Vascular Access
Organizations must test and implement changes to existing processes in order to improve. The current system of care for dialysis patients in the US results in a national arteriovenous (AV) fistula rate of approximately 31 percent (2001 data), with large variation across regions and individual practitioners. For more general information on how to select, test, and implement changes see the How to Improve section.
Fistula First Change Package
These eleven clinical and organizational changes for increasing AV fistula rates were developed by the multidisciplinary National Vascular Access Improvement Initiative (NAVII) Working Group, which was facilitated by the Institute for Healthcare Improvement (IHI), sponsored by the Centers for Medicare and Medicaid Services (CMS), and chaired by Lawrence Spergel, MD, FACS.
All of these changes are evidence-based. They have been reported in the scientific literature or have been tested and proven successful in meeting the goals for the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI): AV fistula use in 50 percent of incident patients (those new to dialysis) and 40 percent of prevalent patients (those currently on dialysis). These changes may be implemented together or separately, and the choice of which changes to focus on will vary by region and clinic.
The following are the eleven clinical and organizational recommendations for increasing AV fistula use and improving hemodialysis patient outcomes:
1. Review Vascular Access as Part of Routine Organizational Improvement Processes
Incorporate vascular access into facility-based continuous quality improvement processes, based on a multidisciplinary team approach.
2. Establish Processes to Facilitate Timely Referral to Nephrologists
Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria.
3. Establish Processes to Facilitate Early “AVF Only” Referral to Surgeons
When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation.
4. Select Surgeons Based on Best Outcomes
Identify the surgeons in your community who have the skills and interest in AV fistula placement and track their outcomes.
5. Use a Full Range of Appropriate Surgical Approaches
Vein transposition techniques allow surgeons to create successful AV fistulas in a substantially greater number of patients.
6. Place Secondary AV Fistulae in Patients with AV Grafts
Evaluate graft patients for placement of a secondary AV fistula.
7. Place AV Fistulae in Patients with Catheters Where Feasible
Higher catheter use is associated with increased infection, morbidity, mortality, and hospitalization. Catheter patients should be evaluated and permanent accesses placed as soon as possible.
8. Provide Cannulation Training
Prevent fistulae from being destroyed by inexperienced staff.
9. Establish Processes for Monitoring and Maintenance to Ensure Adequate Access Function
The health care team should establish a process for monitoring and maintenance of AV fistulae to ensure adequate access function.
10. Educate Caregivers and Patients
Dialysis patients and their caregivers need education and resources to support their decision making about care.