Pediatric Hemodialysis and Advances in Infection Prevention and Vascular Preservation
To reduce the risk of complications related to hemodialysis, the Children’s Mercy Kansas City Division of Nephrology has implemented several strategies. Listen as Dr. Bradley Warady shares how the institution of standardized infection prevention practices has resulted in more than 1,200 consecutive days without an outpatient central line-associated blood stream infection (CLABSI) in a hemodialysis (HD) patient. In addition, Dr. Warady discusses how vascular preservation protocols also are improving the long-term venous access options for these and future patients.
Featured Speaker:
Learn more about Bradley Warady, MD
Bradley Warady, MD
Dr. Warady is Director of the Division of Nephrology at Children’s Mercy and Director of Dialysis and Transplantation. In spring 2015, Dr. Warady was presented with the Henry L. Barnett Award for outstanding teaching and clinical care for children with kidney disease by the American Academy of Pediatrics Section on Nephrology. Dr.Warady’s previous awards include the National Kidney Foundation’s 2013 J. Michael Lazarus Award for enhancing the clinical care of patients on dialysis or with chronic kidney disease (CKD) and the Patrick and Virginia Clune Award of Excellence by the National Kidney Foundation of Kansas and Western Missouri. Dr.Warady is Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. His major areas of research are chronic kidney disease and end-stage renal disease (ESRD) management of children. He is the senior editor of two leading books in the field, “Pediatric Dialysis” and “Pediatric Dialysis Case Studies.” He is also Co-Principal Investigator of the NIH funded “Chronic Kidney Disease in Children (CKiD) Study”, the largest study of CKD in children ever conducted in North America.Learn more about Bradley Warady, MD
Transcription:
Pediatric Hemodialysis and Advances in Infection Prevention and Vascular Preservation
Melanie: To reduce the risk of complications related to hemodialysis, the Children's Mercy, Kansas City Division of Nephrology has implemented several strategies. Welcome to Transformational Pediatrics with Children's Mercy, Kansas City. I'm Melanie Cole. And today, I invite you to listen as we discuss pediatric hemodialysis and advances in infection prevention and vascular preservation.
Joining me is Dr. Bradley Warady, he's the Director in the Division of Nephrology and the Director of Dialysis and Transplantation at Children's Mercy, Kansas City. Dr. Warady, it's a pleasure to have you join us again today. Tell us how big a problem is infection with hemodialysis patients. Tell us a little bit about Children's Mercy's approach to addressing this issue.
Dr Bradley Warady: Well, first of all, thanks again for inviting me back. You know, infectious complications are really a significant issue for children and adults that receive hemodialysis. If these individuals get infected, they can have a significant morbidity and even mortality associated with those infections. And so, while dialysis is important to remove the waste products from the blood of patients with kidney failure, we have to be able to do it in a very safe manner.
In children especially, one of the ways that the blood moves from the patient to the dialysis machine is often through the use of a catheter. And catheters are an access device that very often are complicated by infections. And so, you know, our goal at Children's Mercy has been to try to decrease the risk of catheter-related infections in these patients on hemodialysis.
Melanie: Well then, describe the bundle of tactics that you use to reduce infections. Tell other providers what you're doing in this case.
Dr Bradley Warady: So, you know, there's been a number of approaches to try to decrease the infection risk in these patients. We utilize information from the CDC in terms of recommendations in terms of how to cleanse the catheter before actually entering the catheter to conduct hemodialysis. Hand hygiene by our providers and our patients is also exceedingly important. And then the ongoing education of the providers of the patients is another essential part of this infection prevention strategy.
And thankfully, by doing so, we did not experience any individual with a catheter-related infection for more than 1100 days at Children's Mercy, so virtually three years, and that kind of result is unheard of. But I think if you take a very proactive collaborative approach between the healthcare providers and the patients and families and utilize the tools and the recommendations that come from the CDC or come from collaboratives, like we participated in something called a scope collaborative, which is a national collaborative with pediatric dialysis centers looking at issues pertaining to infection prevention, if you follow that kind of guidance and those recommendations, I think all centers can really see a significant decrease in their infection rates.
