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.