Improving Care and Outcomes for Pediatric Musculoskeletal Infections.

BACKGROUND: Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration. METHODS: We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019). RESULTS: In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%). CONCLUSIONS: Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration.

Examination of nursing drug administration practices via central venous catheter: An observational study.

AIM: To determine the compliance with nursing drug administration procedure steps associated with access to the central venous catheter for bolus infusion in intensive care units. METHODS: This observational study was conducted with 30 nurses working in an intensive care unit of a university hospital. The drug administrations practiced by nurses via central venous catheter were monitored simultaneously at 12:00 a.m., 02:00 p.m., and 06:00 p.m. by two observers. The data were collected using a data collection form and central venous catheter drug administration procedure steps. RESULTS: A total of 90 different drug administrations were observed in three different treatment hours from 30 nurses. The interobserver conformity was found to be moderate in two steps (kappa = 0.520-0.627, P = 0.01) and perfect in all other steps (kappa = 0.821-1.000, P = 0.000). According to the drug administration procedure steps via a central venous catheter, all nurses applied the following steps correctly during all treatment hours: drug card control, preparation of treatment materials, checking the patient's identity, and steps of drug treatment administration. The following tasks were frequently performed incorrectly or not at all: hand hygiene (before treatment 87.8%; after treatment 82.2%), scrubbing the three-way stopcock entrance with an alcohol swab (55.6%), waiting for the alcohol to dry (81.1%), and flushing the lumen with a compatible fluid (before treatment 84.4%: after treatment 75.6%). CONCLUSION: Observation of drug administration procedure steps via central venous catheter according to the treatment hours showed that the nurses performed many incomplete or inaccurate drug administration procedure steps and the mistakes increased toward the evening hours.

Trends in Central Venous Catheter Insertions by Anesthesia Providers: An Analysis of the Medicare Physician Supplier Procedure Summary From 2007 to 2016.

BACKGROUND: Central line insertion is a core skill for anesthesiologists. Although recent technical advances have increased the safety of central line insertion and reduced the risk of central line-associated infection, noninvasive hemodynamic monitoring and improved intravenous access techniques have also reduced the need for perioperative central venous access. We hypothesized that the number of central lines inserted by anesthesiologists has decreased over the past decade. To test our hypothesis, we reviewed the Medicare Physician Supplier Procedure Summary (PSPS) database from 2007 to 2016. METHODS: Claims for central venous catheter placement were identified in the Medicare PSPS database for nontunneled and tunneled central lines. Pulmonary artery catheter insertion was included as a nontunneled line claim. We stratified line insertion claims by specialty for Anesthesiology (including Certified Registered Nurse Anesthetists and Anesthesiology Assistants), Surgery, Radiology, Pulmonary/Critical Care, Emergency Physicians, Internal Medicine, and practitioners who were not anesthesia providers such as Advanced Practice Nurses (APNs) and Physician Assistants (PAs). Utilization rates per 10,000 Medicare beneficiaries were then calculated by specialty and year. Time-based trends were analyzed using Joinpoint linear regression, and the Average Annual Percent Change (AAPC) was calculated. RESULTS: Between 2007 and 2016, total claims for central venous catheter insertions of all types decreased from 440.9 to 325.3 claims/10,000 beneficiaries (AAPC = -3.4, 95% confidence interval [CI], -3.6 to -3.2: P < .001). When analyzed by provider specialty and year, the number of nontunneled line insertion claims fell from 43.1 to 15.9 claims/10,000 (AAPC = -7.1; -7.3 to -7.0: P < .001) for surgeons, from 21.3 to 18.5 claims/10,000 (AAPC = -2.5; -2.8 to -2.1: P < .001) for radiologists, and from 117.4 to 72.7 claims/10,000 (AAPC = -5.2; 95% CI, -6.3 to -4.0: P < .001) for anesthesia providers. In contrast, line insertions increased from 18.2 to 26.0 claims/10,000 (AAPC = 3.2; 2.3-4.2: P < .001) for Emergency Physicians and from 3.2 to 9.3 claims/10,000 (AAPC = 6.0; 5.1-6.9: P < .001) for PAs and APNs who were not anesthesia providers. Among anesthesia providers, the share of line claims made by nurse anesthetists increased by 14.5% over the time period. CONCLUSIONS: We observed a 38.3% decrease in claims for nontunneled central lines placed by anesthesiologists from 2007 to 2016. These findings have implications for anesthesiology resident training and maintenance of competence among practicing clinicians. Further research is needed to clarify the effect of decreasing line insertion numbers on line insertion competence among anesthesiologists.

