"Real-Life" Examples of Best Practices in AVF Management

1. Setting up a Successful CKD/Pre-ESRD Care System

The following example was submitted by Brian Lee, MD (Renal Population Management, Kaiser Permanente Hawaii Region), and Nancy Ikeda (Renal Clinic Supervisor):

Briefly, I work as a nephrologist at Kaiser Permanente, Hawaii Region. We have about 100 new starts every year, around 75% of whom are diabetic. In the first half of 2006, 10/55 HD (18.2%) starts in the first half used an AVF, 40/55 used a catheter. In the second half, 17/37 (45.9%) starts were with an AVF compared to 19/37 with a catheter. There were also 7 PD starts and one preemptive transplant in 2006.

There are two initiatives used to improve our performance. The first is the Renal Population Management System, which I designed and programmed. I screen all un-referred patients in our population for high-risk chronic kidney disease. To determine high risk, I use a model I developed for internal use that considers both GFR and proteinuria, and this predicts outcomes much more accurately than CKD staging alone. On a regular basis, I use our EMR (KP Healthconnect, which is essentially Epiccare) to review each high-risk patient, to see if he/she would be appropriate for referral. If so, I contact the PCP to advise referring the patient. In the last two and a half years we have generated around 200 referrals, many of whom have reached ESRD. PCPs satisfaction with this is high. Our late referral rates (referral less than 4 months and less than 1 year prior to ESRD) have been cut in half, and are much lower than any rates that have been published. Fewer than 30% of patients reaching ESRD have seen a nephrologist for less than one year.

The second is the Multidisciplinary Team (MDT) initiated and overseen by my colleague, Dr. Randy Chen. At least monthly, a list of all patients with GFR<20 and their dialysis preparation status is generated. There is a nurse assigned to this team, and she is given a report each week of this population, with their GFR score and last and next nephrologist appointments. The nurse checks to see that patients are coming in for their appointments with nephrologists, that they have referrals to the kidney and choices classes offered, and that the nephrologists refers them to a vascular surgeon, as deemed appropriate. The nurse calls patients to encourage them to come in to see the doctors and come to classes, and schedules appointments to vascular surgeons. The patients are reviewed by the nephrologists, and, as necessary, steps are taken to ensure that they are appropriately on track for an AVF. For example, a nephrologist might be queried about referral timing, and a slowly maturing fistula might need to go back to the surgeon. Patients who are non-compliant are discussed by the MDT in weekly meetings. We still have problems with noncompliant patients who do not want to go on dialysis until they find themselves in a health crisis. We are working on ways to reduce this problem.

So briefly, we make sure that patients at risk see a nephrologist at least a year prior to dialysis, and once they're being followed, make sure that they are able to obtain a working fistula in time for dialysis.

Of course I am proud to be associated with a great group of nephrologists, vascular surgeons and staff, who make these improvements possible. Ours is a team effort.

2. Boosting AV Fistula Rates in ESRD Patients

This system was developed by Dr. Nguyen of Olympia, Washington. By taking responsibility for the accesses placed in his patients and working with surgeon Chris Griffith and the members of his dialysis team, nephrologist Dr. Vo Nguyen created a treatment system that results in over 90 percent of his patients having AV fistulae.

Boosting Arteriovenous (AV) Fistula Rates in ESRD Patients

Nephrologist Dr. Vo Nguyen got his wake-up call about vascular access in 1996. Actually, it was a triple wake-up call, according to Dr. Nguyen, medical director of Aberdeen Dialysis Center, Renal Care Group of the Northwest, Olympia, Washington, USA, and member of the American Society of Diagnostic and Interventional Nephrology.

His dialysis group got a warning letter from the Medical Review Company about a high rate of hemodialysis arteriovenous (AV) graft failure among its end stage renal disease patients on chronic hemodialysis. Then its vascular surgeon partners balked at the need to intervene when AV grafts thrombosed - sometimes at midnight after all the day’s scheduled operations were completed. And he was shaken by the generally poor patient outcomes from dialysis catheters and grafts, which are more prone to severe access infection.

Nguyen, who had always considered AV access as the concern of the surgeon rather than the nephrologist, went to surgeon Chris Griffith and asked for help. Working with Griffith and other members of the dialysis team - Lynn Treat, RN, Ann Jackson, RN, Kandy Collins, RN, and Becky Lee, RN - they created a program to shift from grafts to fistulae as the standard AV access - an unusual strategy, compared to the standard of practice in the United States.

