50% of all water samples of these centers (Nissenson and Fine 2005). An outbreak in Loiusiana that occurred in 1985 was due to inadequate sterilization of hemodialysis equipment, where 27 patients became infected with mycobacterium chelonei, 14 patients died over a one year period (Nissenson and Fine 2005). Similar outbreaks have occurred over the last twenty years, where bacterial contamination of reprocessed dialyzers was the main culprit (Nissenson and Fine 2005). No bactermias were found in patients who used only new dialyzers (Nissenson and Fine 2005). In a 1995 repo rt, an outbreak of klebsiella pneumoniae bactermia was shown to be due to cross contamination (Nissenson and Fine 2005). These incidences are attributed to failure to adequately use aseptic techniques during the reprocessing of dialyzers used by patients with bacteremia infections, thus allowing the contaminated dialyzers to spread to other patients in the hemodialysis clinics (Nissenson and Fine 2005). Viral infection has been the main epidemiologic concern in the hemodialysis units; however, bacterial infection is responsible for more than 30% of all causes of morbidity and mortality in Portuguese hemodialysis patients, vascular access infection being the culprit in 73% of all bacteremias (Ponce et al 2007). A prospective multicenter cohort study of bacterial infections incidence, conducted from January to July 2004 in five hemodialysis units, to record and track bacterial infections, using a validated database from CDC’s Dialysis Surveillance Network Program (Ponce et al 2007). The results are surmised: 4,501 patient-months (P-M) were surveyed, being dialyzed through a native fistula (AVF) in 60.6%, a graft (PTFE) in 31.3%, a tunneled catheter (TC) in 7.6%, and a transient catheter (C) in 0.5%. 166 hospitalisations were registered as target events and 182 intravenous antibiotic courses were assessed (Ponce et al 2007). Of these 182 antibiotic treatments, 47.8% included van comycin, only 30% had blood cultures drawn pretreatment, and only 36% were positive. The research found 98 infections at the vascular access site and 2.13 infections at other sites. The isolated microorganisms were Staphylococcus epidermidis in 40.1%, Staphylococcus aureus in 30.1%, Pseudomonas in 13.3%, and Escherichia coli in 3.3% (Ponce et al 2007). Researchers found that the number of target events and the bacterial infections incidence were remarkably homogeneous in the five Portuguese centers (Ponce et al 2007). The research concluded with the following major points: (1) High incidence of bacterial infections, causing major morbidity; (2) infectious risk is vascular access type-dependent, with dramatic rise in catheters; (3) underutilization of blood cultures to orient diagnosis and therapy, and (4) high rates of vancomycin prescription (Ponce et al 2007 p 136). Cetin (et al 2007) compared microbial findings and their resistance to antibiotics between hemodialysis patients and patients without end-stage renal failure with diabetic foot infections. An 18-month-long descriptive study analyzed bacterial isolates obtained from 32 hemodialysis (HD) patients with diabetic foot infection in an Antakya hemodialysis center and 65 patients with diabetic foot infection admitted to the Education and Research Hospital of Mustafa Kemal University, Turkey (Cetin et al 2007). The occurrence of gram-positive bacteria in the hemodialysis patients was found to be 59.0%, this rate in the other patients was 53.1% (Cetin et al 2007). The frequent bacterial species isolated in the hemodialysis patients were S. aureus (22.9%), followed by coagulase-negative Staphylococcus spp. (CNS) (19.7%), the microorganisms in the other patients were found as CNS (20.7%), followed S. aureus (18.0%) (Cetin et al 2007). The researches recommend that antibiotic therapy in HD patien ts with diabetic foot infection should be more closely guided by culture findings and antimicrobial susceptibility results (Cetin et al 2007). Patient’s exposure to dialyzer reprocessing allows for a potential for blood borne bacterial infections to occur, where the majority of NTM infections are due to the improper reprocessing techniques (Nissenson and Fine 2005). In recent history, there have been few indications of invasive infections from reprocessed dialyzers; however there are no current and reliable estimates of infection risk attributed to dialyzer reuse in hemodialysis (and other dialysis) clinics (Nissenson and Fine 2005). Standardization of reprocessing techniques has resulted in acceptably low risk of bacterial infections of modern dialyzer reuse (Nissenson and Fine 2005). Infection control practices in hemodialysis units reduce the risk of patient to patient transmissions through directly or indirectly contaminated devices (Mayhall 2004). Devices may include equipment, supplies, environment surfaces (floors, tables), and the personnel’s hands (Mayhall 2004). Practices should be routinely carried out for all patients in the hemodialysis units as there is increased potential for blood contamination during hemodialysis, where many patients undergoing hemodialysis are colonized or infected with pathogens (Mayhall 2004). Practices established for infection control include stringent measures for the prevention of HBV due to the ability of HBV to survive on surfaces and contaminate dialysis machines (Mayhall 2004). Patients with increased risk for transmission of pathogens such as antimicrobial resistant strains may require additional precautions such as dedicated (non-reuse) dialyzers (Mayhall 2004). Infection surveillance and other events is importa nt to monitor the infection control practices and ensure their effectiveness (Mayhall 2004). Chronic hemodialysis patients should have routine HBV and HCV infection tests and these tests