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Advances in Infection Prevention and Vascular Preservation

Achieving Outstanding Outcomes in Hemodialysis

According to the United States Renal Data System, as of Dec. 31, 2016, the point prevalence of children and adolescents, 0 to 21 years of age with end stage kidney disease was 99.1 per million population, with hemodialysis being the most common initial treatment modality for patients aged 10 years and older.1

To reduce the risk of complications related to hemodialysis, the Children’s Mercy Kansas City Division of Nephrology has implemented several strategies. The institution of standardized infection prevention practices has resulted in nearly 1,200 consecutive days without an outpatient central line associated blood stream infection (CLABSI) in a hemodialysis (HD) patient. Vascular preservation protocols also are improving the long-term venous access options for these and future patients.

Five Actions to Reduce Risk of Infection

The Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) collaborative has previously reported a CLABSI rate of 0.8 infections/100 patient months.2

As participants in the SCOPE collaborative since its inception in 2011, the Children’s Mercy hemodialysis program has implemented the recommended care bundle practices to reduce the risk of CLABSIs in its patient population.

Through quality improvement and human factors work, meticulous adherence to five key protocols and procedures has resulted in more effective catheter care and a substantial decrease in the risk of infectious complications. These five actions are:

  1. Video audits of clinical staff while performing self-hand hygiene and patient care to ensure consistency and promote accountability. Routine video surveillance has proven essential in helping staff identify best practices and opportunities for improvement in their individual care management techniques.
  2. Implementation of a standardized protocol for catheter connection/disconnection and exit site care including scrubbing the outside of the disconnect cap in the same manner as the hub.
  3. Reinforcement of patient restrictions regarding patient showers and other water exposures, and repeated education of patients and families regarding the risks of infection associated with showering.
  4. Standard use of ClearGuardTM Caps and StatLock® stabilizers.
  5. Patient, family and staff participation in frequent education activities, employing the “teach-back,” learning technique and emphasizing the need for consistent catheter care to prevent infection.

This multifaceted infection prevention approach has resulted in an unprecedented nearly 1,200-plus days without a CLABSI in hemodialysis patients at Children’s Mercy.

This accomplishment was recognized in September 2020 by the CDC’s Making Dialysis Safer Coalition and will be presented at the Annual Dialysis Conference in March 2021.

Documenting Infection Rates and Buttonhole Practices for Pediatric AVF Cannulation

One key aspect of the Children’s Mercy HD infection prevention strategy is greater use of arteriovenous fistulas (AVF) for dialysis access, and its successful use of the buttonhole cannulation technique. In 2019, the Children’s Mercy team published its experience with AVF buttonhole cannulation in the Nephrology Nursing Journal, reporting the performance of approximately 5,600 cannulations over 215.5 patient months with no infections of the AVF.3

Vital to the Children’s Mercy team’s success with this method has been the attention to infection prevention details, including the use of a select group of highly experienced cannulators to develop the buttonhole and remove scabs; a 30-second vigorous scrub with the disinfection agent chlorhexidine and a one-minute dry time before and after scab removal; and masking of everyone present during cannulation.

To further document the role of buttonhole access, the team recently led the first multicenter study in children comparing buttonhole versus rope-ladder cannulation techniques utilizing data from the SCOPE collaborative, the results of which have been submitted for publication. Whereas the data provides additional evidence of the safety of buttonhole cannulation in pediatric hemodialysis patients, the need for further study in children is emphasized.

Data generated from a survey performed in conjunction with the study revealed that the majority of centers successfully performing the buttonhole procedure were characterized by small patient/nurse ratios and the use of strict antiseptic protocols.4

Save the Vein Has Long-Term Implications for Hemodialysis Patients

Vein preservation in children with end-stage kidney disease (ESKD) is crucial because of the potential need for hemodialysis over a lifetime. To that end, Children’s Mercy instituted an initiative called Save the Vein to increase the frequency of peripheral intravenous line (PIV) placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease.

Each hospitalized patient is given a bright pink Save the Vein armband that highlights which arm (non-dominant) and associated vasculature should be preserved, and this information is documented in their electronic health record. In addition to staff education, patients and families also have been educated about the importance of vascular preservation so they can advocate for themselves or their child.

At baseline and prior to starting the initiative, 47% of PIVs were placed in the patient’s dominant arm, with only 25% of PIVs placed in the dominant arm for children < 5 years. Over the two years since the initiative was launched, 93% of all PIVs were placed in the dominant arm; and in children < 5 years, 94% of PIVs were placed in the dominant arm.

The team concluded that education regarding the importance of vein preservation, along with implementation of a standardized process, can help direct PIV placement and potentially preserve vasculature in pediatric patients with CKD.5

The results of this quality improvement project were recently published in the American Journal of Kidney Diseases.


Learn more about Hemodialysis at Children’s Mercy

Bradley Warady, MD, Division Director, Pediatric Nephrology; Director of Dialysis and Transplantation; McLaughlin Family Endowed Chair in Nephrology; Professor of Pediatrics, University of Missouri-Kansas City School of Medicine


(816) 302-3010

For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466 3729.


  1. United States Renal Data System. 2019 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2019.
  2. Marsenic O, et al. Prevention of Central Line Associated Blood Stream Infections in a Pediatric Dialysis Unit. Pediatric Nephrol 2020 Jan; 35(1): 135-143.
  3. Moore T, Brightman S, Dodson D, Warady B. Arteriovenous Buttonhole Access Cannulation in Pediatric Patients on Hemodialysis. Nephrology Nursing Journal July-August 2019 Vol. 46, No. 4.
  4. Morgans H, Gruhler De Souza H, Richardson T, Claes D, Dharnidharka V, Lee M, Mahesh S, Muff-Luett M, Swartz S, Neu A, Warady B, for the SCOPE Collaborative. A Comparison of the Buttonhole and Rope-Ladder AVF Cannulation Techniques Within the SCOPE Collaborative. Submitted for publication.
  5. Singh N, Grimes J, Gregg GK, Nau AE, Rivard DC, Fields M, Flaucher N, Sherman AK, Williams MU, Wiley KJ, Kerwin K, Warady B. “Save the Vein” Initiative in Children with CKD: A Quality Improvement Study. American Journal of Kidney Diseases. 2021 Jan. doi.org/10.1053/j.ajkd.2020.11.016.
About Us

Children’s Mercy Kansas City is an independent, non-profit, 390-bed pediatric health system, providing over half a million patient encounters each year for children from across the country. Children’s Mercy is ranked by U.S. News & World Report in all ten specialties. We have received Magnet® recognition five times for excellence in nursing services. In affiliation with the University of Missouri-Kansas City, our faculty of nearly 800 pediatric specialists and researchers is actively involved in clinical care, pediatric research and educating the next generation of pediatricians and pediatric subspecialists. The Children’s Mercy Research Institute (CMRI) integrates research and clinical care with nationally recognized expertise in genomic medicine, precision therapeutics, population health, health care innovation and emerging infections. In 2021 the CMRI moved into a nine-story, 375,000-square-foot space emphasizing a translational approach to research in which clinicians and researchers work together to accelerate the pace of discovery that enhances care.