QAPI 104 - Development of an HBV Screening and Management Algorithm for an Inpatient Hemodialysis Unit at a Large Academic Medical Center

Background: Patients with end-stage renal disease (ESRD) are at increased risk for Hepatitis B virus (HBV) exposure and subsequent infection. Waning immunity, despite strong initial vaccination efforts, is increasingly common and leads to serial testing and repeated vaccination efforts. In partnership with our colleagues in hemodialysis (HD), we sought to develop comprehensive, screening, testing, clinical, and infection prevention and control (IPC) guidelines for HBV in the inpatient hemodialysis unit.

Methods: We performed a detailed literature review using Medline and PubMed with specific key words regarding HBV exposure, vaccination, infection prevention and clinical testing guidance. Using the Delphi method and an iterative review process, we developed an algorithm that was reviewed and refined with hemodialysis staff, nephrologists, the IPC team and clinical infectious disease experts.

Results: All possible combinations of HBV test results were reviewed and then paired with testing interpretation guidance, immediate clinical steps, and IPC guidance. Implementation of the tool resulted in improved communication between the HD unit and IPC team around isolation precaution needs, physical placement of the patient and dialysis machine disinfection. However, we also identified several gaps including a lack of closed-loop communication between outpatient HD facilities and our inpatient dialysis unit, difficulty in screening for HBV re-activation risk, lack of standard guidance regarding the frequency of screening leading to confusion for IPC and HD staff, and difficulty in discharge communication with outpatient dialysis facilities.

Conclusions: The use of a standardized evidence-based algorithm improved adherence to HBV screening, vaccination, as well as machine disinfection and isolation practices. However, additional areas for improvement were identified through the implementation process. Future interdisciplinary guidance should address screening ambiguities and how that may lead to mixed IPC practices in both inpatient and outpatient HD settings.