Improving Care for Children on Dialysis

By Alicia Neu MD and Bradley Warady MD

NTDS recommends adult dialysis centers analyze the SCOPE collaborative model.

Fewer than 3000 children undergo dialysis in the United States. (1) Although pediatric dialysis facilities are required to implement quality improvement projects, low patient volume may limit the ability to detect significant changes in outcomes.

To address this challenge, the pediatric nephrology community has embraced multi-center collaborative registries and prospective clinical trials: these have defined and improved the care provided to children with kidney diseases. 

The SCOPE Experience

This collaborative spirit extends to the quality improvement arena. One example, the Children’s Hospital Association’s Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative, launched in October 2011.  Using rigorous quality improvement methodology to reduce peritoneal dialysis catheter-related infections, SCOPE centers significantly increased implementation of a standardized follow up care bundle, reducing peritonitis rates in the first 3 years of the collaborative. (2) SCOPE has now extended its focus to reduce hemodialysis access-related infections. 

Many of the lessons learned can be applied to adult dialysis facilities seeking to reduce dialysis related infections. One of the most important features that has contributed to the success of SCOPE is the sharing of ideas and resources across the collaborative. 

  • Individual centers conduct small tests of change in practice in an effort to increase adherence with care bundles.
  • These changes in practice are tested in a small number of patients or care providers.
  • Feedback on the process is sought from the entire team, the patients, and their caregivers.
  • If required, the practice is modified to improve its impact, feasibility or acceptability.
  • If successful, the change is spread to other patients and then to other centers.

Through this process healthcare providers, patients and families can learn from and motivate one another.   Shared ideas, observations and resources can benefit and inform care in any affiliated unit.

Nephrologists Leading the Charge

Previous articles in ASN Kidney News Online have introduced the Nephrologists Transforming Dialysis Safety (NTDS) initiative and emphasized the central role of the nephrologist as a leader in the effort to “Target Zero Infections” in dialysis units.  As stated in Dr. Wong’s recent article on the topic, nephrologists should inspire others to work together to achieve this goal. 

The same philosophy of nephrologist as leader has been a key aspect of the success experienced by the centers participating in SCOPE. Although the front-line efforts of dialysis nurses and technicians have been crucial to the Collaborative’s infection-prevention effort, the “buy in,” encouragement and active participation of the nephrologist has been essential to reach quality improvement goals and improve care.

The number of staff in a pediatric dialysis facility can be substantially lower than in adult units, so the medical director and rounding nephrologists are often on a first-name basis with most, if not all, of the staff. It is not unusual for the medical director to meet with every new hire for the unit. This personal relationship facilitates the bidirectional communication that promotes an environment in which every person involved in the dialysis process (namely the physician, nurse, technician, patient, and caregiver) is empowered to contribute to change in order to improve care.  While a large staff may preclude the development of this type of relationship in an adult facility, the simple act by the nephrologist of practicing appropriate hand hygiene during rounds or commending staff on improvements emphasizes that infection-prevention is a priority for everyone on the care team.

Targeting Zero Infections

NTDS is committed to supporting nephrologists in the endeavor to enhance safety for our patients with kidney failure, including providing education about how quality improvement can be used to change behaviors.  

Nephrologists who are willing to take the lead will transform dialysis care. 

1. United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016.

2. Neu AM, Richardson T, Lawlor J, Stuart J, Newland J, McAfee N, Warady BA; SCOPE Collaborative Participants. Implementation of standardized follow-up care significantly reduces peritonitis in children n chronic peritoneal dialysis. Kidney Int. 2016 Jun;89(6):1346-54. doi: 10.1016/j.kint.2016.02.015. Epub 2016 Apr 13

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NTDS recommends adult dialysis centers analyze the SCOPE collaborative model.

Fewer than 3000 children undergo dialysis in the United States. (1) Although pediatric dialysis facilities are required to implement quality improvement projects, low patient volume may limit the ability to detect significant changes in outcomes.

To address this challenge, the pediatric nephrology community has embraced multi-center collaborative registries and prospective clinical trials: these have defined and improved the care provided to children with kidney diseases. 

The SCOPE Experience

This collaborative spirit extends to the quality improvement arena. One example, the Children’s Hospital Association’s Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative, launched in October 2011.  Using rigorous quality improvement methodology to reduce peritoneal dialysis catheter-related infections, SCOPE centers significantly increased implementation of a standardized follow up care bundle, reducing peritonitis rates in the first 3 years of the collaborative. (2) SCOPE has now extended its focus to reduce hemodialysis access-related infections. 

Many of the lessons learned can be applied to adult dialysis facilities seeking to reduce dialysis related infections. One of the most important features that has contributed to the success of SCOPE is the sharing of ideas and resources across the collaborative. 

  • Individual centers conduct small tests of change in practice in an effort to increase adherence with care bundles.
  • These changes in practice are tested in a small number of patients or care providers.
  • Feedback on the process is sought from the entire team, the patients, and their caregivers.
  • If required, the practice is modified to improve its impact, feasibility or acceptability.
  • If successful, the change is spread to other patients and then to other centers.

Through this process healthcare providers, patients and families can learn from and motivate one another.   Shared ideas, observations and resources can benefit and inform care in any affiliated unit.

Nephrologists Leading the Charge

Previous articles in ASN Kidney News Online have introduced the Nephrologists Transforming Dialysis Safety (NTDS) initiative and emphasized the central role of the nephrologist as a leader in the effort to “Target Zero Infections” in dialysis units.  As stated in Dr. Wong’s recent article on the topic, nephrologists should inspire others to work together to achieve this goal. 

The same philosophy of nephrologist as leader has been a key aspect of the success experienced by the centers participating in SCOPE. Although the front-line efforts of dialysis nurses and technicians have been crucial to the Collaborative’s infection-prevention effort, the “buy in,” encouragement and active participation of the nephrologist has been essential to reach quality improvement goals and improve care.

The number of staff in a pediatric dialysis facility can be substantially lower than in adult units, so the medical director and rounding nephrologists are often on a first-name basis with most, if not all, of the staff. It is not unusual for the medical director to meet with every new hire for the unit. This personal relationship facilitates the bidirectional communication that promotes an environment in which every person involved in the dialysis process (namely the physician, nurse, technician, patient, and caregiver) is empowered to contribute to change in order to improve care.  While a large staff may preclude the development of this type of relationship in an adult facility, the simple act by the nephrologist of practicing appropriate hand hygiene during rounds or commending staff on improvements emphasizes that infection-prevention is a priority for everyone on the care team.

Targeting Zero Infections

NTDS is committed to supporting nephrologists in the endeavor to enhance safety for our patients with kidney failure, including providing education about how quality improvement can be used to change behaviors.  

Nephrologists who are willing to take the lead will transform dialysis care. 

1. United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016.

2. Neu AM, Richardson T, Lawlor J, Stuart J, Newland J, McAfee N, Warady BA; SCOPE Collaborative Participants. Implementation of standardized follow-up care significantly reduces peritonitis in children n chronic peritoneal dialysis. Kidney Int. 2016 Jun;89(6):1346-54. doi: 10.1016/j.kint.2016.02.015. Epub 2016 Apr 13