Change Concepts for Increasing the Prevalence of AV Fistulas for
Hemodialysis
Change Concept #1
Routine CQI Review of Vascular Access
Dialysis facilities should incorporate vascular access into their continuous quality improvement (CQI) processes. Planning and care for vascular access spans many disciplines and settings; breakdowns in communication put patients at risk for sub-optimal treatment. In order to identify patients who will benefit from secondary arteriovenous (AV) fistula placement, facilities need processes that facilitate multidisciplinary communication, assign responsibility for vascular access information coordination, and regularly collect and use data to identify problems and opportunities for improvement.
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Change Concept #2
Timely Referral to Nephrologist Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria.
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Change Concept #3
Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement
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. Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae (e.g., A strategy for increasing use of autogenous hemodialysis access procedures). Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula. Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization.
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Change Concept #4
Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services
Collect data on the surgeons in your community to find out who has the skills and interest in placing fistulae. Choose surgeons who are willing and able to do AV fistula construction.
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Change Concept #5
Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement
Surgeons who are skilled in vein transposition techniques are able to create successful AV fistulae in a substantially greater number of patients. These options require vein mapping and a surgeon’s willingness to put in the additional time and effort. Make sure surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation.
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Change Concept #6
Secondary AVF Placement in Patients with AV Grafts
Evaluate graft patients for placement of a secondary AV fistula. In the context of the
NVAII initiative, an AV fistula placed in a patient whose initial access was a graft is considered a "secondary" AV fistula. 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.
Note particularly that the outflow vein from a graft is an already matured arterialized vein that could be connected and used right away (see indivual change recommendation: Examine the Outflow Vein of All Forearm Graft Patients to Identify Suitable Veins for Secondary AV Fistula ).
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Change Concept #7
AVF Placement in Patients with Catheters Where Indicated
Higher catheter use is associated with increased infection, morbidity, mortality, and hospitalization. Evaluation and mapping of catheter patients is crucial to facilitate the placement of AV fistulae. While catheters are necessary in some circumstances (e.g., while an AV fistula matures), the increasing prevalence of catheters in the United States is a serious health risk to patients. Strategies for reducing the number of catheters include
early referral to nephrologists,
monitoring and maintenance (so that accesses can be repaired before a catheter needs to be placed), and planning for a permanent access before the patient leaves the hospital.
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Change Concept #8
Cannulation Training for AV Fistulas
Prevent fistulae from being destroyed by inexperienced staff. Discuss the basics of needle cannulation with all staff.
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Change Concept #9
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. It is extremely important to catch problems with fistulae early. Problems must be caught within 24 hours or the fistula will fail and be irreparable. There is a 20 to 30 percent failure rate for early fistulae.
For references from the scientific literature, see Change Concept 9 in the
Literature section.
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Change Concept #10
Education for Care Givers and Patients
To make good decisions about their care, dialysis patients and their caregivers need support and resources, including information about the value of fistulae over other access types, protecting their veins, and advocating for themselves with their health care team.
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Change Concept #11
Outcomes Feedback to Guide Practice
Facilities can start by measuring performance on a monthly basis by access type - catheter, 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 data collection tool (Vascular Access Tracking Tool (VATT) and Instructions) that can help facilities measure and track AV fistula rates (and all access types) in incident and prevalent patients. This data tool permits simple tracking of not only AV fistulae that are in use but also AV fistulae that have been placed and are awaiting maturation.
Performance outcomes for specialists (surgeons, nephrologists, and interventionalists) should also 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.
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