Variations in practice may involve under or excessive use of interventions or procedures. It exists between hospitals, professional groups, groups of doctors or between doctors who have similar expertise (Peveler 2002, Mercuri & Gafni 2011). Variation in practice can be warranted or unwarranted, with warranted variations occurring in response to differences in patient needs. In contrast, unwarranted variations are linked to practices that impact negatively on patient care and exist despite evidence from robust clinical research or agreement among professionals, as to what is best practice (Mercuri & Gafni 2011).
Unwarranted practices may occur due to lack of knowledge, professional attitudes or external/environmental factors. Professionals may not be familiar with guideline recommendations, may not agree with the expected patient outcomes in the guideline recommendations they do know of, or may opt not to adhere to guidelines based on the clinical experience they gained over a number of years. External factors include guidelines offering contradictory advice, being of poor quality, or so complex that professionals may have difficulty understanding them and integrating them into their practice. Environmental factors that impede implementation of evidence-based guidelines include time constraints, lack of resources and organisational resistance (Davis & Taylor-Vaisey 1997, Cabana et al. 1999, Bevans et al.
2009)
6.3.1
Variation in infection prevention & control practices
Inconsistencies in routine practice are apparent in infection prevention and control practices within ICUs, pre-operative preparation, paediatric care and haemodialysis units.
Investigating CVC infection prevention and control practices in 14 Australian ICUs, Richard et al. (2004) noted variation in the frequency of catheter dressing change, which was not in keeping with CDC guidelines. In addition, a wide variety of solutions were used to clean the CVC exit site. These include
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tincture of iodine/iodophor, 70% alcohol, 0.5% CHG in 70% alcohol, saline and chlorhexidine sponges. No unit used a 2% CHG solution even though it was recommended at that time by the CDC guidelines. The inconsistency in practice when compared with CDC guidelines was linked to lack of knowledge of evidence-based practice or a lack of resources to enable the development of up-to-date evidence-based policies.
Variation in preoperative practices was reported among 63 surgeons in Northern Ireland, with more than half continuing to shave the preoperative site hours before surgery even though the evidence suggests this is not necessary (McGrath & McCrory 2005). This audit survey also reported a wide variation in the types of antiseptic solutions used in preoperative skin preparation.
Surveying five healthcare professional groups (n=146), Niedner (2010) investigated catheter-associated bloodstream infection (CABSI) surveillance practices in 16 American paediatric ICUs. There was wide variation in surveillance practices including inconsistencies in the methods used to calculate line days; surveillance methods, timing and resources used to identify possible cases of CABSI and a lack of written policies for classifying bloodstream infections (BSI). More than half of those surveyed did not fully adhere to written guidelines on obtaining blood cultures.
Inconsistency in infection prevention and control practices were also noted in haemodialysis settings. Kumwenda et al. (1996) surveyed nurse managers on vascular access practices across UK dialysis units. Practice varied between units, with 64% using one nurse to change the CVC dressing and 36% of units using two nurses. Dressings were changed at each dialysis session by most units (60%). The most common antiseptic skin solution used to cleanse the CVC exit site was betadine (65%).
An audit of infection prevention and control practices across 393 haemodialysis units in eight European countries suggests considerable variation between countries (De Vos et al. 2006). Differences in isolation procedures were apparent for patients who were hepatitis B positive, HIV positive and Methicillin Resistant Staphylococcus Aureus (MRSA) positive. Substantial disparity in relation to regular screening for MRSA existed between counties, with 50% of centres in Greece, Italy, Belgium and England
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regularly screening for MRSA compared to 10% of centres in Slovakia, Scotland, Norway and the Czech Republic.
