Vascular Access The National Vascular Access Improvement Initiative (NVAII) has developed and adapted a suite of tools to help dialysis facilities and physicians accelerate their work to increase arteriovenous fistula (AVF) rates in hemodialysis patients. In addition, other organizations and individuals have developed tools in the course of their improvement efforts — for example, successful protocols, order sets and forms, instructions and guidelines for implementing key changes — and are making them available here for others to use or adapt in their own organizations. We invite you to submit tools you have found useful!

General Tools
Change Concept 1 – Routine CQI Review of Vascular Access
Change Concept 2 – Timely Referral to Neprhologist
Change Concept 3 – Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement
Change Concept 4 – Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services
Change Concept 5 – Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement
Change Concept 6 – Secondary AVF Placement in Patients with AV Grafts
Change Concept 7 – AVF Placement in Patients with Catheters Where Indicated
Change Concept 8 – AV Fistulas Cannulation Resources for Staff
Change Concept 9 – Monitoring and Maintenance to Ensure Adequate Access Function
Change Concept 10 – Education for Care Givers and Patients
Change Concept 11 – Outcomes Feedback to Guide Practice

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	Excel (Downloadable)			Interactive Tool (Online)

National Vascular Access Improvement Initiative (NVAII) Project Description

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1. Routine CQI Review of Vascular Access

AV Fistula “Roadmap” for Nephrologists
A tool for planning to improve AV fistula rates in a nephrology practice.

Monthly Vascular Access Referral/Intervention Log
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.

Dialysis Access Coordinator Role
For facilities considering implementing a vascular access management program, this resource can be used to describe the role of the Vascular Access Manager (or Coordinator).

Vascular Access Coordinator Role
A sample description of the role of a Vascular Access Coordinator in a dialysis facility.

Implementation Tracking Tool
This tool can help track implementation of high-leverage changes throughout an organization or across multiple facilities.

Monthly Performance Tracking Tool
Excel spreadsheet which can be used to track trends in data on a monthly basis.

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2. Timely Referral to Nephrologist

Fistula Preservation, Development, and Maintenance Policy and Procedure
A sample policy and procedure statement regarding the preservation of veins to avoid the loss of potential access sites and maximize the chances for successful AV fistula placement and maturation.

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

Patient Resource List
This is a comprehensive list of resources for patients and their families on vascular access for hemodialysis including websites, written materials, and videos.

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

Sample Letter to PCPs/Insurance Companies
This sample letter can be used by a nephrologist to educate primary care physicians about the rationale and appropriate “trigger” for early referral to a nephrologist in the treatment of chronic kidney disease (CKD) patients.

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3. Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement

Consensus Document on Pre-Op Hemodialysis Access Mapping Protocol
This form from the Society for Vascular Ultrasound provides the procedure for vessel mapping.

Duplex of Upper Extremity Vessels Prior to AV Fistula Surgery Protocol
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.

Referral Form for New Hemodialysis Access
A form used by nephrologists to refer a patient needing a new hemiodialysis access to a vascular access surgeon.

Vascular Access Diagram
A tool for surgeons and interventional radiologists to communicate vascular access procedure information to dialysis facility staff and nephrologists.

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

Autologous Arteriovenous Fistula (AVF) Algorithm
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.

K/DOQI Vascular Access Clinical Practice Guidelines Summary: Sections I, II, and IV
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.

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4. Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services

Surgeon Questionnaire
A questionnaire to survey surgeons on their skills, experience, and interest level in performing hemodialysis vascular access procedures.

K/DOQI Vascular Access Clinical Practice Guidelines Summary: Sections I, II, and IV
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.

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5. Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement

Consensus Document on Pre-Op Hemodialysis Access Mapping Protocol
This form from the Society for Vascular Ultrasound provides the procedure for vessel mapping.

Autologous Arteriovenous Fistula (AVF) Algorithm
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.

Duplex of Upper Extremity Vessels Prior to AV Fistula Surgery Protocol
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.

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6. Secondary AVF Placement in Patients with AV Grafts

“Sleeves Up” Protocol to Convert Forearm AV Graft to Upper-Arm AV Fistula
A protocol 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.

Referral Form for Existing Hemodialysis Access
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.

Monthly Vascular Access Referral/Intervention Log
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.

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7. AVF Placement in Patients with Catheters Where Indicated

Reducing Central Venous Catheter Infections Cause and Effect DiagramA cause and effect (or “fishbone”) diagram showing the various risk factors for central venous catheter infection, grouped into four major categories: patient, caregiver, equipment, and environment.

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8. Cannulation Training for AVFs

AV Fistula Cannulation Resources for Staff
A list of educational materials and training videotapes for staff, related to AV fistula cannulation technique, including the constant site or “buttonhole” cannulation technique.

Cannulation of New Fistula Policy and Procedure
A sample policy and procedure statement on successfully cannulating new arteriovenous fistulae and preventing infiltration.

Clamp Usage Policy and Procedure
A sample policy and procedure statement on when and how to use clamps in dialysis settings.

Constant Site (Buttonhole) Method of Needle Insertion for Hemodialysis
This paper describes the origin of the buttonhole method, early results, and the reasons why the method has not gained widespread popularity in U.S. hemodialysis centers.

Self-Cannulation of Vascular Access Procedure
An example procedure statement on successful self-cannulation of vascular access.

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9. Monitoring and Maintenance to Ensure adequate Access Function

Monthly Vascular Access Referral/Intervention Log
A log sheet for vascular access monitoring and surveillance that tracks referrals and interventions for patients with abnormal monitoring indicators.

Referral Form for Existing Hemodialysis Access
A form used by nephrologists to refer a patient with existing hemodialysis access to a surgeon or interventionalist.

VAMP© Vascular Access Monitoring and Surveillance Flow Chart
This algorithm/flow chart outlines monitoring mechanisms for vascular access function and provides recommendations for interventions.

K-DOQI Vascular Access Clinical Practice Guidelines Summary: Sections I, II, and IV
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.

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10. Education for Care Givers and Patients

"Electronic Notebook" from the Beneficiary Education Task Force

Best Access Procedures from the Dialysis Unit’s Viewpoint
This slide presentation outlines the benefits of arteriovenous (AV) fistulae and the critical steps necessary to insure successful placement, maturation, and use. 

Fistula First Training Module
An interactive module designed for training both patients and staff regarding the benefits and care of AVFs, how to encourage AVF as a primary access, and how to conduct cannulation training.

Staff Resource List
A comprehensive list of resources related to vascular access for medical staff including websites, written materials, and videos.

Patient Resource List
A comprehensive list of resources for patients and their families on vascular access for hemodialysis including websites, written materials, and videos.

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11. Outcomes Feedback to Guide Practice

Vascular Access Tracking Tool (VATT)
The VATT can be used to collect data on the type of vascular access used for a dialysis treatment. The tool, designed for use at the facility level, can also be used by an individual physician or physician group. The tool distinguishes between patients who are using a temporary access while a permanent one matures, and patients starting dialysis with only a single access. It also contains a patient log and a facility summary.

Monthly Performance Tracking Tool
Excel spreadsheet which can be used to track trends in data on a monthly basis.

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