Catheter crisis – making dialysis safer6 April 2017
Bloodstream infections in dialysis patients in the US could be cut in half if dialysis facilities were to implement new CDC recommendations. A new initiative, the Making Dialysis Safer for Patients Coalition, aims to improve patient safety by bringing these recommendations into wider use. Practical Patient Care speaks with Dale Singer, executive director of the Renal Physicians Association, about alternatives and best practices.
Every year, around 37,000 people in the US get potentially deadly bloodstream infections related to the catheters that are inserted during their dialysis treatment. Facilities that follow CDC recommendations have successfully reduced bloodstream infections in dialysis patients. CDC has launched a new programme in light of this, the Making Dialysis Safer for Patients Coalition, with a simple aim: to significantly expand the use of these recommendations and tools to improve dialysis patient safety.
The coalition is a partnership of healthcare organisations, patient advocacy organisations, industry members and other public-health partners that span dialysis. It is working to introduce and police techniques that will prevent bloodstream infections (BSIs) in haemodialysis patients, and increase the use and visibility of CDC evidence-based practices.
WHO lists catheter-related bloodstream infections (CRBSIs) as the most common cause of healthcare-associated infection (HAI) to the bloodstream, and, according to CDC, “between 12 and 25% of patients who acquire a CRBSI die; many others have extended hospital stays and increased overall treatment costs”. The same report states that a single infection can cost more than $50,000 of extra hospital time and treatments.
Complications such as bloodstream infections caused by catheter-related infections are a major cause of death, but not before they take up time, money and resources with check-ups, drugs, staff time and equipment keeping the patient in the best care possible.
In a 2013 report, Dr Bernard Camins of the division of infectious diseases at Washington University School of Medicine stated that, “Despite improvements in the delivery of care, the annual all-cause mortality rate for end-stage renal disease (ESRD) patients is still around 220 deaths per 1,000 at risk patient-years.”
This is a huge number and shows the high infection risk of patients on dialysis, as well as the host of other illnesses, side effects and complications that can occur at this stage.
“Infection-related causes are second only to cardiovascular events as a cause for mortality among ESRD patients. Almost two thirds of all ESRD patients will require haemodialysis and they are at the highest risk for bloodstream infections,” Camins continues. This means that patients undergoing dialysis suffer a much higher rate of infection, and the infections often come from mundane places.
“Patients suffering downstream infections need access to the blood flow in order to dialyse, so, for many years, the push has been on arteriovenous (AV) fistulas (a graft created by connecting a vein to an artery using a soft plastic tube), which are at a reduced risk for infection, because catheters are much more prone to infections,” explains Dale Singer, executive director of the Renal Physicians Association (RPA), headquartered near Washington, DC.
“The issue is that, for some patients, catheters are a better option. But this is the exception rather than the rule, and we’ve been involved in developing quality performance measures that encourage physicians to refer patients for a fistula placement rather than catheter placement. Catheters are supposed to be temporary until the fistula can mature,” she says.
RPA joined the Making Dialysis Safer for Patients Coalition when it was launched, towards the end of 2016. According to Singer, CDC is still figuring out how to maximise the participation of the different stakeholders and build unified messaging to accomplish its goal.
“The ideal scenario for patients who know they’re approaching ESRD is to obtain access placement via a fistula,” says Singer. “For the patients who crash into ESRD and appear in the emergency room, they don’t have time for the fistula to mature.”
Those patients will then need emergency dialysis. The best way to do that is to place a catheter but, usually, that catheter should then be used on a very temporary basis to avoid infection, exposure and patient discomfort.
“For example, elderly patients, may decide that they want comfort care, palliative care; they don’t really want to be on dialysis for a long period of time,” continues Singer. “For those patients, a catheter is a temporary solution, because they’re only going to be on dialysis for six months to a year. There’s no reason to put them through the process of a surgically implanting a fistula and letting it mature, and the complications that go with that.”
Guidelines and best practices
RPA was created in 1973 and is a professional society for nephrologists licensed to practice medicine in the US. With 4,000 members around the country, it was happy to partner with the coalition to improve standards.
“We’re always happy to partner for something that’s going to benefit patient care,” says Singer. “The goals of RPA are primarily to ensure that the highest quality of care is delivered to kidney patients, and that the right regulatory and legislative provisions are in place to enable nephrologists and members of the care team to provide that care in a way that maximises access, minimises barriers, and ensures high quality of patient safety.
“We became involved in kidney-patient safety about two decades ago, and developed topics that we saw were ripe for education and programming that would improve kidney patient safety – particularity in the dialysis facility, where they are spending a great deal of their time.”
RPA developed and published educational modules, kidney-patient safety best practices, and patient-safety improvement guides.
“We have modules on topics that are particularly problematic for this patient population: hand hygiene, medication or administration errors, non-adherence to procedure, incorrect dialyser or dialysing solution, patient falls and venous needle dislodgement,” Singer explains.
Physicians or facilities can use these modules to educate their healthcare teams on implementation, and RPA presents an annual award for improvement to patient safety, for practices using innovative ways of implementing programmes.
The goal of the coalition, of course, is for downstream and catheter infections to be reduced, and the associations involved have long been at the forefront of pushing better standards, and educating medical professionals and the public. In joining the coalition, RPA’s own goal is to reduce or eliminate bloodstream infections as a result of ESRD therapy.
“RPA focuses on nephrologists’ education primarily, and helping them implement techniques and best practices to reduce infections. We also have toolkits, so [if there is] anything that CDC puts out that they would like us to share, we’re happy to do that,” Singer says.
Control the infection
The best method to date for reducing BSIs that experts want to see more of is an increased use of fistula for dialysis access. For a significant number of elderly patients, however, catheter access is inevitable.
A host of studies over the past decade have pondered viable solutions, most of which primarily involve the application of antimicrobials at the catheter exit site. Other ideas include the use of antibiotic lock solutions, which have resulted in the development of antibiotic resistance.
New connecting devices also may be of use in the future, but more studies are needed to show their efficacy at preventing catheter-related BSIs among haemodialysis patients. As the number of patients on dialysis increases, new attempts at feasible replacements are still in development, while the infection-control problem becomes more apparent. The coalition is more important than ever for increasing the quality of life of those suffering ESRD, and such cooperation is vital in finding new ways of avoiding infection and providing better patient care.