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Controversies in Nephrology Nursing

Should Tunneled Hemodialysis Catheters Really Be Permanent?
Christy Price Rabetoy, Department Editor

Use of Tunneled Catheters Must Be Minimized
Deborah J. Brouwer, RN, CNN
Member, Three Rivers Chapter of ANNA

The National Vascular Access Improvement Initiative (2005) or Fistula First is a breakthrough initiative sponsored by the Centers for Medicare and Medicaid Services (CMS). The rationale for the initiative relates to hemodialysis vascular accesses as one of the most critical issues for improving dialysis quality. Recent trends in clinical practice are highlighting decreasing access patency, increasing morbidity/mortality, and increasing costs. Most often these are attributable to decreasing arteriovenous fistula (AVF) creation, increasing arteriovenous graft (AVG) placement, and increasing use of catheters. Vascular access is a major determinant of patient outcomes as well as financial outcomes.

Fistula First has 11 change concepts that are practical approaches that have been shown to be useful in creating change, which leads to improved outcomes. The seventh change concept is AVF placement in catheter patients.

Barriers to patients with chronic kidney disease (CKD) Stage 5 having an AVF vary. As nephrology nurses, we have a responsibility to be patient advocates and help create change towards more AVF. Often just the words we use can negatively impact patient care. Calling a tunneled cuffed catheter (TCC) a “permanent catheter” misleads patients to believe the “bridge catheter” is a permanent vascular access. A bridge catheter is a TCC placed to establish a useable vascular access until an AVF is created and matures. Many patients have the TCC placed and then refuse to go for AVF creation or let a matured AVF be cannulated.

One role of the nephrology nurse is to (re)educate the patient of the serious risks to TCC if left in place for long-term use. The risk of a life-threatening infection, including sepsis, endocarditis, and osteomyolitis is significantly higher for patients with TCCs than patients with AVGs or AVFs. The National Kidney Foundation (NKF) K/DOQI Vascular Access Guidelines list the rates for bacteremia per 100 patient months as 0.2 for AVF, 0.5 for grafts, 5.0 for cuffed catheters, and 8.5 for noncuffed catheters. The Centers for Disease Control (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections estimate the cost per infection requiring hospitalization to be $34,508-$56,000 (CDC, 2005). TCCs pose an unacceptable risk for infection and create unnecessary cost to U.S. taxpayers through Medicare and Medicaid funding. Dialysis is an entitlement benefit under Medicare, hence the reason for CMS to be funding the Fistula First project. The decreased use of TCCs will not only save lives but also save money.

Bacterial biofilm (coating that traps bacteria) can form within 24 hours of a TCC being placed. This biofilm is responsible for many of the repeat TCC infections. Currently no effective treatment is available to irradiate biofilm. Often the catheter must be removed and a new catheter inserted. Any patient that refuses AVF placement and has a catheter-related infection must be counseled by all members of the end stage renal disease (ESRD) team on the importance of an AVF and the high risk of repeat infections.

Another long-term complication of TCCs can be vessel stenosis, including the superior vena cava, which can prevent the future construction of any vascular access. Catheters are not harmless and must be presented as a serious threat to the patient’s health. The attitude of the entire ESRD team towards TCCs must be a united message. Catheters can and do kill patients on hemodialysis.

Education is our most powerful tool to change patients’ resistance and even our own practices. We can respect a patient’s choice, but we must continue to re-address the issue of an AVF placement and use with routine patient care planning and nurse practitioner or nephrologist rounds. Often the key is to understand the reasons for the patient’s decision. Fear of needle pain, cannulation difficulties, and prolonged post treatment needle site bleeding might be eliminated by the use of the buttonhole cannulation method.

The evidence proves TCCs do harm to patients, and nephrology nurses must remain patient advocates to ensure the health and safety of our patients. Everyone should consider the power of his or her words and actions and keep talking with patients about the need for an AVF. It’s worth the effort.

References/Additional Readings
Brouwer, D.J. (2002). Dialysis catheters: How and when to use them. Nephrology News & Issues, 16(7), 54-57.

Centers for Disease Control (CDC). (2005). Guidelines for the prevention of intravascular catheter-related infections from the CDC. Retrieved September 28, 2005, from www.cdc.gov

Dhingra, R.K., Young, E.W., Hulbert-Shearon, T.E., Leavey, S.F., & Port, F.K. (2001). Type of vascular access and mortality in U.S. hemodialysis patients. Kidney International, 60(4), 1443- 1451.

Lorenzo, V., Martin, M., Rufino, M., Hernandez, D., Torres, A., & Ayus, J.C. (2004). Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: An observational cohort study. American Journal of Kidney Disease, 43(6), 999-1007.

National Vascular Access Improvement Initiative. (2005). Retrieved September 28, 2005, from www.ihi.org/IHI/Topics/ESRD/ VascularAccess

Ortega, T., Ortega, F., Diaz-Corte, C., Rebollo, P., Ma Baltar, J., & Alvarez-Grande, J. (2005). The timely construction of arteriovenous fistulae: A key to reducing morbidity and mortality and to improving cost management. Nephrology Dialysis Transplantation, 20(3), 598-603.

