Tools

Background
Many of these tools listed as "NVAII" were developed through the Tools and Resources subcommittee of the National Vascular Access Improvement Initiative (NVAII) in 2003. The subcommittee worked together to create a toolkit to support the work of the renal community in improving vascular access to hemodialysis patients. All documents were created and/or modified by committee members, and reviewed and edited by the committee leadership including NAVII/FFBI clinical chair, Lawrence Spergel, MD, FACS. The documents appearing in Word can be customized for your own practice.

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! To submit a patient education tool for consideration, click here.

Please Note: Before printing any of these tools, we recommend that you check your printer settings to determine the correct page orientation for the document. Some tools may need to be printed in the 'Landscape' format to avoid cutting off any of the text.

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

  PDF (Downloadable)                      Powerpoint (Downloadable)
  Word (Downloadable)                    Access (Downloadable)
  Excel (Downloadable)                     Interactive Tool (Online)

General Tools

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

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.

Fistula First Outcomes Dashboard
Current data on Fistula use and ESRD Networks.

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.

National Vascular Access Improvement Initiative (NVAII) Project Description
This document describes the National Vascular Access Improvement Initiative whose goal is to increase the appropriate use of AV fistulae for hemodialysis access in the United States.

K/DOQI Vascular Access Clinical Practice Guidelines
These guidelines provide evidence- and opinion-based recommendations and information related to arteriovenous fistulae. For additional information on guidelines and their development, visit the National Kidney Foundation K/DOQI website.

Fistula First Change Package
Clinical and organizational recommendations based on best practices for increasing AV fistula use and improving hemodialysis patient outcomes.

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1. Routine CQI Review of Vascular Access

AV Fistula "Roadmap" for Nephrologists
From: Dr. Vo Nguyen, Medical Director of Aberdeen Dialysis Center, Renal Care Group of the Northwest
Olympia, Washington, USA

This "roadmap" can be used to plan an improvement effort to increase AV fistula rates in your nephrology practice including forming the team, establishing an algorithm for vein mapping and other procedures, and identifying specific improvement activities.

Monthly Vascular Access Referral/Intervention Log
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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
From: Carolyn Barclay RN, CNN, Vascular Access Coordinator, Kaiser Permanente
Portland, Oregon, USA

A key change idea for incorporating vascular access into an organization's ongoing CQI efforts is to designate a staff member in the dialysis facility who will be responsible for vascular access. This PowerPoint presentation describes the key functions and role of a Dialysis Access Coordinator (or Vascular Access Manager) in the context of the entire renal care team.

(Note: The presentation uses the term "Vascular Access Manager" rather than "Vascular Access Coordinator," but the two terms can be used interchangeably.)

Vascular Access Coordinator Role
From; National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

One of the key change ideas for incorporating vascular access into an organization's ongoing CQI efforts is to designate a Vascular Access Coordinator, a staff member in the dialysis facility who will be responsible for vascular access. This description defines the purpose and essential job functions of the Coordinator.

Implementation Tracking Tool
From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

This tool allows assessment of the "spread" of change ideas, that is, to what extent facilities and their associated medical specialists have adopted best practices for increasing AV fistula rates. Dialysis facilities can use this tool (with or without modification) as part of their ongoing CQI activities. The tracking tool is structured around behavioral change theory, recognizing that the change process may be underway for a period of time before new behavior can be observed. The tool allows tracking of a range of improvements including those that facilities control or influence directly, as well as those that facilities can observe among the medical specialists who care for their patients.

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
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This sample policy and procedure statement is based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Preservation of veins and maturation of AV fistulae is a collaborative effort among surgeons, nephrologists, and dialysis staff. The guideline promotes the development and maintenance of AV fistulae by giving patients strategies to help increase the diameter of the vessel, prevent infection, prevent thrombosis, and maintain function.

Pre-ESRD AV Fistula Planning Algorithm
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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

AV Access Plan Checklist for Nephrologists
From: Dr. Vo Nguyen, Medical Director, Aberdeen Dialysis Center, Renal Care Group of the Northwest
Olympia, Washington, USA

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
From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Caring for patients with chronic kidney disease (CKD) is a great challenge for both primary care providers (PCPs) and for nephrologists. Some PCPs may fear that patients referred to a nephrologist will not return to them for further care. This sample letter can be used by a nephrologist to educate his or her community of primary care physicians on the importance of early referral to a nephrologist in the treatment of chronic kidney disease (CKD) patients. It describes the rationale and appropriate "trigger" and assures the PCP that the referred patient will return to their care. This letter could also be used for insurance companies.

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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
From: Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates
Olympia, Washington, USA

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. If suitable vessels are identified, the necessity of performing a bilateral study can be avoided; if suitable vessels are not identified in the preferred extremity, then the contralateral extremity will need to be studied as well.

