Q: What are the responsibilities of the facility staff member in charge of vascular access continuous quality improvement (CQI)?
A: The vascular access coordinator (VAC) serves to coordinate and oversee vascular access information and care for the facility, with a focus on maintaining optimal access function and longevity. The VAC works closely with the facility medical director and assures that a facility-based vascular access CQI program is implemented and functioning.
Among his/her duties, the VAC maintains and reports vascular access data to assure tracking and trending of pertinent vascular access-related performance indicators and outcomes, handles communication and collaboration duties as liaison with the multidisciplinary access care team, and oversees and directs vascular access planning for current and future accesses. At a minimum, the VAC should meet with the medical director and other facility staff on a monthly basis to review VA issues. A meeting of all members of the multidisciplinary vascular access team ideally takes place at least quarterly.
See the following related information:
Routine CQI Review of Vascular Access
Q: What indicators should facilities track that will provide meaningful data for evaluating vascular access programs?
A: Facilities can start by measuring performance on a monthly basis by access type — catheter, arteriovenous (AV) graft, and AV fistula — since access type is the major determinant of outcomes and directly affects dialysis delivery and adequacy. It is also important to focus specifically on native AV fistula outcomes and performance, including tracking the monthly AV fistula placement and failure rate in incident as well as prevalent patients.
The National Vascular Access Improvement Initiative (NVAII) has developed a the Vascular Access Tracking Tool (VATT), a data collection tool that can help facilities measure and track AV fistula rates (and all access types) in incident and prevalent patients. This data tool (in Microsoft Excel format) permits simple tracking of not only AV fistulae that are in use but also AV fistulae that have been placed and are awaiting maturation.
In addition to access types, a summary of the minimum vascular access-related measurements that facilities should track and report include:
- Number and percentage of patients with catheter
- Number and percentage of patients with catheter only
- Number and percentage of patients with AV graft
- Number and percentage of prevalent patients with AV fistula
- Number and percentage of incident patients with AV fistula
- Number of vascular access-related hospital admissions
- Number and percentage of vascular access clotting events for AV graft and AV fistula
- Number and percentage of vascular access infections for catheter, AV graft, and AV fistula
- Number of vascular access-related outpatient events
- Number of missed treatments due to vascular access problems
- Number of vascular access-related deaths
Finally, facilities should measure and track the outcomes of access-salvage interventions, as studies have shown that a significant percentage of interventions are either not successful or fail within a short period of time.
Q: We have been told that women, patients with diabetes, and elderly patients are not good AV fistula candidates. Is this true?
A: Studies have come to different conclusions on these issues. What is key is that strategies such as vessel mapping and vein transpositions will definitely increase the opportunities for all patient groups to have an AV fistula — regardless of demographics, co-morbidities, or other factors.
Q: What is the purpose of referring a new patient to the surgeon for “AVF only”— and what is the role of vessel mapping?
A: Such a referral ensures that a surgeon will initially evaluate the patient for an AV fistula. It also serves to focus everyone’s attention on the goal of providing the patient with the best chance of having an autogenous (native) AV fistula before considering an AV graft or catheter for maintenance hemodialysis.
If the surgeon cannot find suitable blood vessels for an AV fistula on physical exam with a tourniquet, Doppler ultrasound or alternate technique should be used to do vessel mapping (identification of vessel anatomy) to search for suitable vessels that may be too deep to be identified on physical exam. Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.
See the following related information:
Early Referral to Surgeon for “AVF Only” Evaluation and Timely Placement
Q: What criteria should we use to evaluate a surgeon doing vascular access?
A: It is important that the vascular access surgeon be willing to participate as a member of a multidisciplinary vascular access team and possess not only the skills and judgment required for this highly specialized and demanding area of surgery, but also the ability to perform the entire repertory of AV fistula procedures, including vein transpositions. The surgeon treating a hemodialysis patient should also
possess a caring attitude and the willingness to be available and devote the time and attention needed to provide the patient with the best evaluation and optimal surgery in a timely manner and based on a long-term plan. In the absence of a medical contra-indication, the surgeon should be dedicated to providing a native AV fistula as the optimal access for every patient, where feasible.
In addition, the vascular access multidisciplinary team should collect data and evaluate the access surgeon by their outcomes at least every quarter. Questions that need to be answered are: what percentage of access procedures are autogenous (native) AV fistulae, are the minimal K/DOQI standards being met, and are the outcomes of those procedures good? Surgeons doing access should be expected to meet minimal performance standards.
See the following related information:
Surgeon Questionnaire
Q: What are vein transposition AV fistulae and how successful are they?
