Author Interview: Dr. Laura Labriola
Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report.
Labriola L, Crott R, Desmet C, André G, Jadoul M.
Am J Kidney Dis. 2011 Mar;57(3):442-8.
Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
1- What are the main findings of the study?
In this observational study, we incuded all our patients under in-center HD by a native
AVF from January 2001 to June 2010 (ie 193 AVF and 177 patients).
From August 2004 to January 2005 the rope-ladder technique with sharp needles was progressivly
replaced by the button hoe (BH) method with blunt needles.
As the rate of infectious events and complicated infectious events,(metastatic infections,
death related to an infectious event and AVF requiring surgery) progressively increased after the shift,
educational workshops were organized for allnurses in May 2008.
Every step of the BH method was thus carefully reviewed, including the scab removal and disinfection
before cannulation and after needle removal.
After staff re-education, complicated infectious events were almost completely prevented
and the rate of all infectious events decreased also.
2- Were any of the findings unexpected?
The possibility of an increased incidence of infections with BH had already been suggested, although poorly documented.
Nonetheless the increase in infectious rate, including dramatic complications such as endocarditis, was unexpected.
Interestingly, the observed rise in infectious events did not reach statistical significance
until the third year after BH implementation.
We strongly suspect that the nurses, after initial meticulous learning and training,
progressively paid less attention to the hygiene protocol of the BH technique.
The decrease of the rate of infectious events after staff re-education supports this hypothesis.
3- What should clinicians and patients take away from this study?
Our study provides important new information on the risk of infectious events and
especially complicated infectious events associated with the implementation of the BH method
in an in-center HD unit.
A key factor explaining the rise in infectious events rate in BH cannulation
is probably the non-adherence to hygienic rules.
The general procedure of the BH method includes five steps detailed in the article.
One might question the ongoing use of BH in our unit.
However, BH has been used for more than 10 years and is still used in our home HD and low-care patients,
with excellent outcomes and without increase of infectious complications.
Additionally, BH may improve AVF longevity and thus avoid catheters insertion (and the associated infectious risk).
Nevertheless, we think that in units without adequate RN staffing or training,
the risk may outweigh the potential benefits of BH.
4- What recommendations do you have for nephrology health care providers as a result of your study?
BH is a demanding technique and requires strict respect of the protocol.
Careful disinfection not only before but also after scab removal is crucial.
Scab removal is often difficult, and must be complete to prevent scab particles from entering the blood.
We recommend that these steps should not be performed hastily.
On the other hand, scab removal should not be performed with sharp instruments in order to avoid tissue injury at the mouth of the track.
The respect of the angle of cannulation is another crucial point.
Use of videos or pictures can be helpful to show the exact cannulation angle, especially in units with many staff members.
Poor attention to the angle of cannulation may indeed trigger intermittent use of sharp instead of blunt needles.
Use of sharp needles may damage the created track, resulting in the formation of one or more “false tracks”,
which can predispose to larger scabs difficult to remove, more track injury and, finally, infection.
We also emphasize the role of the reference nurse(s), which is crucial not only for teaching BH cannulation to other staff members,
but also for the track creation and for difficult cannulations.
In conclusion, we think that units considering a shift to BH should be warned that this method
requires the strict respect of every step of the procedure in order to avoid severe infectious complications.
Rigorous education and constant training of the nurses are mandatory to reach this goal.
Abstract
Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report.
Labriola L, Crott R, Desmet C, André G, Jadoul M.
Am J Kidney Dis. 2011 Mar;57(3):442-8.
Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
BACKGROUND: Constant-site or buttonhole cannulation of native arteriovenous fistulas (AVFs) has gained in popularity compared with rope-ladder cannulation. However, cannulating nonhealed skin might increase the risk of (AVF-related) infectious events, as suggested by small reports.
STUDY DESIGN: Quality improvement report.
SETTING & PARTICIPANTS: All patients on in-center hemodialysis therapy using a native AVF from January 1, 2001, to June 30, 2010.
QUALITY IMPROVEMENT PLAN: Shift to buttonhole cannulation between August 2004 and January 2005. Because the infectious event rate increased after the shift, educational workshops were held in May 2008 for all nurses, with review of every step of buttonhole protocol.
OUTCOMES: Infectious events (unexplained bacteremia caused by skin bacteria and/or local AVF infection) and complicated infectious events (resulting in metastatic infection, death, or AVF surgery) were ascertained during 4 periods: (1) rope-ladder technique in all, (2) switch to buttonhole, (3) buttonhole in all before workshops, and (4) buttonhole in all after workshops.
RESULTS: 177 patients (aged 70.4 ± 11.5 years) with 193 AVFs were analyzed, including 186,481 AVF-days. 57 infectious events occurred (0.31 events/1,000 AVF-days). The incidence of infectious events increased after the switch to the buttonhole method (0.17 [95% CI, 0.086-0.31], 0.11 [95% CI, 0.0014-0.63], and 0.43 [95% CI, 0.29-0.61] events/1,000 AVF-days in periods 1, 2, and 3, respectively; P = 0.003). This reached significance during only the second full year of buttonhole cannulation. During period 4, the incidence tended to decrease (0.34 events/1,000 AVF-days).
Complicated infectious events (n = 12) were virtually restricted to period 3 (n = 11; 0.153 [95% CI, 0.076-0.273] events/1,000 AVF-days), with a significant decrease in period 4 (n = 1; 0.024 [95% CI, 0.001-0.118] events/1,000 AVF-days; RR for period 3 vs period 4, 6.37 [95% CI, 1.09-138.4]; P = 0.04)
LIMITATIONS: Observational partly retrospective design.
CONCLUSION: Intensive staff education regarding strict protocol for the buttonhole procedure was associated with a decrease in infectious events.
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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