BAPN 2016 Audit of dialysis access and complications in UK children

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1 BAPN 2016 Audit of dialysis access and complications in UK children Version 2, 8 th Dec 2015 Yincent Tse, BAPN audit committee member, yincenttse@nhs.net Introduction For children on dialysis, their access device (central line, peritoneal catheter or arterio-venous fistula) is their life line. Physical or infective complications result in significant morbidity and can be fatal. Less measurable costs include loss of choice of modality, increased clinic burden and psychological trauma of repeated medical procedures. For our healthcare system, these complications are costly. In the UK in December 2013, the prevalent dialysis population <18 years were 104 on haemodialysis (HD) and 72 on peritoneal dialysis (PD). This is a high risk population with 3 deaths (1.7%) over that year although not necessary related to dialysis access. The prevalent data though only tells a partial story as most incident children begin renal replacement therapy on dialysis before proceeding to transplantation. In 2013, of children <16 years commencing renal replacement therapy, 50 started PD and 35 started HD. 45% were <8 years of age. The UK is a geographically large country (243,000 km 2 ). Thirteen paediatric renal centres dispersed in large population centres attempt to deliver an equitable dialysis service available to all children regardless of location. The number of children on dialysis in each centre range from 2 to 35 children in December Maintaining dialysis skills and quality care with small patient numbers can be challenging hence the need to audit outcomes. The British Association For Paediatric Nephrology (BAPN) clinical practice guidelines for children and adolescents on HD and PD were published in 2008 to promote best practice and to reduce the variation of care [1,2]. We aim to prospectively audit dialysis access fistula and their complications. Audit standards We chose to use relevant BAPN 2008 audit measures for objective individual patient outcome measures rather than process measures which are more subjective. For many of these measures there are no agreed targets. Instead this audit will produce contemporary data to generate discussion and as a baseline to measure against for future audits. 1

2 BAPN audit measures HD14 PD4, HD14, PD11, HD16 Audit data Target Data collected Dialysis access device type at start of audit period Monitoring of modality switching and changing of access device The line revision rate Fistula should be considered in children on long-term HD Fistula should be considered in children on long-term HD Type of device e.g.: PD catheter, AV fistula, central venous catheter Event, timeline and reason PD11 PD17 PD17 PD Catheter complications and their resolution PD Peritonitis rates, organism and treatment outcome PD exit site infection rates, organism and treatment outcome Not specified Peritonitis rates of <1 episode per 12 months A primary cure rate of 80% A culture negative rate of < 20% Not specified Events requiring hospitalisation or surgical intervention: e.g. leak, poor flow, obstruction, hernias and prolapse, severe pain Defined as: Clinical peritonitis and treated as such on presentation unless an alternative cause (e.g. eosinophilic peritonitis) is subsequently diagnosed Data collected: Timelines Organism Associated patient factors e.g. weight, age, gastrotomy site Treatment outcome Defined by: The presence of purulent drainage, with or without erythema of the skin at the catheter epidermal interface Requiring iv antibiotics, hospitalisation or change of line Data collected: Timelines Organism Associated patient factors e.g. weight, age, gastrotomy site Treatment outcome HD15 HD bacteraemia observed per 1000 patient days <1.6 episodes per 1,000 central venous catheter days Defined by: Positive blood culture with the suspected source reported as the vascular access 1 Data collected: Timelines Organism Treatment outcome HD16 Access revision rate Not specified Defined by: Any surgical or radiological intervention undertaken on access device to reposition or improve flow Any replacement of access device (including those accidentally displaced) Medication thrombolysis (excludes line lock only) Data collected: Timelines Organism Treatment outcome 1 Also known as Access-related bloodstream infection (ARB). CDC NHSN Dialysis Event Manual Dialysis Event Protocol (2014) 2