Sandroni, S., McGill, R., & Brouwer D. (2003). Hemodialysis catheter-associated endocarditis: Clinical features, risks, and costs. Seminars in Dialysis, 16(3), 263-265.

Editor’s Note: The author is one of the original Work Group members and remains on the current Work Group for the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI) for Vascular Access. This Work Group developed nationally and internationally recognized guidelines for vascular access care in End Stage Renal Disease (ESRD) patients. The guidelines have been accepted by the Centers for Medicare Services (CMS) as the goals for the current CMS National Vascular Access Improvement Initiative (NVAII) or “Fistula First” project currently underway with the ESRD Networks. Deborah served as a Work Group Member for the NVAII and now serves as a member of the National Leadership Group (NLG).

Bottom Line: The Decision Belongs to the Patient
Randee J. Breiterman White, MS, RN, CNN
Clinical Nurse Specialist/Case Manager Nephrology
Vanderbilt University Medical Center
Nashville, TN
Member, Music City Chapter of ANNA)

The literature is replete with examples of short- and long-term complications resulting from the use of hemodialysis catheters. I believe there are circumstances in the chronic hemodialysis population where catheters are welcome.

K/DOQI defines chronic catheters as those being in place for more than 3 months and recommends that they be used in less than 10% of the patients in a given hemodialysis unit (National Kidney Foundation [NKF], 2001). As hemodialysis has improved, patients are living longer and running out of sites for permanent access; therefore, catheter use has actually increased. Whereas catheters began as a temporary solution for required vascular access for hemodialysis, they are increasingly used as the patient’s primary access (Butterly & Schwab, 2001).

When a patient presents for placement of a permanent dialysis access, all things should be considered. Age of the patient, frailty of vasculature, comorbidities that may affect the vasculature such as diabetes or heart disease, plus the risks of anesthesia and surgery must be taken into consideration. It may be worthwhile to attempt permanent vascular access. After the first failure, when the patient declines further attempts, are we serving in the patient’s best interest by continuing to pressure him into further surgery in order to get rid of the evil catheter? I believe that assessment of the patients and their unique situations along with a frank discussion regarding their wishes and their rationale can help us to support them in making the best decision possible.

Observe the elderly patient. With the median age of patients new to dialysis being 65.1 years, we must acknowledge that the access needs of the frail elderly may be different from those of younger patients. According to the most recent U.S. Renal Data System (USRDS) information, among patients on dialysis, those aged 75 and older have the highest rate of hospitalization, most commonly for cardiovascular disease and infection unrelated to internal vascular devices (USRDS, 2004). The Dialysis Outcomes and Practice Patterns Study (DOPPS) evaluated the prevalence of comorbidities in 16,720 patients on dialysis over 5 years in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States. It was found that 83% had hypertension, 50% had coronary heart disease, 46% had diabetes, and 46% had congestive heart failure (Goodkin, Young, Kurokawa, Prutz, & Levin, 2004). Comorbid conditions can greatly reduce the life expectancy of the person on hemodialysis. In a study of 1,136,201 patients in the Medicare database, a 23% mortality was found in patients with congestive heart failure, anemia, and chronic kidney disease combined (Herzog, Muster, Li, & Collins, 2004). The mortality rate for the diabetic patient started on hemodialysis remains high with only 27 % expected to survive 5 years. (USRDS, 2004).

We all know patients, both young and elderly, who have had multiple unsuccessful access attempts. We also know that access surgery itself can result in significant problems. Complications of dialysis access include steal syndrome, wound infection, synthetic graft reaction, and other operative risks. If patients can verbalize understanding of catheter risks including the possibility of a shortened life span due to the possibility of inadequate dialysis, infection, endocarditis, and the risk of death related to sepsis, aren’t they making an informed decision? People turn down life saving operations every day. It is their right. We all know patients who have been maintained on hemodialysis via a catheter for months and perhaps years.

I’m not advocating that all patients should dialyze with catheters, but I would submit that it is their choice or right. Most would admit that a catheter is preferable to two needles in their arm three times a week. I do feel that sometimes we are over zealous in our pursuit of the almighty permanent access to the detriment of some select patients. As nurses we are charged with the role of patient advocate. While we must ensure that patients and surrogates have and understand all the information they need to make informed decisions, I believe that too often we fail to remember that the final decision belongs to them.

References
Butterly, D.W., & Schwab, S.J. (2001). Catheter access for hemodialysis: An overview. Seminars in Dialysis, 14(6), 411-415.

Goodkin, D.A., Young, E.W., Kurokawa, K., Prutz, K., & Levin, N.W. (2004). Mortality among hemodialysis patients in Europe, Japan, and the United States: Case-mix effects. American Journal of Kidney Diseases, 44(5), S16-S21.

Herzog, C.A., Muster, H.A., Li, S., & Collins, A.J. (2004). Impact of congestive heart failure, chronic kidney disease, and anemia on survival in the Medicare population. Journal of Cardiovascular Failure, 10(6), 467-472.

National Kidney Foundation (NKF). (2001). K/DOQI clinical practice guidelines for vascular access: Update 2000. American Journal of Kidney Diseases, 37(Suppl.1), S137-S181.

U.S. Renal Data System. (2004). USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.