A: When suitable superficial veins are not available for AV fistula construction, there are usually deeper veins that are suitable. These veins and their suitability can be identified by vessel mapping and then surgically repositioned (transposed) to a superficial location suitable for cannulation. Transposition can also be done for veins that may be superficial enough but not positioned for safe cannulation.
In general, the success rates of vein transposition AV fistulae are similar to those of the conventional simple direct AV fistulae. What is critically important is that vein transpositions have expanded the AV fistula opportunities and options for patients who would otherwise receive an AV graft or catheter if only the more conventional constructions were employed. Adding transposition AV fistulae to the options, armamentarium is estimated to enable 80 to 90 percent of new patients to be candidates for an AV fistula.
For information on a video training series for surgeons, click here.
Q: Do vein transposition AV fistulae require a longer maturation period or special care?
A: In some cases the maturation period is longer — three months or more — because some of the deep veins used for transpositions are initially more delicate and thin-walled. Cannulation technique and protocol is the same as for conventional AV fistulae (see Cannulation of New Fistula Policy and Procedure).
Q: What is meant by a “secondary” AV fistula?
A: In the context of the NVAII initiative, this is an AV fistula placed in a patient whose initial access was a graft. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when the graft begins to fail. This avoids the need for a catheter or missing an AV fistula opportunity when the graft fails and there is urgency for an immediate usable access.
See the following related Change:
Secondary AVF Placement in Patients with AV Grafts
Q: How soon can a secondary AV fistula be cannulated?
A: If the secondary AV fistula uses the outflow vein from an existing graft, it usually can be cannulated immediately. However, to confirm that the outflow vein can be used immediately if converted to an AV fistula, staff should test the outflow vein before converting (sacrificing) the graft by attempting cannulation of the outflow vein while the graft is still being used.
If the secondary AV fistula uses a new vein, then the maturation period will be the same as for any new AV fistula: a minimum of 6 weeks, with a recommended waiting period of 8 to 12 weeks.
See the following related Change:
Secondary AVF Placement in Patients with AV Grafts
Q: We have many patients with permanent catheters because of exhausted permanent access sites. Is an AV fistula still an option for these patients?
A: In most cases, yes. In fact, studies have shown that when patients considered to have exhausted permanent access sites are re-evaluated and undergo vessel mapping, at least two-thirds are found to be candidates for an AV fistula. Vessel mapping is critical in identifying these AV fistula candidates.
See the following related Change:
AVF Placement in Patients with Catheters Where Indicated
Q: Why is it so important to remove a central venous catheter as soon as possible?
A: Complications, including infection, catheter failure, thrombosis, inadequate dialysis, and central venous stenosis and occlusion, occur frequently with catheters — and the complication rate rises sharply with duration of use. Studies have also reported that catheter use is associated with an increased mortality risk.
See the following related information:
Reducing Central Venous Catheter Infections Cause and Effect Diagram
Q: If a new AVF does not appear to be maturing and cannot be used successfully, what do we do and when?
A: We recommend that four weeks after the operation, patients have mandatory visits with the surgeon, nephrologist and the rest of the team. At that time, the AVF is not ready to use but most problems can be assessed by physical exam. The most common problems are stenosis or sclerosis near the connection with the artery.
If there is any question about whether the AVF is maturing properly, the patient should be referred to a diagnostic study (preferably Doppler ultrasound) or given an appointment for another assessment in two weeks. At that point, the team will decide either to wait, revise the AVF, or make a new AVF.
See the following related information:
Fistula Preservation, Development, and Maintenance Policy and Procedure
VAMP Vascular Access Monitoring and Surveillance Flow Chart
Q: What monitoring and surveillance methods work best for AV fistulae?
A: The K/DOQI has established recommendations and guidelines for monitoring and surveillance:
Monitoring, which K/DOQI defines as physical examination techniques to detect access dysfunction, has been shown in many studies to be able to identify the majority of patients with AV fistula dysfunction.
Surveillance involves the use of a variety of tests to detect access dysfunction. Intra-access blood flow measurement over time is the best surveillance method available for assessing AV fistula function and detecting dysfunction.
Two other methods offer significant value for AV fistula surveillance:
- Pre-pump arterial pressure, which is measured on almost all dialysis machines, indicates the ease or difficulty with which the blood pump is able to draw blood from the access (inflow). A significant restriction of inflow will cause an excessively negative pre-pump arterial pressure. Since most causes of AV fistula dysfunction are inflow problems, an excessively negative pre-pump arterial pressure is often the earliest indication of such a problem.
- Access recirculation measurement. An AV fistula may remain patent but not provide enough blood flow to meet the prescribed blood pump flow rate, resulting in underdialysis. If there is any question about adequacy of blood flow for dialysis, or if there is difficulty dialyzing the patient at the prescribed pump rate, a recirculation study will determine if the AV fistula blood flow is not sufficient to meet the prescribed blood pump flow rate.