Melanie: Dr. Warady, you've had great success with buttonhole cannulation. Why has Children's Mercy had such success with this procedure? Tell us about it.
Dr Bradley Warady: Well, you know, buttonhole cannulation is a way to enter into what's called a fistula in the arm of somebody who's on hemodialysis. It's a way to access again the blood that go from the patient to the dialysis machine. Buttonhole cannulation is not typically used on the adult side of things because one has to have the time, almost the patients, to be able to utilize this buttonhole repeatedly in the fistula in the arm of these patients to allow access but, again, without developing infectious complications.
At Children's Mercy, some of our dialysis technicians are really experts in creating the buttonholes and maintaining the buttonholes in an infection-free manner. And that lends itself to greater longevity of the fistula of these patients and, again, I think a more optimal dialysis access for them. So buttonholes are not very, very common in any dialysis patients, but I think in the pediatric population, it can be a very successful approach to vascular access in these patients in a very infection-free manner.
Melanie: Well, then tell us how does vascular preservation fit into our discussion here.
Dr Bradley Warady: So vascular preservation is important in patients who may ultimately need hemodialysis sometime in their lifetime, because one needs veins to create this fistula, this access again of blood to the dialysis machine. And so what we have instituted at Children's Mercy is a quality improvement project such that we preferentially use the patient's dominant arm for IVs and for laboratory draws to try to maintain the non-dominant arm for creation of a fistula in the future, keeping those veins healthy, if you will.
Initially, when we started this quality improvement project, it was almost a flip of a coin in terms of which earned would be used for IV access, right arm or left arm, again dominant versus non-dominant. But after our quality improvement project, as we looked at our data over two years, we found that 93% of our IVs that are being placed in our patients are now very appropriately being placed in the dominant arm and preserving the vasculature in the non-dominant arm for a future fistula.
So this is something that has not been widespread across the dialysis community, but everybody recognizes that vascular preservation is exceedingly important. And I think our quality improvement project, which has just recently been published in the CJASN journal, I think that more and more people will look at this quality improvement project and see how they can incorporate it into their own programs.
Melanie: So doctor, then expand a little bit more on the Save The Vein initiative you've just been discussing, how it's improving that vascular preservation and what results have you seen so far.
Dr Bradley Warady: So the Save The Vein initiative is indeed a quality improvement initiative designed to maintain healthy vasculature in an arm that may ultimately be used for fistula development in a child or adult who may require a hemodialysis in the future. In this initiative, what we've done is, number one, put a note in the electronic medical record for all patients utilizing this Save The Vein initiative to state which is their dominant arm and which is their non-dominant arm. And when they're in the hospital, a pink arm band is put on the non-dominant arm to help preserve that vasculature and, again, to preferentially use the dominant arm for IV placement.
When we started this initiative, only about 47% of patients had their IVs placed in the preferred or the dominant arm. After two years of study and two years of this quality improvement project, 93% of all IVs at Children's Mercy that are placed in individuals with severe chronic kidney disease on dialysis or transplant patients are being placed appropriately in the dominant arm. And I think this, again, quality improvement project, this approach to vein preservation will help, I think, maintain healthy veins in the non-dominant arm for these patients who, again, may ultimately need a fistula development.
Melanie: This is so interesting, Dr. Warady. As we wrap up, please tell other providers what you would like them to know about advances in infection prevention for pediatric hemodialysis and vascular preservation, and what you're doing that's exciting at Children's Mercy, Kansas City.
Dr Bradley Warady: Well, what we're trying to do at Children's Mercy is provide our kids that are on hemodialysis with the best possible therapy from both a safety standpoint and an efficacy standpoint. So I think in terms of infection prevention, we need to all be very compulsive about, again, especially when we're accessing catheters in terms of doing so in a very, very appropriate manner, following recommendations oftentimes from the CDC. And we need to work collaboratively with our patients so that we both recognize the importance of infection prevention and carry out the evidence-based recommendations.