Current practice in dialysis central venous catheter management: Multi-disciplinary renal team perspectives.

AIM: To explore the current practices related to the insertion, management and removal of dialysis central venous catheters (CVCs) used in patients with chronic kidney disease requiring haemodialysis. METHODS: This qualitative descriptive study involved semi-structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal researchers involved in the care of patients with chronic kidney disease requiring haemodialysis. Data were collected from staff at eight hospitals in six states and territories of Australia. Thirty-eight face-to-face interviews were conducted. A modified five-step qualitative content analysis approach was used to analyse the data. RESULTS: Improved visualization technology and its use by interventional radiologists has steered insertions to specialist teams in specialist locations. This is thought to have decreased risk and improved patient outcomes. Nurses were identified as the professional group responsible for maintaining catheter access integrity, preventing access failure and reducing access-related complications. While best practice was considered important, justifications for variations in practice related to local patient and environment challenges were identified. CONCLUSION: The interdisciplinary team is central in the insertion, maintenance, removal and education of patients regarding dialysis CVCs. Clinicians temper research-based decision-making about central dialysis access catheter management with knowledge of individual, environmental and patient factors. Strategies to ensure guidelines are appropriately translated for use in a wide variety of settings are necessary for patient safety.

A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion.

RATIONALE & OBJECTIVE: Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. STUDY DESIGN: Retrospective multicenter observational study. SETTING & PARTICIPANTS: 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June 2018. EXPOSURE: Application of the IOA approach to gain vascular access. OUTCOME: The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). ANALYTICAL APPROACH: Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. RESULTS: 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. LIMITATIONS: No comparison to other methods to place CVCs and the observational study design. CONCLUSIONS: The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

Predialysis nephrology care and its impact on initial vascular access type in hemodialysis patients in Jordan.

Chronic kidney disease (CKD) patients who reach end-stage renal disease (ESRD) require early nephrology referral and appropriate vascular access. Arteriovenous fistula (AVF) is the preferred access for hemodialysis (HD). Referral to nephrology of CKD patients starting HD in Jordan and its impact on AVF utilization is unknown. Patients on in-center HD in a large Jordan Ministry of Health dialysis unit were interviewed, and medical records reviewed to assess prior nephrology care and AVF use. Of 104 total patients, 93 met the inclusion criteria. The mean age was 50 ± 16 years, with 44% being females. The average body mass index was 25 ± 5. The cause of ESRD was diabetes mellitus in 28 (30%), hypertension in 28 (30%), and polycystic kidney disease in three (3%). Type of HD access at the initiation of dialysis was central venous catheter (CVC) in 80 (86%) and AVF in 12 (13%). Of the overall group, 50 (54%) were seen by nephrology before initiating dialysis, and of these, 39 patients (78%) were seen >1 year before HD initiation. Of the patients who initiated dialysis with a CVC, 38 (48%) had received prior nephrology care. All 12 patients who initiated dialysis with AVF had received prior nephrology care. Of the 50 patients who received nephrology care before dialysis initiation, 12 patients (24%) had started dialysis with an AVF; in patients without prior nephrology care, all were started with a CVC. In conclusion, our study suggests that a large percentage did not have nephrology care before initiating dialysis. The ones who were seen by nephrology before dialysis were significantly more likely to initiate dialysis using an AVF. A national focus on improving nephrology referral in advanced CKD may allow better utilization of AVF as the method of access at dialysis initiation.

