Dr Ginger Chu

Key PointsThe inter-rater reliability of reporting hemodialysis catheter-related infectious events between site investigators and trial adjudicators in Australia and New Zealand was substantial.The high concordance level in reporting catheter infections improves confidence in using site-level bacteremia rates as a clinical metric for quality benchmarking and future pragmatic clinical trials.A rigorous adjudication protocol may not be needed if clearly defined criteria to ascertain catheter-associated bacteremia are used.BackgroundHemodialysis catheter-related bloodstream infection (HD-CRBSI) are a significant source of morbidity and mortality among dialysis patients, but benchmarking remains difficult because of varying definitions of HD-CRBSI. This study explored the effect of clinical adjudication process on HD-CRBSI reporting.MethodsThe REDUcing the burden of Catheter ComplicaTIOns: a National approach trial implemented an evidence-based intervention bundle using a stepped-wedge design to reduce HD-CRBSI rates in 37 Australian kidney services. Six New Zealand services participated in an observational capacity. Adult patients with a new hemodialysis catheter between December 2016 and March 2020 were included. HD-CRBSI events reported were compared with the adjudicated outcomes using the end point definition and adjudication processes of the REDUcing the burden of Catheter ComplicaTIOns: a National approach trial. The concordance level was estimated using Gwet agreement coefficient (AC1) adjusted for service-level effects and implementation tranches (Australia only), with the primary outcome being the concordance of confirmed HD-CRBSI.ResultsA total of 744 hemodialysis catheter-related infectious events were reported among 7258 patients, 12,630 catheters, and 1.3 million catheter-exposure days. The majority were confirmed HD-CRBSI, with 77.9% agreement and substantial concordance (AC1=0.77; 95% confidence interval [CI], 0.73 to 0.81). Exit site infections have the highest concordance (AC1=0.85; 95% CI, 0.78 to 0.91); the greatest discordance was in events classified as other (AC1=0.33; 95% CI, 0.16 to 0.49). The concordance of all hemodialysis catheter infectious events remained substantial (AC1=0.80; 95% CI, 0.76 to 0.83) even after adjusting for the intervention tranches in Australia and overall service-level clustering.ConclusionsThere was a substantial level of concordance in overall and service-level reporting of confirmed HD-CRBSI. A standardized end point definition of HD-CRBSI resulted in comparable hemodialysis catheter infection rates in Australian and New Zealand kidney services. Consistent end point definition could enable reliable benchmarking outside clinical trials without the need for independent clinical adjudication.

Rationale & Objective: More than 50% of hemodialysis patients experience sleep disturbance and most have coexisting sleep apnea. However, how sleep apnea affects sleep and the overall experience of patients with chronic kidney disease treated by hemodialysis has not been evaluated. Study Design: A mixed-methods design, incorporating cross-sectional observational and descriptive qualitative methodologies. Setting & Participants: Patients receiving maintenance hemodialysis in Newcastle, New South Wales, Australia, with newly diagnosed sleep apnea (apnea-hypopnea index = 5 per hour). Assessments: In-laboratory polysomnography to assess sleep apnea and objective sleep parameters. Epworth Sleepiness Scale to assess daytime symptoms. A semi-structured qualitative interview to explore patient experience. Analytical Approach: Descriptive and iterative thematic analysis. Results: We analyzed 36 patients with newly diagnosed sleep apnea and interviewed 26 (mean age, 62 years, median apnea-hypopnea index, 32 per hour). Severity of sleep apnea did not affect patients' sleep duration, sleep efficiency, or self-reported Epworth Sleepiness Scale score. From the qualitative interviews, 4 themes emerged: "broken sleep" related to short sleep duration, with waking and dozing off a common sleep cycle, caused by uncontrolled pain and dialysis. Many participants reported regularly "feeling unrefreshed" on waking. "Impact of sleep disturbance" included reduced physical, mental, and self-management capacity. Finally, interviewees described the need to use strategies to "soldier on" with symptoms. Limitations: Participants' views are only transferrable to hemodialysis patients with sleep apnea. Conclusions: Our findings suggest that severity of sleep apnea does not affect sleep time or patient-reported daytime sleepiness; however, hemodialysis patients with sleep apnea report disturbed and unrefreshed sleep and the debilitating effects of sleep disturbance is profound. Broken and unrefreshed sleep were the dominant symptoms of sleep apnea and should be assessed routinely to identify patients with sleep apnea and improve quality of life in patients with chronic kidney disease treated with hemodialysis.