3 Method Patient population: All children <18 years requiring chronic dialysis treated in the 13 paediatric nephrology units. Patients will be analysed if require dialysis for 3 months Time period: Data is collected for 12 months (Jan to Dec) Census baseline data is taken of the dialysis population at the start and for new patients during the twelve months (data already collected for renal registry will be used to minimise data entry duplication) Data collection discontinues when a patient is transplanted or dialysis is permanently discontinued New patients start data collection on insertion of access device Baseline data for each existing and new patient: BAPN access complication audit Patient local identifier Baseline characteristics at start of audit Access device Selected by units to identify patient every month DOB to calculate age, Weight When inserted (to calculate longevity) Presence of factors that may increase infection risk eg gastrostomy or unusual anatomy Haemodialysis via central line Lumen size, brand, single or double lumen Home or in-hospital Haemodialysis via AV fistula Anatomical description Home or in centre Peritoneal dialysis Lumen size, brand, straight or curled Reason for modality and access device Reasons for choice of PD or HD board category and specifics Patient choice Psycho-social/safeguarding factors Loss of original modality Others If HD, reason for CVL or AV fistula 3

4 Event recording: At the end of every month, each dialysis unit nominated contact will be sent a list of their dialysis cohort. For example: Centre: ZZZZZZZ List of current dialysis patient identifier and access device. Has an dialysis access event occurred in month of January Events include (not exhaustive): Change of modality Replacement of access device Any hospitalisation or surgical intervention because of access device e.g. blockage, displacement or leak Peritonitis or line infection Exit site infection requiring iv antibiotics, hospitalisation or change of line AV fistula issues requiring surgical intervention Medical thrombolysis Centre Patient identifier Access device Event? One line description AAAAAA PD catheter Y/N BBBBBB PD catheter Y/N CCCCCC PD catheter Y/N DDDDD PD catheter Y/N EEEEEE PD catheter Y/N FFFFFFF CVL Y/N GGGGG CVL Y/N HHHHH CVL Y/N IIIIIIIIIIII CVL Y/N JJJJJJJJJJ CVL Y/N KKKKKK CVL Y/N LLLLLLLL CVL Y/N MMMM CVL Y/N OOOOO AV fistula Y/N PPPPPP AV fistula Y/N Has any new patients had dialysis access devices inserted who is expected to need permanent ( 3 months) renal replacement therapy? Transplanted or stopped dialysis permanently? Y/N Any event will be followed up with request for details Detailed information will then be requested for dialysis events. After the 12 month study period, data collection and interrogation will continue for events commencing on the last month until treatment outcome is known. 21 day rule There must be 21 or more days from the end of one IV antimicrobial course to the beginning of a second IV antimicrobial start for two starts to be reported as separate dialysis events, even if different antimicrobials are used. If IV antimicrobials are stopped for fewer than 21 days and then restarted, the second start is NOT considered a new dialysis event and therefore, is not reported. Similarly, access complications and revisions on one access device are counted as one event if they are similar and occur within 21 days of each other. If an access device is changed, subsequent events will be counted as separate events. 4

5 Transmission of data Local patient identifiers will be used to maintain anonymity. Anonymous data will be transmitted between unit nominated leads via secure nhs.net Analysis of results Dialysis event rates will be stratified by access type and expressed per 100 patient-months. Rates are calculated by dividing the number of events by the number of patient-months and multiplying the result by 100. Published data will be primarily aggregate pooled mean rates for each event type by combining rates from all participating facilities. We will highlight ranges and variation between the centres. As we wish to encourage data fidelity no specific centre will be identified in published reports. We will not link patient caseload to centres. After analysis, centres will be sent their own rates privately which they can compare with the aggregate rates. Centres are encouraged to reflect on the data they report and provide regular feedback to their staff about patient outcome event rates. rate = Dialysis Events (numerator) / Patient-Months (denominator) 100 Project summary This will be the first BAPN audit focusing on dialysis access and complication in children. The data will illustrate the challenges of dialysing children in our current era and provide comparison data for future audits. Final report Data will be the property of BAPN audit and registry committee Report will be published in a peer review journal on behalf on BAPN Authorship: will include one nominated contributor from each centre who will be the link person for sending data 5

6 Appendices: Complex peritonitis definitions The 2010 ISPD Guidelines give the following definitions: Refractory peritonitis results when there is failure of the effluent to clear after 5 days of appropriate antibiotics. Relapsing peritonitis can be defined by an episode that occurs within 4 weeks of completion of a therapy of a prior episode with the same organism or 1 sterile episode. Recurrent peritonitis refers to an episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism. Repeat peritonitis occurs more than 4 weeks after completion of therapy of a prior episode with the same organism. Catheter-related peritonitis is in conjunction with an exit-site or tunnel infection with the same organism or 1 site sterile. When peritonitis rates are calculated, relapsing episodes are not considered another peritonitis episode; however, repeat and recurrent episodes are counted 6