Evaluation of dialysis practice patterns in children having end-stage renal disease on maintenance hemodialysis at a pediatric nephrology unit.

Hemodialysis (HD) involves purifying the blood of waste products through diffusion through a semipermeable membrane. We aimed to evaluate dialysis practice patterns among children with end-stage renal disease (ESRD) on maintenance HD (MHD). This cross-sectional study was conducted on 30 children with ESRD on MHD at the pediatric nephrology unit of Menoufia University and 18 age- and sex-matched children who served as the control group. Consent was obtained from children more than seven years old and their parents and from parents of younger children. They were all subjected to full history, complete physical examination, efficiency measures estimation (for cases), and laboratory investigations. Risk factors for death were determined using the logistic regression model; data were analyzed using the Statistical Package for the Social Sciences software. The study showed that the causes of ESRD in children were unknown in 43.3%; about 73.3% of cases were short-statured and 53.3% were underweight. About 40% of the cases were hypertensive showing a significant difference from controls (P <0.01). A double-lumen jugular catheter (DLJC) was the initial access in 80% of cases. The urea reduction ratio and Kt/V were significantly higher in children with arteriovenous fistula (AVF) than those with DLJC (P <0.0001 and 0.004), respectively. About 66.7% of cases had anemia showing a significant difference from controls (P <0.01). Hypoalbuminemia, anemia, elevated C-reactive protein, and left ventricular hypertrophy were the significant risk factors resulting in death (P <0.0001). Although the most common initiating vascular access used for HD patients was a DLJC, the efficiency of dialysis was significantly higher in patients who had AVF. Stature was affected more than weight in HD patients in the study group.

Hemodialysis vascular accesses in patients on chronic hemodialysis at the Kenyatta National Hospital in Kenya.

INTRODUCTION: The objective of our study was to document the level of preparedness for renal replacement therapy assessed by incident hemodialysis vascular access and the access at least 3 months after initiation of hemodialysis at Kenyatta National Hospital, Nairobi. METHODS: Between June and July 2018, we carried out a cross-sectional descriptive study on the preparedness for hemodialysis by patients who were on chronic hemodialysis in the Kenyatta National Hospital Renal Department. Sociodemographic, medical history, duration of follow-up, and state of preparedness parameters were obtained through interview and entered into the questionnaire. The data were entered in preprogrammed format in the Statistical Package for the Social Sciences (SPSS) version 20.0 for analyses. RESULTS: Eighty-two patients were enrolled. Males were 50% (41). The mean age was 45.39 ± 15.96 years but females were 5 years younger than their male counterparts. About 85.4% of the patients were drawn from the hypertension and diabetes clinics, and the mean, mode, and median of the duration of follow-up were 41, 0, and 0 months, respectively, in these clinics. Almost three in every four patients (74.4%) were initiated on hemodialysis as emergency (p value < 0.001). About 80% were initiated hemodialysis via acute catheters placed in the jugular and subclavian veins (p value < 0.001). At least 3 months later, 40% still had acute catheters on the same veins (p value < 0.001). Acute venous catheters in the femoral veins were in 9.2% at initiation and 6.6% of the patients at least 3 months later. Less than 2% of the patients had arteriovenous fistulae at initiation, which rose to 14.5% in 3 months. Tunneled catheters were placed in 11.8% initially and at least 3 months, were almost in 40% of the patients. CONCLUSION: In conclusion, our young hemodialysis population mainly drawn from hypertension and diabetes clinic requires more input in hemodialysis vascular access planning. Focused individualized follow-up and early referrals to nephrologists are required. Uptake of arteriovenous grafts for hemodialysis might reduce the prevalence of hemodialysis catheters. As it is, this population is threatened with iterative vascular accesses complications as well as real danger of exhaustion of their vascular capital. There is real danger of increase in mortality from access complications.

