Change Concept #1 – Related Tools

Dr. Vo Nguyen, Medical Director of Aberdeen Dialysis Center, Renal Care Group of the Northwest
Olympia, Washington, USA

This “roadmap” can be used to plan an improvement effort to increase AV fistula rates in your nephrology practice including forming the team, establishing an algorithm for vein mapping and other procedures, and identifying specific improvement activities.

Background

See the related feature story Boosting Arteriovenous (AV) Fistula Rates in ESRD Patients for more information on the development of this tool by Dr. Nguyen. 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.

Directions
Download the tool for complete instructions.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

A log sheet for vascular access monitoring and surveillance that tracks referrals and interventions for patients with abnormal monitoring indicators who are to be referred for fistulography or consultation and/or treatment as indicated on the form.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

Carolyn Barclay RN, CNN, Vascular Access Coordinator, Kaiser Permanente
Portland, Oregon, USA

A key change idea for incorporating vascular access into an organization’s ongoing CQI efforts is to designate a staff member in the dialysis facility who will be responsible for vascular access. This PowerPoint presentation describes the key functions and role of a Dialysis Access Coordinator (or Vascular Access Manager) in the context of the entire renal care team.

(Note: The presentation uses the term "Vascular Access Manager" rather than "Vascular Access Coordinator," but the two terms can be used interchangeably.)

Directions
Download this document for complete information. The role of the Vascular Access Manager can be adopted as-is or modified to meet your specific needs.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes

<< back

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

One of the key change ideas for incorporating vascular access into an organization’s ongoing CQI efforts is to designate a Vascular Access Coordinator, a staff member in the dialysis facility who will be responsible for vascular access. This description defines the purpose and essential job functions of the Coordinator.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the document for complete information. The job description can be adopted as-is or modified to meet your specific needs.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes

<< back

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

This tool allows assessment of the “spread” of change ideas, that is, to what extent facilities and their associated medical specialists have adopted best practices for increasing AV fistula rates. Dialysis facilities can use this tool (with or without modification) as part of their ongoing CQI activities. The tracking tool is structured around behavioral change theory, recognizing that the change process may be underway for a period of time before new behavior can be observed. The tool allows tracking of a range of improvements including those that facilities control or influence directly, as well as those that facilities can observe among the medical specialists who care for their patients.

Background
This tracking tool was developed by the Institute for Healthcare Improvement and Lawrence Spergel, MD, FACS, for the National Vascular Access Improvement Initiative (NVAII) to help track the implementation of the key change ideas for increasing AV fistula rates.

Directions
This tool can be used to assess the implementation of changes in your facility or practice. Download and adapt it to meet your local needs.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes

<<back

Change Concept #2 – Related Tools

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This sample policy and procedure statement is based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Preservation of veins and maturation of AV fistulae is a collaborative effort among surgeons, nephrologists, and dialysis staff. The guideline promotes the development and maintenance of AV fistulae by giving patients strategies to help increase the diameter of the vessel, prevent infection, prevent thrombosis, and maintain function.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download and use this sample policy and procedure statement as an aid in creating one for your organization.

Related Changes
Establish Processes to Facilitate Timely Referral to Nephrologists
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This algorithm can be used to determine a pre-ESRD vascular access/AV fistula plan.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Establish Processes to Facilitate Timely Referral to Nephrologists

<< back

Dr. Vo Nguyen, Medical Director, Aberdeen Dialysis Center, Renal Care Group of the Northwest
Olympia, Washington, USA

Use this checklist to document key information for a surgical plan to place AV fistulae, including mandatory preoperative vein mapping for all patients.

Background
See the related feature story Boosting Arteriovenous (AV) Fistula Rates in ESRD Patients for more information on the development of this tool by Dr. Nguyen. 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.

Directions
Download and adapt this tool for use in your facility.

Related Changes
Establish Processes to Facilitate Timely Referral to Nephrologists

<< back

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Caring for patients with chronic kidney disease (CKD) is a great challenge for both primary care providers (PCPs) and for nephrologists. Some PCPs may fear that patients referred to a nephrologist will not return to them for further care. This sample letter can be used by a nephrologist to educate his or her community of primary care physicians on the importance of early referral to a nephrologist in the treatment of chronic kidney disease (CKD) patients. It describes the rationale and appropriate "trigger" and assures the PCP that the referred patient will return to their care. This letter could also be used for insurance companies.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership, including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool and modify it to meet your local needs.

