900 
The number of patients with end-stage kidney disease requiring dialysis is increasing worldwide. A radical change of approach is needed
Margaret Higgins
RN DipNS BSc MSc
Clinical Nurse Manager
David Evans
BSc MSc PhD
Haemodialysis Unit
Health Service Executive West
Merlin Park Hospital
Galway, Republic of Ireland
Between 1999 and 2004 there was a 21% increase in the number of patients in the US.[1] In the Republic of Ireland there has been an eightfold increase in the last 16 years, with over 1500 patients on dialysis in 2008.[2]
Dialysis infections are common and often result in great cost, morbidity and mortality for haemodialysis patients.[3,4] The majority of bacteraemias are primarily caused by staphylococcal organisms and are associated with high mortality rates.[5,6] Studies indicate that infection is second to cardiovascular infection disease as the leading cause of death in patients with end-stage kidney disease (ESKD).[7] In the US, vascular access (VA) complications represent 20% of total spending for haemodialysis.[6] Care for one patient with a central venous catheter (CVC) access infection in the US costs some $34,000, with a total annual cost of $2.3 billion.[8] Haemodialysis is not possible without access to the vascular system to provide an adequate flow of blood to maximise the amount of blood cleansed during treatments. Three access types are used: the rteriovenous fistula (AVF), arteriovenous graft (AVG) and the CVC. The AVF is the “gold standard” in access as it has the lowest infection and thrombosis rates and the longest patency rates, and is associated with the best outcomes of all types of access.[9]
Despite the National Kidney Foundation/Kidney Dialysis Outcome Quality Initiative (NFK/KDOQI) recommended guideline of an AVF prevalence rate greater than 65% and a CVC prevalence of less than 10%,[9] the majority of haemodialysis patients are relying on a CVC for their treatment.[10] In Europe, patients are dialysed predominately with an AVF.[10] However, this contrasts sharply with US practice of only 20% AVF utilisation.[10] Republic of Ireland patients are treated in 20 centres; 16 are hospital-based, two of which are in Northern Ireland, and four are private facilities.[2] Prevalence rates obtained from each centre by personal communication show four centres have an AVF prevalence rate of greater than 65% and no centre has a CVC prevalence rate of less than 10%. A National Survey of Renal Nurses on VA care in Ireland highlighted a lack of consensus in terms of infection control guidelines.[11]
There was a wide variation in practice patterns to reduce cross-infection and poor adherence to available infection control guidelines. Various guidelines are used in the Republic of Ireland: Centers for Disease Control and Prevention,[12] National Kidney Foundation Kidney Disease Outcomes Quality Initiative[9] and the Health Promotion Surveillance Centre (HPSC) for hand hygiene.[13] However, these guidelines offer conflicting advice on methods of VA infection control prevention that can lead to confusion and inconsistent care. There are no national guidelines on VA infection in Ireland. The HPSC) is currently formulating a set.[14] These will incorporate both British and EU guidelines. They will also follow a five-component “care bundle” strategy to reduce infection and optimise patient outcomes. This is based on Epic 2 guidelines, aiming to improve and measure the implementation of key elements of care.[15]
Renal staff at all centres in Ireland have reported (personal communication) that VA data are collected and monitored. Three centres have an assigned infection control nurse specialist specifically for renal infection monitoring. However, there is a lack of shared information, and information is not readily accessible. One initiative aiming to address this issue is an EU-funded project (INTERREG IIIA programme), secured by the cross-border health services partnership Cooperation and Working Together (CAWT), to have common specialised information systems installed. This enabled all six participating renal centres to share data to assist in the treatment and care of patients. The potential of further benefit for patients can be realised by extending this project to the rest of Ireland.[2]
To prevent bloodstream infections in patients having haemodialysis cutaneous antisepsis for CVC insertion, AVF, AVG and CVC site care is crucial. All international organisations recommend the skin-cleansing solution chlorhexidine 2%. However, healthcare workers must be aware that while chlorhexidine 2% is the first choice, there are some CVC materials that can be damaged by alcohol-containing solutions. Consequently, the CDC highlighted the need for manufacturers’ recommendations to use disinfectants that are compatible with specific catheter material.[12]
There are eight different CVC types in use in the country. Although chlorhexidine 2% is based on reliable efficacy,[15] only four centres are utilising the product. Another intervention used to prevent VA infection is a Biopatch disc-shaped hydrophilic polyurethane absorptive foam, infused with time-release chlorhexidine gluconate secured around the CVC at the exit site and changed weekly.[15] Only three of the 20 centres are currently utilising this product, while three others utilise it on a small number of patients. Giving staff the correct tools to perform clinical skills to the highest standard is paramount.[17] To reduce CVC clotting, infection and subsequent bactermia, a high concentration of sodium citrate (an anticoagulant with intrinsic antibacterial activity) is inserted into both CVC lumens postdialysis as a locking solution. 18 Out of 20 centres, three are utilising this product and three other centres utilise it on a small number of patients.