should be reviewed promptly (Mayhall 2004). This allows the facility to identify potential cross contaminations before they result in an epidemic, allowing for proper infection control measures and possible staff retraining based on the test results (Mayhall 2004). It is important to note that test results must be communicated to other units of the facility when patients are moved for care, for example a HCV positive patient moves from hemodialysis to ICU allowing for better patient care (Mayhall 2004): Routine HCV testing should include use of both a screening immunoassay to test for anti-HCV and supplemental or confirmatory testing with an additional, more specific assay. Use of NAT for HCV RNA as the primary test for routine screening is not recommended, because few HCV infections will be identified in anti-HCV negative patients. However, if alanine amino-transferae levels are persistently abnormal in anti-HCV negative patients in the absence of another etiology, testing for HCV RNA should be considered. Blood samples collected for NAT should not contain heparin, which interferes with the accurate performance of this assay (Mayhall 2004 p 1152) Procedures for cleaning, disinfection, and sterilization for infection control in a hemodialysis center are important to reduce cross contamination, and do not differ greatly from those in other health care settings. However, the uniqueness of the hemodialysis setting allows for higher potentials for blood contamination due to the routine vascular system access that increases the potential for cross contamination of blood borne pathogens (Mayhall 2004). Critical medical items that require stronger disinfection and disposal techniques include needles and catheters and other equipment that requires invasive procedures (Mayhall 2004). Semicritical equipment includes those that come in contact with the mucous membranes, such as endoscopes (Mayhall 2004). Noncritical equipment is that which comes into contact with the skin, such as blood pressure cuffs. Hemodialysis units should maintain infection control policies that prevent cross contamination based on these critical levels to ensure t hat infection potential is reduced (Mayhall 2004). Specifically related to needles as critical medical equipment in the hemodialysis unit, the CDC issued the following statement regarding infection control and cross contamination: â€Å"To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, CDC recommends that all single-use injectable medications and solutions be dedicated for use on a single patient and be entered one time only. Medications packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared in a clean area separate from potentially contaminated items and surfaces. In hemodialysis settings where environmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area. Proper infection control practices must be followed during the preparation and administration of injected medications. This is consistent with official CDC recommendations for infection control precautions in hemodialysis and other health-care settings. Health departments and other public health partners should be aware of the n ew CMS conditions for ESRD facilities. All dialysis providers are advised to follow official CDC recommendations regarding Standard Precautions and infection control in dialysis settings. Specifically, CDC has recommended the following: ‘Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed’. (MMWR 2008:875-876). Environmental surfaces that are frequently touched, such as equipment and tables, should be cleaned after each patients hemodialysis procedure with a detergent or detergent germicide (Mayhall 2004). This cleaning step is imperative to preventing cross contamination, but may be often overlooked. The cleaning process interrupts the cross contamination and transmission routes, and should be completed each time the equipment is used (Mayhall 2004). Patient to patient transmission of viruses and pathogens through the hemodialysis machine and its various components is an environmental risk, where the external surfaces such as the control pane and attached waste containers used for priming, as well as blood tubes and other items such as dialyzer caps and medication vials that may come into contact with the machine surfaces are all potential vehicles for cross contamination (Alter et al 2001). Microorganisms, including resistant bacterial spores, are killed by sterilization. The procedures for sterilization are generally steam cleaning or ethylene oxide gas used on critical medical equipment. However for equipment that is heat sensitive, FDA approved liquid chemicals can be used according to the manufacturer’s directions and with appropriate exposure timeframes (Alter et al 2001). High-level disinfectant may kill viruses and bacteria, but is not adequate for killing bacterial spores that exist in high numbers (Alter et al 2001). High-level disinfection includes heat pasteurization and chemical sterilants (also must be FDA-approved). The sterilants and high-level disinfectants can be used on medical devices, but not on environmental surfaces (Alter et al 2001). For environmental surfaces, the CDC recommends intermediate-level disinfectants that kill bacteria and most viruses (Alter et al 2001). This includes tuberculocidal hospital disinfectant and diluted bleach. Lo w-level disinfectants such as general purpose cleaners kill most bacteria and are designed for environmental surfaces, these can also be used on noncritical medical devices in accordance with manufacturer’s labels (Alter et al 2001). It is important to note that antiseptics such as chlorhexidene and iodine are designed for use on skin and are ineffective for cleaning medical equipment and environmental surfaces (Alter et al 2001). Prior to