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:
- 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.
- 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.
- 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.
- Standard use of ClearGuard Caps and StatLock stabilizers.
- 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 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 accepted for publication 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
For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466 3729.
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.
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.
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.
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.
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. Accepted for publication, American Journal of Kidney Diseases.
Children’s Mercy Kansas City is ranked as one of “America's Best Children's Hospitals” in all 10 specialties rated by U.S. News & World Report and has received MagnetTM recognition for excellence in nursing services four consecutive times. With 366 licensed beds and a medical staff of more than 750 pediatric subspecialists, we care for children from all 50 states and from around the world. In addition, our leadership in pediatric genomic medicine and individualized pediatric therapeutics is driving research and innovation in neonatology, nephrology, endocrinology, gastroenterology, neurology, heart, cancer and other subspecialties to transform outcomes for children. Children’s Mercy also is nationally recognized for innovation in psychosocial care and creating a family-centered environment focused on the unique needs of hospitalized children and their families. Our love for children powers everything we do, inspiring our research, innovations and our everyday care. Because love has no limits. And with it, neither do we.