Higgins and Evans (2008) investigated nurses’ knowledge and practice of vascular access infection prevention and control, among adult haemodialysis patients in Ireland. A questionnaire was posted to 190 nurses in nine haemodialysis units, and the response rate was 74% (n=140). A majority of units had written infection prevention and control policies; but, there was considerable variation in practices between respondents. Differences related to time spent on hand hygiene, with only 29% identifying the recommended minimum time of 15 seconds. Diversity also existed among respondents in the type of antiseptic solution used to clean the CVC, with 38% using 10% povidone iodine and 20% using a chlorhexidine based solution. Differences also existed in the length of time 10% povidone iodine and chlorhexidine antiseptic soaks were applied to the catheter hubs even though this was not recommended practice for a CHG solution. Indeed, CDC and NKF-K/DOQI guidelines at the time of the survey advocated the use of 2% CHG as the antiseptic solution for cleaning the CVC, yet 38% of respondents used a povidone iodine solution. Variation in practice was also evident in dressing of the CVC, with 51% reflecting guideline recommendations on frequency of CVC dressing change. It is important to note that the Higgins and Evans (2008) survey was completed before the publication of national guidelines on the prevention of intravascular catheter related infections (Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) 2009). A number of infection prevention and control interventions evaluated in the survey are now outdated
Finally, a survey of 320 Swedish haemodialysis nurses, investigated self- reported knowledge and actual knowledge of MRSA, and routine practices used to prevent its transmission. Findings indicated that 24% of those surveyed were not aware that gloves were inadequate in preventing MRSA transmission (Lindberg & Lindberg 2012). Nurses also lacked knowledge of routine practices in MRSA management, common sites of colonisation (53%), treatment of colonisation (42%) and the symptoms of MRSA infection (44%). Consistency in knowledge was evident in relation to hand washing procedure (96%) and the use of protective apron (95%).
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6.3.2
Variation in renal care practices
Infection prevention and control is not the only area of renal care that experienced variation in routine practices. Practice variation was seen in nutritional care (Burrowes et al. 2005, Schatz et al. 2006, McKnight et al.
2010, Trudel et al. 2010, Hall-McMahon & Campbell 2012), peritoneal dialysis (Allen et al. 2011) and the management of anticoagulation therapy (Parker et al. 2012).
Bannister and Snelling (2006) in a retrospective study, investigated compliance to national anaemia management guidelines among 15 dialysis centres in Australia. The number of chronic haemodialysis patients achieving the haemoglobin target remained similar to that in 2001, 66% and 65% respectively. This study highlights an interesting dilemma within the field of nephrology where many practices are guided by evidence that is not supported by trial evidence because few trials are undertaking in nephrology (Lok & Moist 2007; McCann et al. 2012). Since Bannister and Snelling (2006) study, evidence from a randomised trial involving 1,432 patients (Singh et al.
2006), found that normalisation of haemoglobin using erythropoietin was dangerous in haemodialysis patients. A higher risk of death, myocardial infarction and stroke was observed. This contradicts guideline recommendations that were based on observational studies.
Routine practice in AVF creation also varied across renal care settings. Lopez-Vargas et al. (2011), using a mixed methods approach, investigated the barriers and enablers to AVF creation across nine nephrology centres in Australia and New Zealand. There was considerable variation in patients’ attendance at pre-dialysis education sessions, which ranged from 25% to 97%. Similarly, non-attendance by patients at surgical review for AVF creation, while low, varied between centres. There was no difference for wait times for surgical review among centres; but this was not the case for those patients waiting for access creation. Centres also differed on the type of vascular access used by patients commencing haemodialysis, with incident AVF use ranging from 14% to 51%.
Variation in practice within the haemodialysis environment is apparent across a breath of treatment strategies used in the management of patients with CKD. This is no more evident than in results published from the Dialysis Outcomes Practice Pattern Study (DOPPS). This international longitudinal
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study of haemodialysis practice has, since 1996, reported on variation in dialysis practices in such areas as vascular access and associated risk of hospitalisations and mortality (Pisoni et al. 2002, Young et al. 2002, Mendelssohn et al. 2006, Pisoni et al. 2009, Ng et al. 2011); starting and withdrawal of haemodialysis (Lambie et al. 2006); mortality and hospitalisation in dialysis patients (Rayner et al. 2004); imbalance in calcium, phosphate and PTH concentrations and mortality risk (Tentori et al. 2008) and length of dialysis session and impact on patient survival (Tentori et al. 2012). There is no published literature on routine practices in haemodialysis units in Ireland and consequently it is not possible to be sure that practice variation exists among units, although given the worldwide evidence of variations in dialysis practices it would seem likely that such variations are present in Irish dialysis settings.