And in terms of vascular preservation, we just have to recognize that we're treating these patients for the long-term, not the short-term, and maintaining healthy vasculature in the nondominant arm is a primary importance to these kids. And so we should utilize the approach that we have used in the Save The Vein protocol, if you will, in preferentially placing IVs and lab draws from the dominant arm of all patients with advanced CKD on dialysis or following kidney transplant.
Melanie: Thank you so much, Dr. Warady, for filling us in on such important information today. This has been Transformational Pediatrics with Children's Mercy, Kansas City. To refer your patient or for more information, please visit childrenmercy.org to get connected with one of our providers, or you can listen to more podcasts at transformpeds.childrensmercy.org, the Transformational Pediatric series. Please also remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.
Pediatric Hemodialysis and Advances in Infection Prevention and Vascular Preservation
Melanie: To reduce the risk of complications related to hemodialysis, the Children's Mercy, Kansas City Division of Nephrology has implemented several strategies. Welcome to Transformational Pediatrics with Children's Mercy, Kansas City. I'm Melanie Cole. And today, I invite you to listen as we discuss pediatric hemodialysis and advances in infection prevention and vascular preservation.
Joining me is Dr. Bradley Warady, he's the Director in the Division of Nephrology and the Director of Dialysis and Transplantation at Children's Mercy, Kansas City. Dr. Warady, it's a pleasure to have you join us again today. Tell us how big a problem is infection with hemodialysis patients. Tell us a little bit about Children's Mercy's approach to addressing this issue.
Dr Bradley Warady: Well, first of all, thanks again for inviting me back. You know, infectious complications are really a significant issue for children and adults that receive hemodialysis. If these individuals get infected, they can have a significant morbidity and even mortality associated with those infections. And so, while dialysis is important to remove the waste products from the blood of patients with kidney failure, we have to be able to do it in a very safe manner.
In children especially, one of the ways that the blood moves from the patient to the dialysis machine is often through the use of a catheter. And catheters are an access device that very often are complicated by infections. And so, you know, our goal at Children's Mercy has been to try to decrease the risk of catheter-related infections in these patients on hemodialysis.
Melanie: Well then, describe the bundle of tactics that you use to reduce infections. Tell other providers what you're doing in this case.
Dr Bradley Warady: So, you know, there's been a number of approaches to try to decrease the infection risk in these patients. We utilize information from the CDC in terms of recommendations in terms of how to cleanse the catheter before actually entering the catheter to conduct hemodialysis. Hand hygiene by our providers and our patients is also exceedingly important. And then the ongoing education of the providers of the patients is another essential part of this infection prevention strategy.
And thankfully, by doing so, we did not experience any individual with a catheter-related infection for more than 1100 days at Children's Mercy, so virtually three years, and that kind of result is unheard of. But I think if you take a very proactive collaborative approach between the healthcare providers and the patients and families and utilize the tools and the recommendations that come from the CDC or come from collaboratives, like we participated in something called a scope collaborative, which is a national collaborative with pediatric dialysis centers looking at issues pertaining to infection prevention, if you follow that kind of guidance and those recommendations, I think all centers can really see a significant decrease in their infection rates.
Melanie: Dr. Warady, you've had great success with buttonhole cannulation. Why has Children's Mercy had such success with this procedure? Tell us about it.
Dr Bradley Warady: Well, you know, buttonhole cannulation is a way to enter into what's called a fistula in the arm of somebody who's on hemodialysis. It's a way to access again the blood that go from the patient to the dialysis machine. Buttonhole cannulation is not typically used on the adult side of things because one has to have the time, almost the patients, to be able to utilize this buttonhole repeatedly in the fistula in the arm of these patients to allow access but, again, without developing infectious complications.
