Wait times to create a vascular access drop 35-50%

Improving our incidence and prevalence rates for permanent vascular access on hemodialysis has been an FHA wide goal.

As part of our strategy to improve our rates, we looked at the wait times to get an access created.  We figured that if we could get an AV access created faster for patients on hemodialysis, our prevalence rates would improve.  And if we could ensure that wait times for patients with advanced chronic kidney disease were better, we’d see less people starting hemodialysis before their AVF was ready to be used, thereby improving our incidence rates.

As a result of a collection of strategies including a) more dedicated vascular access nurses, b) greater collaboration with our surgical colleagues and c) the implementation of a novel process of expedited vascular access creation under regional block or local aneasthesia with recovery outside the post-anesthetic care unit, we’ve noticing striking improvements in wait times from referral to vascular access creation.  Between January and September 2013, we’ve seen surgical creation wait times decrease from 138 days to 91 days for patients referred to the Surrey program and 111 to 95 days in the Abbotsford program.

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Vascular access getting better in the FHA renal program

The lastest vascular access data provided by BCPRA is out and things look promising for our program.

VA incidence
FHA Renal is  now one of the top 3 centres in the province.
Between April 2010 and Sep 2012, our incidence rate of AVF/AVG has increased from 24% to 36%.
During the same interval, the provincial mean is flat (31% to 32%).
VA Prevalence
Between April 2010 and Sep 2012, our prevalence rate of AVF/AVG has increased from 48% to 58%.  However, we’ve seen little improvement over the past year and are still far below top performing centres that are achieving 72% prevalence.  We do have much higher rates of AVF/AVG + CVC than most centres, suggesting we’re on the cusp of seeing our efforts comes to fruition as we get patients transitioned from CVC to AVF/AVG.
I think we have some momentum here but need to keep pushing.
a) In KCC
  • keep pushing our strategy of earlier modality decision making with referral at GFR 20 for patients choosing facility HD or HHD.
c) In the HD units
  • continue our VA review weeks to identify patients at risk of access failure or who could transition from CVC to AVF/AVG
  • continue to have all bedside RNs and MDs share the message of the value of an AVF over CVC
  • continue to work with IR to ensure we have rapid access to VA maintenance & salvage
  • bring in the transition nurses to ensure all new starts have optimized care pathways, including AVF referral for patients choosing facility HD or HHD
b) In PD
  • Earlier referral for AVF in patients who are showing signs of UF failure
  • Continue to support urgent start PD to ensure patients who are facing a suboptimal HD start with a CVC have a safer option
c) In Transplant
  • Earlier referral for AVF with progressive transplant failure who choose facility HD or HHD after modality education
d) In the Nephrologist offices
  • Continue to recommend permanent access creation for patients not choosing conservative care, pre-emptive transplant or PD, and communicate this messaging to the primary care providers in order to secure their support
e) In the ORs
  • Continue to explore innovative ways to get patients quicker access creation
Thanks for everyone’s hard work on this initiative.  It’s incredibly encouraging to see things move in the right direction,
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Optimizing Interventional Radiology Referrals for Vascular Access

Back in November 2011, I posted that we would target some reasonably aggressive goals for AV access rate in the FHA renal program.

For those who don’t recal, we’re aiming for:

Incidence of AVF + AVG = 33% at 12 months and 40% by 24 months

Prevalence of AVG + AVG = 65% at 12 months and 70% by 24 months

We’re about 6 months away from our first target and still much work remains to be done.  I’m excited to announce the implementation of a triage tool that we hope will ensure our patients have their permanent AV access better maintained and salvaged when necessary.  It won’t help to create AVFs more quickly if we don’t make sure to avoid premature access failure.

So, we’re going to start using a new form (though it may be slightly modified).  This form provides radiology with additional clinical information regarding urgency of a patient’s need for intervention.  It also ties clinical paramaters to our provincial wait time guidelines that were developed by the BCPRA Vascular Access Working Group.

Download form

Our hope is that this will allow our IR colleagues to better triage our referrals and use their limited time & resources more efficiently.  Urgent cases should get seen urgently and cases that are less time sensitive can be done at a later date.

 

 

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Alteplase: Program savings

This guest post was written by Kim Norman, BA (hons) Nursing who is the Clinical Nurse Educator for ARHCC and ACDU Hemodialysis Units in the Fraser Health Renal program.

It became quite frustrating to watch, as a Clinical Nurse Educator, the use of alteplase within our Renal Program at a cost of $64 a vial.

After identifying a $100,000 expenditure on alteplase use within the hospital hemodialysis units  it was time to ask why, what could be done to reduce costs and how? This needed to be done while keeping in mind the best interests of the patients in relation to best practices.

After  identifying a huge cost to our Renal program what was also highlighted in the review process was a large cost in sterile supplies.  Alteplase and sterile supplies added up to $716,000 being spent each year in the FHA hemodialysis units.

After collaborating with the community dialysis staff, educators across Canada and within my own province of BC, we identified products that could potentially cut the cost of alteplase by reducing the exposure of the hub of a catheter to air (theory, not evidence based) by using a needle-less hemodialysis cap designed to withstand the blood pump speeds of dialysis.

The needless cap would also potentially reduce the costs of our sterile supplies due to the cap only needing to be changed every 7 days.

Once the product had been approved by the leadership team, the educators made all efforts (through education) to implement the device along with streamlining our hemodialysis access and flushing techniques. The implementation did not go without its barriers which are highlighted in the education powerpoint; such barriers are still being addressed between the educators and the company who distributes the device.

