Kulawik Deuzimar, Sands Jeffrey J, Mayo Kelly, Fenderson Mary, Hutchinson Janet, Woodward Cindy, Gore Sally, Asif Arif
The End Stage Renal Network of Florida, Florida, USA.
Semin Dial. 2009 Nov-Dec;22(6):692-7. doi: 10.1111/j.1525-139X.2009.00647.x.
Tunneled hemodialysis catheters (TDCs) carry the highest mortality risk for chronic hemodialysis patients of any access modality. Recent data have emphasized that mortality risk decreases when these devices are discontinued. Herein, we present the results of a gap-reduction assisted catheter elimination strategy that Network 7 employed as its quality improvement initiative to reduce the use of TDCs. Hemodialysis facilities with high catheter rates (>90 days) were identified. Interventions included focused vascular access education, monthly follow-up and site visits to assist the facility catheter reduction program. The "goal" of interventions was defined as the gap-reduction of 50% from the baseline catheter rate to the Network mean plus sustainability of catheter reduction for at least 3 consecutive months. Fifteen facilities (n = 891) were identified with high catheter rates (31.5 +/- 5.3%) in May 2006. Interventions resulted in a catheter reduction to 12.2 +/- 8.5% in May 2007 (p = 0.0001). Five of the 15 facilities (n = 280) achieved the goal (preintervention = 31.7 +/- 5.3%, postintervention = 8.7 +/- 2.8%, p = 0.001). In May 2007, eight additional facilities (n = 438) with high catheter rates (31.7 +/- 7.8%) were added to the 10 that failed to achieve the goal previously. Interventions employed in these 18 facilities (n = 1,049) resulted in catheter reduction in all (preintervention = 31.5 +/- 5.5%, postintervention = 16.2 +/- 5%, p = 0.01). Five of these 18 met the goal (preintervention = 32 +/- 8%, postintervention = 5.9 +/- 4.3%). Overall, all 23 facilities (n = 1,329) demonstrated catheter reduction postintervention (preintervention = 31.6 +/- 6%, postintervention = 13.9 +/- 6%, p = 0.001), and 10/23 (43%) met the project goal (preintervention = 31.9 +/- 6%, postintervention = 7.3 +/- 4%, p = 0.002). Medical director's involvement had a positive impact in achieving the goal (p = 0.003). The presence or absence of a vascular access coordinator did not affect catheter reduction. The results of this analysis reveals that an organized approach implemented by an ESRD Network can have a significant impact in reducing catheter use.
对于慢性血液透析患者而言，隧道式血液透析导管（TDC）在所有血管通路方式中具有最高的死亡风险。近期数据强调，停用这些装置时死亡风险会降低。在此，我们呈现了第7网络作为其质量改进举措采用的一种减少差距辅助导管消除策略的结果，该策略旨在减少TDC的使用。确定了导管使用率高（>90天）的血液透析机构。干预措施包括针对性的血管通路教育、每月随访以及实地考察，以协助机构的导管减少计划。干预措施的“目标”定义为从基线导管使用率降至网络平均水平的差距减少50%，并使导管减少持续至少连续3个月。2006年5月，确定了15个机构（n = 891）导管使用率高（31.5±5.3%）。干预措施使2007年5月的导管使用率降至12.2±8.5%（p = 0.0001）。15个机构中有5个（n = 280）实现了目标（干预前 = 31.7±5.3%，干预后 = 8.7±2.8%，p = 0.001）。2007年5月，另外8个导管使用率高（31.7±7.8%）的机构（n = 438）被加入到之前未实现目标的10个机构中。在这18个机构（n = 1,049）中采用的干预措施导致所有机构导管减少（干预前 = 31.5±5.5%，干预后 = 16.2±5%，p = 0.01）。这18个机构中有5个实现了目标（干预前 = 32±8%，干预后 = 5.9±4.3%）。总体而言，所有23个机构（n = 1,329）在干预后均显示导管减少（干预前 = 31.6±6%，干预后 = 13.9±6%，p = 0.001），并且23个中有10个（43%）实现了项目目标（干预前 = 31.9±6%，干预后 = 7.3±4%，p = 0.002）。医疗主任的参与对实现目标有积极影响（p = 0.003）。血管通路协调员的有无并不影响导管减少。该分析结果表明，终末期肾病网络实施的有组织方法在减少导管使用方面可产生重大影响。