Current state of dialysis access management in Korea.

The prevalence rate and the incidence rate of hemodialysis and functioning kidney transplant recipients have continuously increased; on the contrary, those of peritoneal dialysis have continuously decreased since 2006. Dialysis patients have been getting older and have been maintained on dialysis longer. Diabetic nephropathy was the leading cause of end stage renal disease. The type of hemodialysis vascular access has been stable during the last 5 years (arteriovenous fistulas 76%, arteriovenous grafts 16%, central venous catheters 8% at 2016). Peritoneal dialysis catheter was mostly inserted surgically (67%), and swan neck straight tip peritoneal dialysis catheter was the most commonly used (48%). Vascular access was managed by radiologists and surgeons, and the management was fragmented among them in the past. However, since the nephrologists became interested in and knowledgeable about the vascular access, they began to play roles in vascular access management. Vascular access has been mostly created by vascular surgeons (≈60%); tunneled central venous hemodialysis catheter insertion and endovascular intervention such as percutaneous transluminal angioplasty (PTA) and thrombectomy have been mostly performed by radiologists (≈70%). Tunneled hemodialysis catheter insertion and endovascular intervention by nephrologists have slowly but consistently increased. Recently, the number of central venous hemodialysis catheter insertion has decreased, and tunneled hemodialysis catheter has been inserted more than non-tunneled hemodialysis catheter, indicating that vascular access has been created timely and the vascular access team has been educated about and following international guidelines.

Knowledge and behavior of professionals about bundled strategies of central venous catheter.

OBJECTIVE: To investigate the factors that influence the knowledge and behavior of professionals of neonatal and pediatric units about bundled strategies of insertion of central venous catheter. METHOD: This is a cross-sectional study, conducted in one neonatal and one pediatric intensive care units in a public hospital in Belo Horizonte, Brazil, from April to July, 2016. The sample consisted of 255 professionals who answered a structured instrument. Descriptive and comparative analyses were made using the SPSS software. RESULTS: The category nursing professional (p = 0.010), working hours of 12×36 scale (p < 0.001), training as a form of acquiring knowledge (p < 0.001) and participation in training programs (p < 0.001) are associated to greater knowledge about the bundle. Regarding behavior, no significant associations were observed. CONCLUSION: The study showed that there are factors that influence the knowledge about bundled strategies of insertion of central venous catheter, reflecting the need to consider these practices for making more effective educational practices in health care.

Knowledge and behavior of professionals about bundled strategies of central venous catheter / Conocimiento y comportamiento de profesionales sobre el bundle de catéter venoso central / Conhecimento e comportamento de profissionais sobre o bundle de cateter venoso central

ABSTRACT Objective: To investigate the factors that influence the knowledge and behavior of professionals of neonatal and pediatric units about bundled strategies of insertion of central venous catheter. Method: This is a cross-sectional study, conducted in one neonatal and one pediatric intensive care units in a public hospital in Belo Horizonte, Brazil, from April to July, 2016. The sample consisted of 255 professionals who answered a structured instrument. Descriptive and comparative analyses were made using the SPSS software. Results: The category nursing professional (p = 0.010), working hours of 12×36 scale (p < 0.001), training as a form of acquiring knowledge (p < 0.001) and participation in training programs (p < 0.001) are associated to greater knowledge about the bundle. Regarding behavior, no significant associations were observed. Conclusion: The study showed that there are factors that influence the knowledge about bundled strategies of insertion of central venous catheter, reflecting the need to consider these practices for making more effective educational practices in health care.