Related Changes
Establish Processes to Facilitate Timely Referral to Nephrologists

<< back

Change Concept #3 – Related Tools

Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates
Olympia, Washington, USA

Use this vessel mapping protocol to assess the patency and suitability of the arteries and veins for use as a dialysis arteriovenous fistula (AVF). The cephalic and basilic veins are preferred AVF conduits for hemodialysis. The patient is usually first referred from the nephrologist to the surgeon for AVF evaluation. After examining the patient, the surgeon selects the preferred extremity for the preoperative mapping study. If suitable vessels are identified, the necessity of performing a bilateral study can be avoided; if suitable vessels are not identified in the preferred extremity, then the contralateral extremity will need to be studied as well.

Background
This tool was adapted from a tool used by the Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates in Olympia, Washington, USA. The members of the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII) worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient needing a new hemodialysis access to a vascular access surgeon. The nephrologist can request the site preference for the desired access on the form, and the surgeon is requested to notify the nephrologist if the preferred access will not be placed.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

This comprehensive faxable form can be used by surgeons and interventional radiologists to communicate important vascular access procedure information to dialysis facility staff and nephrologists. The form includes information on access type, configuration, interventions performed, and a diagram that can be used to indicate configuration of access.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download and use this tool to communicate important vascular access information between the surgeon and the dialysis facility staff and nephrologist.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

This algorithm describes the process of selecting appropriate arteriovenous fistulae (AVF), including normal and transposed options, for patients requiring chronic renal replacement therapy (RRT) or possible hemodialysis.

Directions
Surgeons and nephrologists can download and use this algorithm to review the timing of access placement, vein options for fistula placement, and post-operative assessment.

Related Changes
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place Secondary AV Fistulae in Patients with Catheters Where Feasible

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This tool provides a summary of sections I, II, and IV of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) Vascular Access Clinical Practice Guidelines: evidence- and opinion-based guideline information related to arteriovenous fistula. For the complete text of the K/DOQI Vascular Access Clinical Practice Guidelines visit the National Kidney Foundation K/DOQI website.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal care community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download this document for complete information.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function
 

<< back

Change Concept #4 – Related Tools

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Some surgeons are willing and able to perform the necessary evaluative and surgical procedures necessary for establishing successful arteriovenous (AV) fistulae. This questionnaire can be used to survey the surgeons in your community about their skills, experience, and interest in order to determine which surgeons are most appropriate to perform AV fistula procedures.

Background
The questionnaire was adapted from a tool used by the Renal Network of the Upper Midwest – ESRD Network 11 by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download and adapt this questionnaire to meet the needs in your setting.

Related Changes
Select Surgeons Based on Best Outcomes

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This tool provides a summary of sections I, II, and IV of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) Vascular Access Clinical Practice Guidelines: evidence- and opinion-based guideline information related to arteriovenous fistula. For the complete text of the K/DOQI Vascular Access Clinical Practice Guidelines visit the National Kidney Foundation K/DOQI website.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal care community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download this document for complete information.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function
 

<< back

Change Concept #5 – Related Tools

Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

This algorithm describes the process of selecting appropriate arteriovenous fistulae (AVF), including normal and transposed options, for patients requiring chronic renal replacement therapy (RRT) or possible hemodialysis.

Directions
Surgeons and nephrologists can download and use this algorithm to review the timing of access placement, vein options for fistula placement, and post-operative assessment.

Related Changes
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place Secondary AV Fistulae in Patients with Catheters Where Feasible

<< back

Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates
Olympia, Washington, USA

Use this vessel mapping protocol to assess the patency and suitability of the arteries and veins for use as a dialysis arteriovenous fistula (AVF). The cephalic and basilic veins are preferred AVF conduits for hemodialysis. The patient is usually first referred from the nephrologist to the surgeon for AVF evaluation. After examining the patient, the surgeon selects the preferred extremity for the preoperative mapping study. If suitable vessels are identified, the necessity of performing a bilateral study can be avoided; if suitable vessels are not identified in the preferred extremity, then the contralateral extremity will need to be studied as well.

Background
This tool was adapted from a tool used by the Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates in Olympia, Washington, USA. The members of the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII) worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Establish Processes to Facilitate Early "AVF Only" Referral to Surgeons
Use a Full Range of Appropriate Surgical Approaches
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

Change Concept #6 – Related Tools

National Vascular Access Improvement Initiative Tools and Resources Working Group with assistance from Lawrence M. Spergel, MD, Dialysis Management Medical Group
San Francisco, California, USA

This protocol is used to identify a suitable outflow vein to convert a forearm arteriovenous (AV) graft to an upper-arm AV fistula, in anticipation of secondary AV fistula construction by the surgeon.

