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Prevention of vascular access infection in
haemodialysis in the Republic of Ireland
5 June, 2009  

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
for alternative modalities of treatment. Am J Kidney Dis 1997;30(2 Suppl 1): S160-S177.
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).
10. Pisoni RL, et al. Vascular access use in Europe and the Unites States: results from
DOPPS 2002. Kidney Int
2003;61:305-16.
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
2004;25:668-74.
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

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