RESUMEN Objetivo: Investigar los factores que influencian el conocimiento y comportamiento de los profesionales de unidades neonatales y pediátricas sobre el bundle de inserción del catéter venoso central. Método: Estudio transversal que se realizó en dos unidades de terapia intensiva neonatal y pediátrica de un hospital público de Belo Horizonte, en el período de abril a julio de 2016. La muestra se constituyó de 255 profesionales, que respondieron a un instrumento estructurado. Se realizaron análisis descriptivos y comparativos por medio del software SPSS. Resultados: La categoría profesional de enfermero (p = 0,010), la jornada de trabajo de 12 × 36 horas (p < 0,001), el entrenamiento como forma de adquisición del conocimiento (p < 0,001) y la participación en entrenamientos (p < 0,001) se asocian al mayor conocimiento sobre el bundle. En cuanto al comportamiento, no se observaron asociaciones significativas. Conclusión: Se ha revelado que existen factores que influencian el conocimiento sobre el bundle de inserción de catéter central, reflejando la necesidad de considerarlos para la realización de prácticas educativas más efectivas en salud.

RESUMO Objetivo: Investigar os fatores que influenciam o conhecimento e comportamento dos profissionais de unidades neonatais e pediátricas sobre o bundle de inserção do cateter venoso central. Método: Estudo transversal, realizado em duas unidades de terapia intensiva neonatal e pediátrica de um hospital público de Belo Horizonte, no período de abril a julho de 2016. A amostra constituiu-se de 255 profissionais, que responderam a um instrumento estruturado. Foram realizadas análises descritivas e comparativas por meio do software SPSS. Resultados: A categoria profissional de enfermeiro (p = 0,010), a jornada de trabalho de 12×36 horas (p < 0,001), o treinamento como forma de aquisição do conhecimento (p < 0,001) e a participação em treinamentos (p < 0,001) estão associados ao maior conhecimento sobre o bundle. Quanto ao comportamento, não se observou associações significativas. Conclusão: Revelou-se que existem fatores que influenciam o conhecimento sobre o bundle de inserção de cateter central, refletindo a necessidade de considerá-los para a realização de práticas educativas mais efetivas em saúde.

Vascular access for hemodialysis: Current practice in Vietnam.

A well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure, which directly affects the quality of life in hemodialysis patients. We use three main types of access: native arteriovenous fistula, arteriovenous graft, and central venous catheter. Arteriovenous fistula remains the first and best choice for chronic hemodialysis. It is the best access for longevity, the lowest related complications, and for this reason, arteriovenous fistula use is strongly recommended by guidelines from different countries, including Vietnam. In practice, well-functioning arteriovenous fistula creation is not always simple. In this case, arteriovenous fistula creation with vein transposition or translocation is certainly useful. When native vein options have been exhausted, prosthetic can be used as the second option of maintenance hemodialysis access alternatives. Central venous catheters are very common and have become an important adjunct in maintaining patients on hemodialysis. In Bach Mai hospital, we certainly create about 1000 new arteriovenous fistulas every year (among these, about 84.98% new hemodialysis patients start hemodialysis without permanent accesses and depend on temporary central venous catheters) and successfully matured arteriovenous fistula rate is 92.6%. Among hemodialysis population in Bach Mai, 2.29% have arteriovenous grafts and 2.81% of patients still depend on cuffed tunneled catheters. The preferable locations for catheter insertions are the internal jugular and femoral veins. Proper vascular access maintenance requires integration of different professionals to create a vascular access team. Percutaneous transluminal angioplasty is not available. In our circumstance, we have achieved some advantages for hemodialysis patients but still a big gap to an advanced country.

Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

Accumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and intensive care in the Netherlands, identify barriers for further implementation of US guidance and to evaluate whether personality traits are associated with the choice of technique. We conducted a web-based national survey, distributed among members of the Dutch societies of anaesthesiology (NVA) and intensive care (NVIC). The survey contained questions regarding physician and hospital characteristics, frequency of US use and reasons for use or non-use, as well as the NEO-FFI-3, a validated, translated questionnaire to characterize personality traits according to the 'Big Five' concept. Response rate was 22% (506/2291), of which 400 had also the personality questionnaire complete. Ultrasound guidance was used always or almost always in 68%; barriers for US use were working in a non-academic non-teaching hospital, providing cardiac anaesthesia and more years of physician experience. Reasons for not using US were perceived lack of benefit, increased procedure time, lack of US equipment and fear of loss of landmark technique skills. 13% of respondents had never experienced a complication during CVC placement, and 67% knew of a complication occurring the past year at their department. Ultrasound was thought not to be able to prevent the complication in half of these cases. Of the personality traits, only neuroticism and extraversion showed a minor positive association with US guidance. A majority of anaesthesiologists and intensivists uses US guidance for CVC placement, but a significant proportion of physicians still prefers the landmark technique. Most arguments from respondents against US guidance can be challenged. Personality traits most likely do not play a major role in the acceptance of US guidance for central venous catheterization. A potential intervention to increase US use could be formalizing local hospital policies mandating compliance with US guidance. Future research can perhaps focus on cognitive biases that currently limit more widespread use of US guidance.

Current status of dialysis and vascular access in Taiwan.

Due to the implementation of the National Health Insurance system in 1995, the number of patients receiving maintenance dialysis has increased rapidly. This contributed to Taiwan to be in an unfortunate position of possessing the highest prevalence of end-stage renal disease globally. Although the age-standardized incidence of end-stage renal disease gradually decreased to -1.1% in 2014, the huge economic burden that comes with dialysis is detrimental to the quality of dialysis treatment. To achieve a balance between economy and quality of care requires multidisciplinary cooperation. Through a variety of chronic kidney disease-related care projects, we have gradually reversed this situation and achieved good results. Further promotion of kidney transplantation and hospice care for terminal patients will improve the situation. With respect to vascular access, the "fistula first" policy is carried out and percutaneous transluminal angioplasty is the mainstay of treatment to resolve vascular access dysfunction. The medical expenses for dialysis and vascular access management are both fully paid for by the National Health Insurance, and patients do not have to worry about the medical expenses. However, the statistics and vascular access monitoring are relatively insufficient in the past. The comprehensive integration of vascular access management into public policy related to kidney disease will complete the missing piece of the puzzle of overall care.

Diagnostic and Interventional Nephrology in Spain: A snapshot of current situation.

BACKGROUND:: Diagnostic and Interventional Nephrology has been a rising field in recent years worldwide. Catheter insertion, renal biopsy, renal ultrasound, and peritoneal dialysis catheter or permanent dialysis catheter insertion are vital to our specialty. At present, many of these procedures are delegated to other specialties, generating long waiting lists and limiting diagnosis and treatment. METHODS:: An online survey was emailed to all Nephrology departments in Spain. One survey response was allowed per center. RESULTS:: Of 195 Nephrology departments, 70 responded (35.8%). Of them, 72.3% (52) had ultrasound equipment, 77.1% insert temporary jugular catheters, and 92.8% femoral. Up to 75.7% (53 centers) perform native renal biopsies, of which 35.8% (19) are real-time ultrasound guided by nephrologists. Transplant kidney biopsies are done in 26 centers, of which 46.1% (12) by nephrologists. Tunneled hemodialysis catheters are inserted in 27 centers (38.5%), peritoneal catheter insertion in 18 (31.6%), and only 2 centers (2.8%) perform arteriovenous fistulae angioplasty. In terms of ultrasound imaging, 20 centers (28.5%) do native renal ultrasound and 16 (22.8%) transplanted kidneys. Of all units 71.4% offer carotid ultrasound to evaluate cardiovascular risk, only in 15 centers (21%) by nephrologists. AVF ultrasound scanning is done in 55.7% (39). CONCLUSION:: Diagnostic and Interventional Nephrology is slowly spreading in Spain. It includes basic techniques to our specialty, allowing nephrologists to be more independent, efficient, and reducing waiting times and costs, overall improving patient care. Nowadays, more nephrologists aim to perform them. Therefore, appropriate training on different techniques should be warranted, implementing an official certification and teaching programs.

Utilization, patency, and complications associated with vascular access for hemodialysis in the United States.

BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.