Vascular access The KidneyCare Audit

The challenge of vascular access – Renal National Service Framework Standard 3 “All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

 Overall 13,343 (77%) of prevalent patients were having dialysis therapy delivered by definitive access.  Centres varied from 52% to 95%.  For HD patients only, definitive access was used in 69%, range from 44% to 94%.

Renal Registry Vascular access survey – incident cohort

Infection: aetiology

Morbidity and mortality

Causes of death in dialysis patients USRDS 1996 Annual Data Report 10.2% 16.9% 16.1% 5.5% 12.6% 3.5% 15.6% 19.6%

Venous catheters and morbidity UK Vascular access survey 2005 Year 2004: 1547 Staph. Aureus infections (462 (29%) related to MRSA) in haemodialysis population One third of bed days in HD population related to catheter related problems Cost of a single episode of bacteraemia: £6209

Infection pathways and access CatheterComplicationInfection Catheter Infection Complication Infection Catheter Complication

Further information The National Kidney Care Audit

Audit QuestionStandard/Best Practice ReferenceAssociated MeasuresImpact of non-achievement Does the proportion of patients starting haemodialysis with functioning permanent access meet the Renal Association and Vascular Society Guidelines for permanent vascular access? No patient on dialysis, including those patients who present late, should wait more than four weeks for fistula construction (Clinical Practice Guidelines for Haemodialysis, UK Renal Association, 4th Edition, 2006) Number of days spent in hospital to establish first functioning permanent vascular access At risk of infection especially MRSA Number of operations and other interventions (eg. angioplasty, revision surgery) to establish first functioning permanent access. No time to prepare or make informed choice, educate and empower A proxy for failure to pre-emptively transplant list and therefore long await time for transplantation Patients should undergo fistula creation between 6 and 12 months before haemodialysis is expected to start to allow time for adequate maturation of the fistula or time for a revision procedure if the fistula fails or is inadequate for use (source as above) Percentage of catheter starters who have functioning permanent access established within three and twelve months Repeated admissions for percutaneous lines Increased crash landing At least 65% of patients presenting more than three months before initiation of dialysis should start HD with a usable native Arteriovenous fistula (source as above). Percentage of Haemodialysis patients starting with permanent access Inadequate dose of dialysis delivered Percentage of Haemodialysis patients starting with catheter access Poor correction of metabolic abnormalities - legacy of poor care impact on long term adaptation to dialysis and adverse clinical outcomes Checksum of these two measures should equal 100% Percentage of Haemodialysis patients starting with temporary access due to late referral (known to the renal service for less than 3 months before starting dialysis) Higher ESA (erythropoietin stimulating agent) requirements Worse transplant outcomes What are the hospital-acquired infection rates associated with vascular access in the maintenance of the haemodialysis population and how does this compare with the national average and the best performance? No avoidable HCAI in dialysis patients and an overall reduction in MRSA by 50 % by 2008 (Department of Health) Percentage of RRT patients diagnosed with hospital acquired infection including complications relating to vascular access, eg. line-related sepsis, clotted graft The number of Staphylococcal systemic infections per annum varies from 2.3 to 33.8, average 13, the figures for MRSA alone being from 0 to 21.5, average 4.

Content Patient Transport Vascular access – Stream 1 Prevalent Patient Access Data – Stream 2 Comorbidity In patient utilisation Infection – Stream 3 Process measures (based on NRDS)

Part 1:Prevalent recording

April 07 – Mar 08196(4.4)188(4.2)4438 o Not shared 29(15)29(15) o Shared, not completed 78(40)70(38) o Shared & completed 89(45)89(47) MESS data England

Modality Modality of dialysisNo. (%) MRSA bacteraemia Haemofiltration3(3.4) Haemodialysis84(94.4) Unknown2(2.2) All89(100) Table 2: Modality of dialysis in patients in established renal failure where record shared and completed

Access type Renal access typeNo. (%) MRSA bacteraemia AV- simple23(26) AVG3(3.4) Non-tunnelled – femoral6(6.8) Non-tunnelled - jugular4(4.5) Tunnelled – femoral5(4.7) Tunnelled - Jugular47(53) All89(101.9) Table 3: Type of renal access in patients in established renal failure where record shared and completed

Linkage with Renal Registry Infection Bacteraemia – Staph. Aureus – ?CDT In patient stats Bed utilisation Admissions by code – Bacteraemia – Pneumonia – Endocarditis – Spinal Abscess

Procedure

Recurrent data

What is needed from units Prevalent dataset – Electronic coding of access type at each session – Target 80% of units Comorbidity datset – HES and HPA linkage Process measures – Pilot sites – Use NRD (all ready finished a small pilot)