Emil P. Lesho
A multistep process may help to confirm whether hemodialysis patients are chronic carriers of hepatitis B virus and protect other patients from HBV exposure, according to findings published in Infection Control & Hospital Epidemiology.
Dedicated equipment and a segregated setting are required when carriers receive dialysis. Providers should be aware of a patient’s serostatus before each dialysis session, but when medical history and records are “sparse” there is a greater chance that a patient’s serostatus is missed.
At a health system in upstate New York, inpatients receiving hemodialysis were exposed to after a new patient’s HBV serostatus went unverified during predialysis, prompting researchers to minimize further exposure risk and review electronic medical records to prevent future incidents.
After the incident was discovered, all patients who may have been exposed — either by being dialyzed in the same room or dialyzed on the same machine as the index patient — received the HBV vaccine and immunoglobulin within 7 days of the exposure, and their seroconversion was monitored weekly. The machines used by these patients were sequestered, bleached and heat treated following each dialysis session, according to the study.
The researchers conducted a root cause analysis found four factors that contributed to the index patient’s serostatus being missed.
“Emergent initiation of the first dialysis session, automatic importing of laboratory results, a single manual verification step, and the ‘off-the shelf’ appearance of the graphic user interfaces of a widely used EMR platform contributed to this untoward event,” Emil P. Lesho, DO, a health care epidemiologist at Rochester Regional Health, told Infectious Disease News.
As a result, a multistep verification process was implemented, and changes were made to the EMR including:
- a “highly” visible column for HBV;
- a “hard-stop” during electronic dialysis orders; and
- a hepatitis toolbar.
Two years after EMR, there were zero additional exposures, zero near and no detection of HBV DNA or seroconversions among the exposed patients.
“Given the prevalence of HBVinfections and the increasing incidence of end-stage renal disease, chronic HBV carries could be inadvertently hemodialyzed in un-cohorted settings,” Lesho said. “Such breaches are likely not rare and may be underreported.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.