Background: In Australia, more than 50% of end-stage kidney disease patients start haemodialysis treatment with a central venous catheter (CVC). While there are benefits of CVC access, they are associated with a high risk of bacteraemia infection. National guidelines for prevention of catheter-related infections advocate the importance of hand hygiene and asepsis practices, and for this reason, many dialysis units have regular auditing on hand hygiene and aseptic technique. Aim: To report the relationship between hygiene audit results and infection rates in our facility. Method: A hygiene audit tool was developed with 17 hygiene measures, categorised into three domains: environment, aseptic technique, and dressing care. This tool was used to observe nursing staff's hand hygiene compliance and aseptic technique during CVC care across five regional and remote units. Audit results were collected from 2011 to 2015. Results: A total of 350 audits were analysed, and the overall hygiene compliance was consistently high (85-99%). The relationship between mean hygiene score and infection rates was negative and the association was non-significant (p=0.7). Conclusion: The overall infection rates have decreased in our facility, by an average of 76% across sites. The decrease in infection was correlated to interventions such as minimising catheter utilisation, implementation of antimicrobial dressings and streamlining protocols but not hygiene audit results. Good hygiene is fundamental in the care of a CVC; however, whilst all facilities should strive for excellent audit results, it should not be the sole focus to prevent catheter infection.

Sleep disturbance is one of the most common dialysis-related symptoms reported by hemodialysis patients. Poor sleep confers significant physical and psychological burden on patients with kidney disease and is associated with reduced quality of life and survival. More recent evidence also indicates that sleep-disordered breathing may be a risk factor for kidney injury.

Introduction Heparin is commonly used after hemodialysis treatments as a locking solution to prevent catheter thrombosis. The comparative efficacy and safety of different heparin concentrations to maintain catheter patency has been previously reported in retrospective studies. We conducted a prospective, randomised, controlled study of 1000 U/mL heparin (low dose) versus 5000 U/mL heparin (high dose) locking solution to maintain patency of tunnelled catheters. Methods One hundred patients receiving chronic, unit-based hemodialysis with newly placed tunnelled hemodialysis catheters (less than 1 week) were randomly assigned to either a low dose (n = 48) or high dose heparin (n=52). The primary intention-to-treat analysis examined time to malfunction in both groups over a 90 day period. A secondary analysis compared baseline patient characteristics in relation to catheter malfunction. Findings Overall rate of catheter patency loss was 32% of catheters by 90 days. There was no significant difference in time to malfunction of catheters locked with low dose or high dose heparin (P = 0.5770). Time to catheter malfunction was not associated with diabetic, hypertensive or smoking status. There was no difference in mean delivered blood flow rate, venous and arterial pressure, and dialysis adequacy between low dose and high dose groups. No patient suffered a hemorrhagic complication requiring hospitalisation during the study period. Discussion Low dose heparin is adequate to maintain tunnelled hemodialysis catheter patency when compared with high dose heparin. The study also suggests that there is no relationship between catheter malfunction and diabetic, hypertensive or smoking status.

Background Peritonitis is the most common infection and cause of treatment failure for patients receiving peritoneal dialysis (PD). Peritonitis can be life-threatening if treatment is not initiated in a timely manner. We have identified in our facility that patients presenting to the emergency department (ED) with peritonitis often have delayed treatment. This could be due to a lack of understanding from ED clinicians and/or poor communication between ED and the renal department. Therefore, a local clinical pathway was developed to optimise peritonitis patient care. Aims To evaluate the effectiveness of a local peritonitis clinical pathway designed to reduce time for patients with PD-related peritonitis receiving their first antibiotic treatment. Setting All patients with PD peritonitis presenting through a tertiary hospital ED. Main outcome measured Time for patients with PD-related peritonitis receiving their first antibiotic treatment in hospital. Results The average time for peritonitis treatment decreased from 6 hours and 49 minutes to 5 hours and 18 minutes after the clinical pathway was implemented. Currently there is no published data to benchmark our result, even though the results indicated that the local clinical pathway may have been effective. Implications for clinical practice Since the implementation of this project, three patients were able to be safely discharged from ED without needing hospital admission and this is due to prompt management and good communication between ED and the renal department. Delayed treatment not only causes increased demand in ED service, but also results in unnecessary hospital admission, which impacts on both the patient and the overall health care system.

Catheter-related blood stream infection (CRBSI) contributes to hospitalisation and death in the haemodialysis population. Increasing numbers of catheter infections prompted a unit practice development program to reduce infection episodes. Objective/hypothesis: Improvement in clinical practice in dialysis catheter care would decrease dialysis CRBSI in the haemodialysis population. Context: Five dialysis units and one nephrology ward in regional Australia. Participants: Nephrology nurses working with haemodialysis patients who have central venous dialysis catheters (CVDC) in situ. Method: Use of a practice development framework to engage clinicians in reviewing their clinical practice and developing strategies to decrease dialysis CRBSI. Clinical practice was measured by undertaking clinical audits of CVDC care. The CRBSI rate was monitored and reported by the infection control department annually. Results: Rates of dialysis CRBSI have decreased from 4.39 per 100 patient-months to 3.42 per 100 patient-months (p<0.001) 12 months after the implementation of the project. There was a statistically significant association between improved staff practice and infection outcome measures. Conclusion: Dialysis CRBSI is a common, yet preventable complication in the dialysis unit. The results show that dialysis nurses play a significant role in preventing dialysis CRBSIs. Basic infection control standards are paramount and should be strictly followed for effective CVDC care.