We are now one year post implementation and have seen a significant reduction in total costs.  Specifically, we’re seeing approximately $112K reduction in sterile supply costs and $23K reduction in tPA costs per year.

In fast paced hemodialysis units, we have received reports that this new intervention allows for more efficient use of time at the bed side.

The cost savings documents and education tool are attached for review.

Cost analysis:

Renal Tray costs for ARHCC

Tego Connectors FHA Cost Analysis

TPA Monitoring Tego

Educational Information:

TEGO patient pamphlet

Tego Poster Fraser Health

 

Kim Norman

Clinical Nurse Educator

Fraser Health Renal Program.

 

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Targets & Strategies for Vascular Access

Targets & Strategies for Vascular Access

Enhancing vascular access for patients on hemodialysis has been recognized as a priority for the Fraser Health Renal Program.  We know that the safest access for hemodialysis is an  Arteriovenous Fistula (AVF), followed by an AV Graft.  Central venous catheters are recognized to be far inferior and associated with increased risk of serious infection (line sepsis), hospitalization and death.

Karen Mahoney, Ruth Burns and Henry Wong will be working with a vascular access improvement team in an effort to enhance vascular access in order to improve the quality of patient care in the FHA Renal program.  The group has said aggresive goals which include:

Incidence of AVF + AVG = 33% at 12 months and 40% by 24 months
Prevalence of AVG + AVG = 65% at 12 months and 70% by 24 months

In an effort to enhance vascular access care in FHA, the Nephrologists met up for a brainstorming session.  Some of the following ideas came out of the meeting and will be shared with the rest of the program for further development and implementation.

Suggested Strategies to Enhance Vascular Access

Kidney Care


In the Kidney Care Centres, move to a referral policy whereby all patients are ordered an AVF be created if GFR ≤20 unless:

  • Pre-emptive transplant is imminent
  • PD is planned (this should be confirmed at least every 6 months)
  • Expected lifespan <12 months or the patient has elected not to receive dialysis in the event of ESRD

When patients are learning about renal replacement therapy through the Kidney Care Centres, HD with a central venous catheter (CVC) should not be taught or offered as a possible modality, since it represents poor care.  While CVCs are certainly used, this form of access should be viewed as sub-optimal care designed for emergency use.  The only options that should be formally taught include:

  • Transplantation
  • Conservative care
  • Peritoneal Dialysis (PD)
  • Hemodialysis (facility-based or home-based) with an AVF

As part of this strategy, we will be moving to remove education around CVCs in the Kidney Care Centres and enhance educational offerings around AV Fistula creation.

Each Nephrologist should regularly get a list of their KCC patients with GFR <20 ml/min and remain undecided about dialysis modality or have chosen HD but have no vascular access created.  Plans will be created with the KCC team.

In the Nephrologist’s Office

Given that Nephrologists are generally the first point of contact for patients as they enter the renal program, we will it is critical that physicians strongly reinforce key messages with patients.  These include the benefit & important of transplantation, home dialysis and AVF creation (for those patients who choose hemodialysis).  The Nephrologists will endeavor to ensure that for all patients referred to the KCC, we will verbally state these 3 key message, include them in our dictation back to the referring physician and give patient a written, brief document summarizing these key messages.

In the Hemodialysis Units

There is a significant opportunity within the HD units to encourage optimal vascular access.   It is recommended that the vascular access nurse will review all patients with CVCs with the HD Nephrologist once per month and create a plan of action.

In order to implement this program, each month the unit clerk in the HD unit will print a list of all patients currently dialyzing with CVC from our PROMIS database.  The vascular access nurse would review the list on the 1st week of the month.  During the 2nd week of the month (either on Monday or Tuesday), the vascular access RN would meet with the rounding Nephrologist and together they would create action plan for the Nephrologist.  The rounding Nephrologist would discuss vascular access with patients on 1st and 2nd shift, and leave pink notes for the physician rounding 3rd shift.  Efforts will be made to ensure vascular access review does not occur on a  blood work review week.

If a patient declines the creation of a vascular access, this will be revisited on a 6-monthly basis.

In an effort to ensure that patients who start hemodialysis urgently and sub-optimally via a CVC get best care, we will ensure that a checkbox referral option be added to many HD order sheets in order to simplify the process of vascular access referral.

In order to enhance inter-caregiver communication, we will need a standardized vascular access section in the hemodialysis chart, and efforts will be made to replicate that being used in the Abbotsford Hospital HD unit.

Each Nephrologist will regularly get a list of their primary patients on hemodialysis.  They will have the opportunity to see the breakdown of their patients based on dialysis access , and see how their patients compare to their colleagues’ patients.

The Renal Care Co-ordinators (RCCs) have an opportunity to encourage appropriate vascular access creation as they follow new HD starts.  The RCCs will be supported and encouraged to pursue this important goal.

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Additional OR Time For Vascular Access Made Available at ARH

Additional OR Time For Vascular Access Made Available at ARH

Efforts to increase the number of patients receiving hemodialysis with an Arteriovenous Fistula (AVF) are well underway in the Fraser Health Renal program.  One of the barriers to better AVF rates is access to OR time for our vascular surgeons.

The Renal Program is incredibly excited by the announcement of increased OR time at Abbotsford Regional Hospital to support the creation of vascular access.  Will keep everyone posted on our vascular access rates going forward.

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