7 Peritoneal Dialysis access audit measures UK Renal Association clinical practice guideline Peritoneal Dialysis in CKD (2010) Guideline PD Infectious Complications : Prevention Strategies We recommend that PD units should undertake regular audit of their peritonitis and exit-site infection rates, including causative organism, treatment and outcomes. They should enter into active dialogue with their microbiology department and infection control team to develop optimal local treatment and prevention protocols. (1B) Prevention strategies: Both the International Society of Peritoneal Dialysis (ISPD) 2005 guidelines and the NSF Part 1 place increasing emphasis on prevention strategies. Regular audit is essential to this progress and the following standards should be considered as minimal: 1. Peritonitis rates of less than 1 episode per 12 months in children 2. A primary cure rate of 80% 3. A culture negative rate of < 20% Summary of Audit Measures for Peritoneal Dialysis Audit Measure 2: Monitoring of modality switching Audit Measure 12: Catheter complications and their resolution Audit Measure 20: Routine annual audit of PD peritonitis rates (including proportion of culture negative cases) Audit Measure 21: Routine annual audit of infection outcomes BAPN Peritoneal dialysis clinical practice guidelines for children and adolescents (2008) Summary of Audit Measures for Peritoneal Dialysis Audit Measure 4: Monitoring of modality switching Audit Measure 11: Catheter complications and their resolution Audit Measure 17: Routine annual audit of infection outcomes (exit site and peritonitis rates) International Society for Peritoneal Dialysis (ISPD) 2010 Every program should regularly monitor infection rates, at a minimum, on a yearly basis 7

8 Haemodialysis access audit measures BAPN Haemodialysis clinical practice guidelines for children and adolescents (2008) Paediatric clinical practice guidelines Paediatric standard 7: A fistula should be considered in children on long-term dialysis; psychological preparation is necessary before fistula creation, and pain during needling prevented (Good practice) Rather than specify a minimum proportion of HD patients who should have a functioning AVF this guideline emphasizes that as many patients as possible should have a functioning AVF in preference to other forms of vascular access and the prevalent form of vascular access should be audited in each unit at least annually. Paediatric standard 7.16: All HD units should collect and audit data on the form of vascular access in use in incident and prevalent haemodialysis patients and the rates of infection per 1000 patient days using central venous catheters, polytetrafluoroethylene (PTFE) grafts and fistulae. (Good practice) Infections in central venous catheters are an important cause of morbidity in children treated with haemodialysis and may lead to loss of dialysis access sites. Catheter related blood stream infection rates reported in paediatric and adult studies are reported as episodes per 1,000 central venous catheter days. However, this does of course depend on many factors that may not be open to improvement (e.g. need for femoral access, access difficulty requiring frequent line disconnections during haemodialysis, immunosuppression) Comparative audit of the different forms of vascular access that are used for HD and the incidence of access related infections should help identify to what extent the above guidelines have been achieved and promote good clinical practice. Paediatric standard 7.17: All units should collect and audit data on the line revision rate Poor flow rate as well as infection can lead to line replacement, particularly in small children. Reported rates range from a line revision of 35% in infants (1), to 15 and 36% in older children (2,3). Summary of Audit Measures for Haemodialysis Audit measure 12: The proportion of prevalent patients on long-term haemodialysis who use an arterio-venous fistula, arterio-venous graft and tunnelled or non-tunnelled central venous catheters as the mode of vascular access Audit Measure 14: The proportion of prevalent patients on long-term haemodialysis who use an arterio-venous fistula, arterio-venous graft and tunnelled or non-tunnelled central venous catheters as the mode of vascular access, according to age Audit Measure 15: The rates of bacteraemia (and specifically the rates of MRSA bacteraemia) observed per 1000 patient days using central venous catheters, polytetrafluoroethylene (PTFE) grafts and arterio-venous fistulae Audit Measure 16: The line revision rate. 8