Referral Form for New Hemodialysis Access
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

This form can be used by nephrologists to refer a patient needing a new hemodialysis access to a vascular access surgeon. The nephrologist can request the site preference for the desired access on the form, and the surgeon is requested to notify the nephrologist if the preferred access will not be placed.

Vascular Access Diagram
From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

This comprehensive faxable form can be used by surgeons and interventional radiologists to communicate important vascular access procedure information to dialysis facility staff and nephrologists. The form includes information on access type, configuration, interventions performed, and a diagram that can be used to indicate configuration of access.

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
From: Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

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.

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

Surgeon Questionnaire
From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Some surgeons are willing and able to perform the necessary evaluative and surgical procedures necessary for establishing successful arteriovenous (AV) fistulae. This questionnaire can be used to survey the surgeons in your community about their skills, experience, and interest in order to determine which surgeons are most appropriate to perform AV fistula procedures.

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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
From: Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

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
From: Olympic Vascular Lab, Surgical Associates, and Memorial Nephrology Associates
Olympia, Washington, USA

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. If suitable vessels are identified, the necessity of performing a bilateral study can be avoided; if suitable vessels are not identified in the preferred extremity, then the contralateral extremity will need to be studied as well.

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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
From: National Vascular Access Improvement Initiative Tools and Resources Working Group with assistance from Lawrence M. Spergel, MD, Dialysis Management Medical Group
San Francisco, California, USA

This protocol is used 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.

An effective strategy for increasing arteriovenous (AV) fistula prevalence is the planning and construction of AV fistulae in existing AV graft patients prior to graft failure. Although the primary access may currently be a graft, all graft patients should be evaluated and considered (where feasible) for an AV fistula as their next permanent access (secondary AV fistula).

Although evaluation for a secondary AV fistula may require bilateral vessel mapping to identify a suitable vein and artery for AV fistula construction, the simplest opportunity to convert a graft patient to a fistula patient, when present, is the conversion of an arterialized (mature) upper-arm outflow vein of a forearm graft to a direct upper-arm AV fistula. Such a conversion opportunity should be looked for and considered in all forearm graft patients.

Referral Form for Existing Hemodialysis Access
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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.

Patient Assessment Video
Secondary AVF Fistula Conversion (includes the Sleeves-Up exam) - Dr. Lawrence Spergel

"Sleeves Up" Checklist
Checklist for Access Managers

Evaluate Every AV Graft Patient for Possible Secondary AVF
A secondary AV fistula plan should be documented in the chart and discussed with the patient, family, staff, nephrologists and surgeon in anticipation of AV fistula construction on the earliest evidence of graft failure.

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7. AVF Placement in Patients with Catheters Where Indicated

Reducing Central Venous Catheter Infections Cause and Effect Diagram
From: National Vascular Access Improvement Initiative, National Coordinating Center
Los Angeles, California, USA

Cause and effect (or "fishbone") diagrams are a useful way to graphically display the possible causes of a certain effect. This diagram shows the various risk factors that can lead to central venous catheter (CVC) infection, grouped into four major categories: patient, caregiver, equipment, and environment.

AV Fistula Cannulation Resources for Staff
From: National Vascular Access Improvement Initiative Tools and Resources Workgroup
Los Angeles, California, USA

In support of the National Vascular Access Improvement Initiative (NVAII) goal of increasing the appropriate use and care of AV fistulas for hemodialysis access, this tool contains a number of reference articles, videotapes, workbooks, and other training materials. These materials specifically focus on proper technique for cannulation of an AV fistula, and include information on the constant site or "buttonhole" technique of fistula cannulation.

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.

Buttonhole Damage from Sharp Needles
Power point presentation

Buttonhole Damage from Sharp Needles
Handout

Patient Assessment Video
Assessment of the upper arm AV fistula - Dr. Gerald Beathard

Patient Assessment Video
Assessment of forearm AV fistula - Dr. Arif Asif

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9. Monitoring and Maintenance to Ensure adequate Access Function

Monthly Vascular Access Referral/Intervention Log
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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.

Referral Form for Existing Hemodialysis Access
From: National Vascular Access Improvement Initiative, Network Coordinating Center
Los Angeles, California, USA

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.

VAMP© Vascular Access Monitoring and Surveillance Flow Chart
From: Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group
San Francisco, California, USA

This algorithm/flow chart outlines monitoring mechanisms for vascular access function, normal and abnormal findings, and recommendations for interventions. It can be used by facilities, hospitals, nephrologists, surgeons, and interventional radiologists.

Monitoring, Surveillance, and the Failing AVF

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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10. Education for Care Staff and Patients

Electronic Notebook of Patient Education Materials 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 Education Materials List
A comprehensive list of resources related to vascular access for medical staff including websites, written materials, and videos.

What Professionals can do to Maximize AVF as Primary Access
A healthcare team working in collaboration and following recommended practice guidelines can make a difference in maximizing the use of native arteriovenous fistulae (AVF).

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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.

Summary Grid of Vascular Access Measures

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