disinfection and sterilization, it is imperative that hemodialysis clinics support the use of germicidal detergents (Alter et al 2001). Germicidal detergents remove organic material such as blood and feces, as well as dirt and debris (Alter et al 2001). Dirt, debris, and organic material act as a protective shield for microorganisms by blocking or inactivating disinfectants and sterilants (Alter et al 2001). Therefore, hemodialysis clinics must add germicidal detergents to their cleaning and sterilization regimens (Alter et al 2001). Training and education of staff and patients is underlined as the most imperative component to ensuring the quality of infection control practices. Chronic hemodialysis clinics should update practices and policies to ensure that they are implemented and rigorously followed, where efforts should center on the education of new staff members and continuing education for tenured staff. Emphatically, hemodialysis units should consult CDC recommendations and approved practices to ensure that they are following the most appropriate and up to date infection control procedures. Staffs working in renal units are frequently unaware of the level of microbiologic contamination in their dialysis fluid arising from the presence of biofilm in the dialysis machines and the water distribution network (Hoenich and Levin 2003). Bacterial fragments generated by such biofilms are able to cross the dialysis membrane and stimulate an inflammatory response in the patient (Hoenich and Levin 2003). Such inflammation has been implicated in the mortality and morbidity associated with dialysis (Hoenich and Levin 2003). The desire to improve treatment outcomes has led to the application of more stringent standards for the microbiologic purity of dialysis fluid and to the introduction of ultraclean dialysis fluid into clinical practice (Hoenich and Levin 2003). Other researchers found that blood exposure is common for healthcare workers in hemodialysis, requiring the use of gloves when in contact with patients and patient equipment followed by appropriate hand washing techniques. Researchers examined staff members from a sample of 45 US hemodialysis facilities though anonymous survey questionnaires. The results show that of the 420 (69%) responses as: registered nurses, 41%; dialysis technicians, 51%; and licensed practical nurses, 8%. Only 35% of all respondents reported that dialysis patients were at risk for blood borne virus infections, and only 36% reported always following recommended hand hygiene and glove use practices (Shimokura et al 2006). Technicians, over registered nurses, reported more frequent compliance and measures for cross contamination prevention (Shimokura et al 2006). Compliance with recommended hand hygiene and glove use practices by hemodialysis staff was very low, and understanding of the reasons for compliance is seemingly ignored by some licensed nurses (Shimokura et al 2006). Infection control practices specific to the hemodialysis setting, and the reasons for these practices, was poorly understood by all staff (Shimokura et al 2006). This underlines that infection control training should be tailored to this setting and should address misconceptions of cross contamination and the risks of infections (Shimokura et al 2006). In one case of staff education, researchers reported an increase in Gram Negative Bacillus (GNB) infection in patients with long term catheters (LTC) (Mayor et al 2005). An objective was set to design an action plan and a new working methodology in order to eradicate the infection and the cause (Mayor et al 2005). Three periods were established in the prospective follow-up of LTC patients: the pre-epidemic period (01/94 to 03/99), with a bacteraemia every 144 days per patient, the epidemic period (04/99 to 12/00) with a bacteraemia every ten days per patient, and the post-epidemic period (01/01 to 04/02) (Mayor et al 2005). A multidisciplinary working group was established, which produced action plans for nursing and technical staff (Mayor et al 2005). The working methodology of the service was studied and analysed by means of a review (Mayor et al 2005). The dialysis and connector cultures were positive for GNB, confirming that they were of the same genetic origin (Mayor et al 2005) . An evaluation of the periods was carried out, studying the working methodology, to which no changes were made between the pre-epidemic and epidemic period (Mayor et al 2005). In the post-epidemic period, a number of changes were made to the care dynamic, with no other bacteraemia arising to date (Mayor et al 2005). Adapting and improving protocols is a good indicator of quality. The role of nursing staff communication, education, training and practices are vital in prevention of GNB (Mayor et al 2005). At Sentara Bayside (SBH), Leigh (SLH), Norfolk General (SNGH) and Virginia Beach General (SVBGH) Dialysis Units, researchers examined the ability of hemodialysis clinical areas of each hospital according to The JCs National Patient Safety Goals (NPSG) knowledge of Standards of Care/ANNA (Grier-Smith 2008). The research found that staff is able to articulate standards and requirements, where monthly and hourly rounds at each unit occur as well as peer to peer unit evaluations and daily huddles prior to work day based on behavior based expectations, the environment of care, and constant daily checks and balances (Grier-Smith 2008). The adherence to peer to peer communications, behavior support, and team work has been instrumental in supporting staff ability in the hemodialysis clinics to maintain strong positive scores in knowledge of standards of care, this underlines the importance of staff training and education that is continuously supportive of behaviors associated with lowering i nfection risks and