An effective strategy for increasing arteriovenous (AV) fistula prevalence is the planning and construction of AV fistulae in existing AV graft patients prior to graft failure. Although the primary access may currently be a graft, all graft patients should be evaluated and considered (where feasible) for an AV fistula as their next permanent access (secondary AV fistula).

Although evaluation for a secondary AV fistula may require bilateral vessel mapping to identify a suitable vein and artery for AV fistula construction, the simplest opportunity to convert a graft patient to a fistula patient, when present, is the conversion of an arterialized (mature) upper-arm outflow vein of a forearm graft to a direct upper-arm AV fistula. Such a conversion opportunity should be looked for and considered in all forearm graft patients.

Directions
Download the tool for complete instructions.

Related Changes
Examine Outflow Vein of All Forearm Graft Patients
Place Secondary AV Fistulae in Patients with AV Grafts

<< back

Dialysis facility staff and/or rounding nephrologists should examine the outflow vein of all forearm graft patients during dialysis treatments (with a recommended minimum frequency of at least monthly) to identify patients who may have a suitable upper outflow vein for elective secondary AV fistula conversion in the upper arm. If such a suitable vein is found, dialysis facility staff and/or rounding nephrologists should inform the patient’s nephrologist and surgeon of the need to evaluate the identified outflow vein for AV fistula conversion.

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient with existing hemodialysis access to a surgeon or interventionalist. The form indicates the reason for referral and procedure requested, as well as current hemodialysis treatment and vascular access information.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

A log sheet for vascular access monitoring and surveillance that tracks referrals and interventions for patients with abnormal monitoring indicators who are to be referred for fistulography or consultation and/or treatment as indicated on the form.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

Change Concept #7 – Related Tools

National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Cause and effect (or "fishbone") diagrams are a useful way to graphically display the possible causes of a certain effect. This diagram shows the various risk factors that can lead to central venous catheter (CVC) infection, grouped into four major categories: patient, caregiver, equipment, and environment.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NVAII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download and use this tool to:

• Help your team understand that there are many causes that contribute to CVC infections.
• Identify opportunities for improvement to reduce CVC infections.

Related Changes
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This algorithm/flow chart can be used by dialysis facilities to transition patients from central venous catheters to arteriovenous fistulae.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NVAII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download and use this tool to plan for transitioning patients from central venous catheters to AV fistulae.

Related Changes
Place AV Fistulae in Patients with Catheters Where Feasible

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient with existing hemodialysis access to a surgeon or interventionalist. The form indicates the reason for referral and procedure requested, as well as current hemodialysis treatment and vascular access information.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

Change Concept #8 – Related Tools

National Vascular Access Improvement Initiative Tools and Resources Workgroup
Los Angeles, California, USA

In support of the National Vascular Access Improvement Initiative (NVAII) goal of increasing the appropriate use and care of AV fistulas for hemodialysis access, this tool contains a number of reference articles, videotapes, workbooks, and other training materials. These materials specifically focus on proper technique for cannulation of an AV fistula, and include information on the constant site or “buttonhole” technique of fistula cannulation.

Background
Each of the references in this tool was reviewed by the committee members and the committee leadership, including NVAII Clinical Chair, Lawrence Spergel, MD, FACS.

Directions
Download the document for detailed information.

Related Changes
Cannulation Training for AVFs

<< back

Change Concept #9 – Related Tools

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

A log sheet for vascular access monitoring and surveillance that tracks referrals and interventions for patients with abnormal monitoring indicators who are to be referred for fistulography or consultation and/or treatment as indicated on the form.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Review Vascular Access as Part of Routine Organizational Improvement Processes
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient with existing hemodialysis access to a surgeon or interventionalist. The form indicates the reason for referral and procedure requested, as well as current hemodialysis treatment and vascular access information.

Background
This tool was developed by the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII). The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII clinical chair, Lawrence Spergel, MD, FACS.

Directions
Download the tool for complete instructions.

Related Changes
Place Secondary AV Fistulae in Patients with AV Grafts
Place AV Fistulae in Patients with Catheters Where Feasible
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back

Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

This algorithm/flow chart outlines monitoring mechanisms for vascular access function, normal and abnormal findings, and recommendations for interventions. It can be used by facilities, hospitals, nephrologists, surgeons, and interventional radiologists.

Directions
Download the tool for complete instructions.

Related Changes
Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function

<< back