By Kelly M. Mayo, MS & Susan McGovern, ARNP, MS Vascular access is the “lifeline” for end-stage renal disease (ESRD) patients who receive hemodialysis. This lifeline allows your blood to be pumped from your body, cleansed through dialysis and returned to your body. The three most common types of vascular access are catheters, grafts and fistulas. However, experts agree the best access for hemodialysis is an arterial-venous (AV) fistula. An AV fistula is created when an artery and a vein are surgically joined together, usually in the forearm. “Fistulas are the ‘gold standard’ for establishing access to a patient’s circulatory system in order to provide life-sustaining dialysis,” said Centers of Medicare and Medicaid Services (CMS) Administrator Mark B. McClellan, MD, PhD. “They last longer, need less rework, and are associated with lower rates of infections, hospitalization and death for Medicare beneficiaries than other types of access.” For these reasons, work began on a special project in July 2003 called the National Vascular Access Improvement Initiative. This initiative is known to most as “Fistula First.” What is “Fistula First”? CMS is leading the national initiative, titled Fistula First. The goal is to increase the use of AV fistulas for hemodialysis access in Medicare beneficiaries with ESRD. For this project, CMS has partnered with the Institute for Healthcare Improvement (IHI), the 18 ESRD Networks, dialysis providers, primary care physicians, nephrologists, vascular access surgeons, interventional radiologists, state survey agencies, professional societies and patient advocacy groups. The goal is to increase fistula use as recommended by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI): Currently, only about 30 percent of hemodialysis patients nationwide dialyze with a fistula. Why is an AV fistula important? Whether or not your dialysis access can sustain a good blood flow plays an important part in removing the fluid and toxins that build up between your treatments. Use of catheters and grafts increases the risk of infection, clotting and hospitalization. Patients who use catheters or grafts, for dialysis, have a higher risk of death mostly due to infection. Compared to catheters and AV grafts, AV fistulas have a lower chance of infection, do not clot as often and tend to last for many more years. Overall, the fistula provides the best performance for dialysis patients. Implementation of Fistula First Traditionally, the ESRD Networks only work with dialysis facilities and kidney patients to improve quality of care. The Fistula First effort is very different – it focuses on other important players in your healthcare, including nephrologists, surgeons and primary care physicians. A multi-disciplinary team from CMS, the ESRD Networks and major stakeholder groups developed approaches to increase fistula use and improve patient outcomes. There are suggestions for improvement for dialysis facilities, doctors and even patients. A sample of recommendations includes: 1. Routine continuous quality improvement (CQI) review of vascular access. Your ESRD Networks are working with dialysis facilities to collect data and implement new ideas to increase AV fistula usage. Your facility and nephrologist should review this data and other information on a regular basis to improve vascular access outcomes for patients.
2. Timely referral to nephrologists. Primary care physicians should use pre-ESRD/CKD (chronic kidney disease) to be sure that kidney patients are referred to a nephrologist early enough to receive a fistula.
3. Early referral to a surgeon for “AV fistula only” evaluation and timely placement. If possible, your nephrologist should refer you for vessel mapping before you see the surgeon for a fistula. Mapping is a special x-ray that gets a picture of your available blood vessels. Not all kidney patients are able to have a fistula placed before they start dialysis. If an AV fistula is not created before you begin dialysis, your nephrologist should make sure you are evaluated for a fistula and, if possible, it should be placed while you are in the hospital.
4. Surgeon selection based on best outcomes, willingness and ability to provide access services. When your nephrologist refers you to a surgeon for the creation of a vascular access, you should ask if the surgeon is willing and able to meet the AV fistula standards and expectations. Do not be afraid to ask. You have the right to the best vascular access possible.
5. Full range of appropriate surgical approaches to AV fistula evaluation and placement. Your surgeon should be able to use current techniques for fistula placement. Ask your nephrologist to refer you to a surgeon who uses the most advanced techniques.
6. Fistula placement in patients with AV grafts. Even if you have an AV graft that is functioning, your nephrologist should evaluate you for a possible AV fistula as well. If you have a forearm graft, have you noticed the vein in your upper arm growing? If so, a surgeon may be able to convert your graft to an upper arm fistula. Ask your nephrologist.
7. Fistula placement in patients with catheters where indicated. If you have a catheter, your nephrologist or surgeon should evaluate you as soon as possible for a fistula. Catheters are not the best choice for a permanent access because of high infection rates.
8. Cannulation training for AV fistulas. Cannulation is the process of sticking the needles into your fistula or graft. Your facility should identify and use the best “stickers.” However, you may want to learn to put your own needles in for each dialysis treatment.
9. Monitoring and maintenance to ensure adequate access function. Your facility should have a standard procedure for monitoring, and observing your access and take action quickly if it starts to fail. You can help monitor your access too. Signs of possible access problems include: Trouble maintaining good blood flow (above 300-350 ml/minute). Excessively negative pre-pump arterial pressure (greater than -200 to -250). High venous pressure (causing the alarm to go off too often).
10. Education for caregivers and patients. Not only should regular education be provided to facility staff on the topic of vascular access, but patients should learn about caring for their own vascular access. Did you know: Needle sites should be rotated each treatment. You should not sleep on your access arm or leg. You should not wear tight fitting clothes on your access arm or leg – not even a watch. You should feel your access for a thrill (vibration) and listen to your access for a bruit (swishing sound) every day. Clamps are not recommended for use after dialysis to stop the needle sites from bleeding.
11. Outcomes feedback to guide practice. In order to track and identify opportunities for improvement, the ESRD Networks collect data from all dialysis facilities and provide feedback reports that compare their vascular access rates with the average rates in the ESRD Networks and the United States. Do you know what your facility’s AV fistula rate is?
Where are we now? The renal community is now one year into the Fistula First Project. Each ESRD Network developed an action plan that best fits its region in relation to patient population, dialysis facilities and physicians. However, all plans have the same goal – increase the number of patients dialyzing with fistulas to at least 40 percent. CMS and the ESRD Networks are dedicated to making this project a success. Through the efforts of all stakeholders, this goal is achievable. Ask your doctor or nurse how you can participate in Fistula First and ensure the best possible vascular access. Remember, think Fistula First! Find out more about Fistula First For more information about Fistula First, ask your dialysis unit staff or contact your ESRD Network. You can locate your ESRD Network by contacting the Forum of ESRD Networks at (804) 794-2586 or www.esrdnetworks.org. Kelly M. Mayo, MS is the Project Director for Florida Medical Quality Assurance, Inc: The Florida ESRD Network (Network 7). She also serves on the AAKP Board of Directors. Susan V. McGovern, ARNP, MS is the Quality Improvement Coordinator for FMQAI: The Florida ESRD Network. Susan has been a nurse for 24 years and has an extensive background in quality improvement, legal nurse consulting and various hospital and home health positions. “The analyses upon which this publication is based were performed under Contract Number 500-03-NW07 entitled End Stage Renal Disease Networks Organization for the State of Florida, sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.” This article originally appeared in the September 2004 issue of aakpRENALIFE, Vol. 20, No. 2.
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