A CLEAR(ing) solution for the dialysis community | MEDICUS 2024 Issue 2

A CLEAR(ing) solution for the dialysis community

Credit: iStock.com / Edwin Tan

In a newly introduced health service, Singapore General Hospital has joined hands with the National Kidney Foundation to equip the Foundation’s centres islandwide with tools and expertise to unblock dialysis catheters on site. This new service, offered under the Catheter Flow Restoration with Lytic Dwell at Community Dialysis Centre (CLEAR) programme, will provide much-needed respite to hundreds of dialysis patients, who currently have to be hospitalised for days to get their catheters unblocked and undergo further dialysis.

Dialysis is the standard treatment prescribed to chronic kidney disease patients, whose kidneys have lost their ability to remove excess fluids and toxins from the body. More than 8,700 kidney failure patients across the nation rely on dialysis for this filtration, without which toxins and fluid will build up to fatal levels.

The most common type of dialysis is haemodialysis and some 4,642 patients receive this type of dialysis at one of the forty-one centres run by the National Kidney Foundation. Of these 700 or more use a central venous catheter inserted into a vein in the neck, chest or groin, through which blood is drawn out for filtration and filtered blood is pumped back into the body. A major challenge is the formation of blood clots that block the central catheter, and disrupt the filtration, something that can happen repeatedly.

“With the right-siting of care, patients can receive treatment for their blocked catheters at the dialysis centre they go to and proceed with dialysis at the centre right after without having to make their way to the hospital.”
Dr Tan Ru Yu

When a catheter is blocked, patients are referred to hospital emergency departments, where they are admitted and treated with medications that help in breaking up or dissolving the clots. If the clots do not completely disappear, they undergo a catheter replacement procedure. Once blood flow through the catheter is completely restored, they then wait to receive dialysis at the hospital. From start to end, this process can take an average of three to six days—long enough to leave patients physically exhausted and grappling with hospitalisation costs, time crunches and disruption of their daily routines.

With more than 50 catheter blockage patients being referred to hospitals every month, the extra space and resources needed to the care for these patients could overwhelm healthcare systems too.

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Since the implementation of the CLEAR programme in December 2022, a team of specialists from SingHealth, including Drs Tan Ru Yu and Pang Suh Chien, both senior consultants with the department of renal medicine at Singapore General Hospital, and Dr Charles Ng, an associate consultant with the renal medicine department at Changi General Hospital, have trained more than 100 National Kidney Foundation nurses on the catheter unblocking procedure.

The programme has also expanded with the integration of other major hospitals in Singapore, including Changi General Hospital, Alexandra Hospital, Khoo Teck Puat Hospital, National University Hospital, Ng Teng Fong General Hospital, Sengkang General Hospital and Tan Tock Seng Hospital.

“With the right-siting of care, patients can receive treatment for their blocked catheters at the dialysis centre they go to and proceed with dialysis at the centre right after without having to make their way to the hospital,” noted Tan, who co-leads the programme with Associate Professor Jason Choo, a senior consultant also with the renal medicine department at the Singapore General Hospital, and medical director at the National Kidney Foundation.

While patients with increased risk of bleeding will continue to be referred to a hospital emergency department, the new health service comes as a timely and impactful solution to the nation’s rapidly-expanding dialysis community, which grows by about six patients every day.

Even with this caveat, the programme has eased the pressure on hospital systems. “The partnership with the National Kidney Foundation has enabled the hospital (and other hospitals) to focus on complex cases requiring immediate attention,” pointed out Tan.

The SGH-NKF partnership is supported by the National Improvement Unit as an initiative under the Ministry of Health’s National Diabetes Collaborative.

Adapted by Sruthi Jagannathan from SingHealth News (CLEARing catheter blockages at dialysis centres - SingHealth)