At Children's Mercy, some of our dialysis technicians are really experts in creating the buttonholes and maintaining the buttonholes in an infection-free manner. And that lends itself to greater longevity of the fistula of these patients and, again, I think a more optimal dialysis access for them. So buttonholes are not very, very common in any dialysis patients, but I think in the pediatric population, it can be a very successful approach to vascular access in these patients in a very infection-free manner.
Melanie: Well, then tell us how does vascular preservation fit into our discussion here.
Dr Bradley Warady: So vascular preservation is important in patients who may ultimately need hemodialysis sometime in their lifetime, because one needs veins to create this fistula, this access again of blood to the dialysis machine. And so what we have instituted at Children's Mercy is a quality improvement project such that we preferentially use the patient's dominant arm for IVs and for laboratory draws to try to maintain the non-dominant arm for creation of a fistula in the future, keeping those veins healthy, if you will.
Initially, when we started this quality improvement project, it was almost a flip of a coin in terms of which earned would be used for IV access, right arm or left arm, again dominant versus non-dominant. But after our quality improvement project, as we looked at our data over two years, we found that 93% of our IVs that are being placed in our patients are now very appropriately being placed in the dominant arm and preserving the vasculature in the non-dominant arm for a future fistula.
So this is something that has not been widespread across the dialysis community, but everybody recognizes that vascular preservation is exceedingly important. And I think our quality improvement project, which has just recently been published in the CJASN journal, I think that more and more people will look at this quality improvement project and see how they can incorporate it into their own programs.
Melanie: So doctor, then expand a little bit more on the Save The Vein initiative you've just been discussing, how it's improving that vascular preservation and what results have you seen so far.
Dr Bradley Warady: So the Save The Vein initiative is indeed a quality improvement initiative designed to maintain healthy vasculature in an arm that may ultimately be used for fistula development in a child or adult who may require a hemodialysis in the future. In this initiative, what we've done is, number one, put a note in the electronic medical record for all patients utilizing this Save The Vein initiative to state which is their dominant arm and which is their non-dominant arm. And when they're in the hospital, a pink arm band is put on the non-dominant arm to help preserve that vasculature and, again, to preferentially use the dominant arm for IV placement.
When we started this initiative, only about 47% of patients had their IVs placed in the preferred or the dominant arm. After two years of study and two years of this quality improvement project, 93% of all IVs at Children's Mercy that are placed in individuals with severe chronic kidney disease on dialysis or transplant patients are being placed appropriately in the dominant arm. And I think this, again, quality improvement project, this approach to vein preservation will help, I think, maintain healthy veins in the non-dominant arm for these patients who, again, may ultimately need a fistula development.
Melanie: This is so interesting, Dr. Warady. As we wrap up, please tell other providers what you would like them to know about advances in infection prevention for pediatric hemodialysis and vascular preservation, and what you're doing that's exciting at Children's Mercy, Kansas City.
Dr Bradley Warady: Well, what we're trying to do at Children's Mercy is provide our kids that are on hemodialysis with the best possible therapy from both a safety standpoint and an efficacy standpoint. So I think in terms of infection prevention, we need to all be very compulsive about, again, especially when we're accessing catheters in terms of doing so in a very, very appropriate manner, following recommendations oftentimes from the CDC. And we need to work collaboratively with our patients so that we both recognize the importance of infection prevention and carry out the evidence-based recommendations.
And in terms of vascular preservation, we just have to recognize that we're treating these patients for the long-term, not the short-term, and maintaining healthy vasculature in the nondominant arm is a primary importance to these kids. And so we should utilize the approach that we have used in the Save The Vein protocol, if you will, in preferentially placing IVs and lab draws from the dominant arm of all patients with advanced CKD on dialysis or following kidney transplant.
Melanie: Thank you so much, Dr. Warady, for filling us in on such important information today. This has been Transformational Pediatrics with Children's Mercy, Kansas City. To refer your patient or for more information, please visit childrenmercy.org to get connected with one of our providers, or you can listen to more podcasts at transformpeds.childrensmercy.org, the Transformational Pediatric series. Please also remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.