Why AV Fistulae?

Like most US nephrologists, Nguyen did not have any formal training in AV fistula creation and had gone with AV grafts as the default because they are simpler and quicker to create than fistulae. To create an AV fistula, a surgeon needs a well-mapped target for joining an artery and a vein, and it typically takes weeks or months for the fistula to mature before use. "Who wants to spend six months waiting?" says Nguyen.

Studies show, however, that AV fistulae achieve a higher survival rate than AV grafts, with less thrombosis and infection. Nguyen also knew that most European dialysis patients receive fistulae.

Making the transition became a "true passion" for Nguyen, as he describes it. Dr. Griffith helped him understand the vascular surgeon’s information needs and operating procedures. Nguyen also read extensively about AV access and talked with European nephrologists during several visits there and online with Renaliste, an email distribution list for Francophone nephrologists. Key nursing staff volunteered to learn the sometimes forgotten art of cannulating fistulae, including the Buttonhole technique, and trained others.

The program proved highly successful, with all dialysis patients with failing grafts converted to secondary fistulae by the year 2000 and all new patients strating dialysis with fistulae. A more recent survey showed that 98 percent of Dr. Nguyen’s patients had fistulae, with greatly reduced use of catheters. And the approach was adopted by the Northwest Renal Network in 2002 as the basis for the Network’s VA Quality Improvement Program, as mandated by the Centers for Medicare and Medicaid Services.

Steps for Change

Here are some of the tactics that worked for Dr. Nguyen and his team, also detailed in an article in Nephrology News & Issues (A multidisciplinary team approach to increasing AV fistula creation. June 2003):

• Recognize that this is a team effort. It requires collaboration and trust, not just between nephrologists and surgeons, but with nursing staff, other dialysis team members, primary care physicians, and patients and their families.
   
• The nephrologist must play a central role. In addition to coordinating the effort, nephrologists must have a thorough understanding of Doppler analysis and other vein mapping techniques, surgical options for creating fistulae, and cannulating techniques.
   
• Make a roadmap. Establish an outline for the effort.
   
• Prepare for the fistula long before it is needed. Ideally, a referral should be made at least three months before dialysis is needed.
   
• Establish a relationship of trust with primary care physicians. Nguyen’s nephrology group started with a letter sent to local primary care physicians, to encourage early referrals. Building this relationship, according to Nguyen, is "a lot of work; a simple letter is not going to do it."
   
• Educate patients and their families. Patients don’t want to hear about the operation when they do not feel sick and yet early surgery for fistula is key to success. "I spend a lot of time talking to patients and their families," Nguyen says. "I always invite the whole family to come to the first visit. Convince the family, and they will beat on the patient to do it." It’s important to explain the procedure in very simple terms - "I tell them the [result] is just like varicose veins, the uglier the better." A fistula is like car insurance: we hope that we’ll never need to use it, but we’ll be glad to have it in case of an accident." To set expectations properly in case the first operation doesn’t do the job, since we are dealing with sicker and older patients with higher risk of fistula failure to mature properly, we tell them that another surgery may be needed. In addition, patients must learn to protect all veins that may be needed for future fistula construction: needle sticks are allowed only in hand veins.
   
• Use new surgical approaches when needed. Patients who are older or obese may need special procedures, including transposition of deep upper arm veins. Small anastomosis size helps preventing steal syndrome (hand ischemia after fistula creation).
   
• Stop revising failing grafts and convert all existing grafts into secondary fistulas using a long term vascular access planning.
   
• Late referral patients are encouraged to consider home peritoneal dialysis until the fistulae mature in order to avoid the use of hemodialysis catheters which are the worst dialysis vascular access.
   
• Maintain a checklist for each patient. The AV Access Checklist for Nephrologists documents key material for a surgical plan, including mandatory preoperative vein mapping for all patients.
   
• Educate staff. Proper training in AV access is key for all team members. That’s a particular issue, in Nguyen’s opinion, because historically "there’s been no training whatsoever in vascular access for nephrologists and not much for surgeons." Graft cannulation is very different from fistula. Dialysis staff are more familiar with graft cannulation, since the majority of vascular accesses in use in this country are grafts. Training in fistula cannulation is the key of a successful fistula program.
   
• Monitor results as part of a comprehensive quality care control program. Maintain and analyze statistics on AV access by the nephrologist, surgeon, and dialysis unit to encourage change in practice behavior.