Note: While physicians commonly use venous pressure measurement to detect access dysfunction, it is of very limited value in AV fistula surveillance. This is because most of the flow-limiting problems in AV fistulae are on the arterial of the venous needle (and often the arterial needle as well) and therefore are not detectable by pressure measurements made at the venous (or arterial) needle, which can only detect an outflow obstruction downstream of the measuring needle(s). In addition, the fistula has tributaries that can dissipate pressure in the presence of an outflow obstruction. Finally, access pressure measurements are not likely to identify centrally located venous obstructions.
See the Pre-ESRD AV Fistula Planning Algorithm, a monitoring and surveillance algorithm with recommended criteria.
Q: Our facility is understaffed. What are some creative ways that we can provide AV fistula education for our patients?
A: Many resources are available for patients and their families such as the Patient Resource List and Staff Resource List. The National Kidney Foundation’s Kidney Learning System is also an excellent resource.
Switching to an AV fistula (AVF) can require a change in attitude on the part of patients and staff, and everyone needs to understand the associated benefits. You may want to invite current fistula patients, who have made a positive adjustment to treatment, to share their stories about why and how they chose to have an AV fistula. They could also share their feelings about their perceived and actual improved outcomes. This patient-to-patient discussion could be done in either a group or one-on-one setting, or by pairing up patients with and without AVF. It’s important to remember that patients should not be giving health care/medical advice!
See the following related information:
Education for Care Givers and Patients
Q: Some patients refuse to have an AV fistula because they don’t like the look of a bulging fistula. How do we deal with such body image issues?
A: The issue of body image is a very real concern that may dictate a patient’s decision regardless of the health benefits of an AV fistula, and despite the education and support that health care professionals offer. Every patient has the right to make an informed decision; it is the responsibility of the caregivers to ensure that the patient’s decision is an informed one.
See the following related information:
Education for Care Givers and Patients
Q: How do we assist in providing education and resources for surgeons and interventionalists?
A: A dual approach to education can be helpful: provide evidence-based information on the benefits of AV fistulae to the surgeons and interventionalists, as well as “empower” patients to share their preferences with the surgeons and interventionalists involved in their individual treatment. The literature and resources available on this website can be helpful. For example, the National Kidney Foundation launched a best practice newsletter in July 2004 that highlights clinical protocols that are successful in improving outcomes, including a theme issue on vascular access.
Q: How can health care professionals convince patients to have an AV fistula and accept the long maturation period, and possibly one or more catheters as well?
A: Patients can’t simply be “convinced.” Health care professionals should discuss the outcome benefits associated with having an AV fistula (e.g., decreased infection rate, improved blood flow which increases adequacy of dialysis, decreased incidence of clotting) and make sure patients understand these benefits. Determining each patient’s actual concerns is also important. For example, a woman may be more concerned than a man about body image with an AV fistula. Once the patient’s
concerns are known, they can be addressed to help the patient cope with specific challenges which may include body image, the long maturation process, and the potential need for one or more catheters.
See the following related information:
Education for Care Givers and Patients
Q: What are the most effective ways to teach a patient about access options and the superiority of an AVF — and who should provide this education?
A: All members of the health care team have a professional obligation for patient teaching. However, to optimize effectiveness and avoid duplication of effort it can be beneficial to plan a comprehensive patient teaching approach that clarifies responsibilities and involves a multidisciplinary perspective. This should be part of the organization’s vascular access management plan.
See the following related information:
Routine CQI Review of Vascular Access
Education for Care Givers and Patients
Q: For tracking and reporting purposes, please define the terms “incident” and “prevalent.”
A: “Prevalent” refers to all chronic (maintenance) hemodialysis patients on dialysis in the provider facility at a given time.
“Incident” is the subset of prevalent patients who are new hemodialysis patients. That is, they are patients who have their first outpatient chronic hemodialysis treatment in the provider facility during the month being reported.
Q: Which specific AV fistula-related outcomes are important to track and report for the facility, nephrologists, surgeons, and interventionalists?
A: In addition to the facility performance measures listed above, the following performance outcomes for specialists (surgeons, nephrologists, and interventionalists) should be tracked and reported to everyone on the team on a regular basis:
- For surgeons, track the AV fistula placement rate (compared to K/DOQI standards) as well as success and patency rates.
- For nephrologists, track the distribution of access types their patients receive, with a focus on the AV fistula rate and the percentage of new patients starting dialysis with only a catheter.
- For interventionalists, measure the success rate of interventions and track patency rates for their procedures.