To improve infection in VA, one centre in Ireland has undertaken a retrospective review (1997–2003) of CVC infection rates and types. A devised tracking tool enabled staff to monitor infection rates and helped to reduce VA infection to below 10%.[19] During recent networking with centres, all reported the presence of infection with the exception of two private centres. These centres are at Stage 2 of the Practice Accreditation Process in which they must provide evidence that they are meeting a framework of 15 evidencebased and well-tested criteria.[20] These centres revealed that two staff members are always involved in connecting the patient to the dialysis machine.[20] Another example of an initiative to improve VA infection and to adopt measures to prevent its occurrence can be viewed in Table 1 and 2. Education was encouraged and practice was changed, resulting in infection-free VA.
[[HHE.C18]]
Many renal nurses are carrying out research. They are aware that they have a responsibility to challenge traditional and ritualistic practice to ensure they are providing the highest standards of care possible for their patients. Education is an important component of VA infection prevention as it encourages awareness and motivates hospital staff to assume responsibility for infection control practice.[21] All doctors in the Republic of Ireland must now attend mandatory infection control education at induction to a hospital and every six months when changing teams. Dialysis staff attend regular in-service training on theory and practice of hand hygiene and CVC care. The National Council for Vocational Awards has set standards for certification in partnership with course providers for healthcare assistants (HCAs). Following an audit of staff skill-mix in haemodialysis by the National Hospitals Office,[22] a renal module for HCAs is planned that will develop skills and knowledge for maintaining standards specific to renal centres. Primary prevention of VA infection requires an attempt to minimise the use of CVCs.[23]
The demand for VA is constantly rising, but there is a global lack of consensus on standardised guidelines on infection control for haemodialysis units, which can lead to confusion and inconsistencies in care. National guidelines on VA infection control are urgently needed, together with a renal information system to allow monitoring of the patient’s clinical health and evaluate quality of care provided. A national renal strategy review was commissioned by the DOH/C in 2003, and the review group are awaiting the final report discussed in September 2007 by the DOH/C.[24] The renal services will then be included in a major change management programme that aims to transform health services in Ireland in coming years.[25]
References
1. United States Renal Data System. Annual data report: atlas of end stage renal disease in the United States. 2006.
http://www.usrds.org (accessed July 2008).
2. Irish Kidney Association. Support 2008. Dublin: IKA. www.IKA.ie (accessed July 2008).
3. Bloembergen BE, Port FK. Epidemiological perspective on
infections in chronic dialysis patients. Adv Renal Replacement Ther 1996;3:201-7.
4. Polkinghorne KR, et al. Vascular access and all-cause mortality: a propensity score analysis. J Am Soc Nephrol 2004;15(2):477-86.
5. Peacock SJ, et al. Outcome following haemodialysis catheter-related Staphylococcus aureus bacteraemia.
J Hosp Infect 1999;41:223-8.
6. Powe NR, et al. Septicaemia in dialysis patients: incidence, risk factors and prognosis. Kidney Int 1999;55:1081-90.
7. United States Renal Data System. The economic cost of ESRD vascular access procedures and Medicare spending
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8. Hadawa LC. Infusing without infecting. Nursing 2003;33(10):58-63.
9. NFK/KDOQI. 2006. www.kidney.org/professional/kdoqi/guidelines (accessed July 2008).
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11. Higgins M, Evans DS. Nurses’ knowledge and practice of vascular access infection control in haemodialysis patients in the Republic of Ireland. J Renal Care 2008:34(2):48-53.
12. Centres for Disease Control and Prevention. MMWR 2002;51(RR-10):1-36.
13. Health Protection Surveillance Centre (HPSC). A strategy for the control of antimicrobial resistance in Ireland.
http://www.ndsc.ire/hpsc/A-Z/gastroemeric/handwashing/guidelines/file,10… (accessed July 2008).
14. Health Protection Surveillance Centre. 2008. www.ndsc.ie
15. Pratt RJ, et al. Epic 2: national evidence-based guidelines for preventing healthcare-associated infections in NHS Hospitals in England. J Hosp Infect 2007;655:S1-S64.
16. Crawford AG, et al. Cost benefit analysis of clorhexidine gluconate dressing in the prevention of catheterrelated
bloodstream infections. Infect Control Hosp Epidemiol
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17. Inwood S. Skin antisepsis: using 2% clorhexidine gluconate in 70% isop. alcohol. Br J Nursing 2007;16(22):1390-4.
18. Cornelius JD, et al. Examination of trisodium citrate (citra-lock™) remaining in central venous catheters after the interdialytic interval. Nephrol Dial Transplant 2005;10(1093):1-3.
19. Roussell A, Ferrins B. Mayo achieves infection rates below 10%. Managing the Bacterial Burden 2004 Oct:5-8.
20. PEI. 2008. www.wellstone.ie (accessed July 2008).
21. Nettleman MD, et al. Assigning responsibility: using feedback to achieve sustained control of methicillin-resistant
Staphylococcus aureus. Am J Med 1991;91 Suppl 3B:3B-228S.
22. National Hospitals Office. www. hse.ie
23. Winearls CG, Fluck R. The organisation and delivery of the
vascular access service for maintenance haemodialysis patients. 2006. The Renal Association.
24. Department of Health and Children. www.doh/c.ie
25. INNA 2008. www.inna-ireland.com
