Tools and Resources
Vascular Access Patient/Staff Education Toolkit
In an effort to meet educational needs of patients and staff, Network 8, Inc. has developed a vascular access toolkit entitled Vascular Access: Before, During, & After. Click here to view the toolkit contents.
Fistula First Facility Toolkit
The Network 8 Fistula First Toolkit has been distributed to each facility. We encourage you to use the tools and resources in your quality improvement efforts. Please contact the Network office if you did not receive a kit. Area managers, educational and quality directors may request a kit by contacting the Network office. Click here to view and download toolkit contents.
Other Fistula First Tools and Resources
Fistula First tools and resources can be found on the current project website (link opens in a new browser.)
Commonly Used Permanent Vascular Access Codes
Vascular Access Technical Assistance Provided
Network 8 will offer technical assistance by request to those seeking to improve their vascular access programs and outcomes. Questions regarding vascular access procedures and requests for technical consultation may be forwarded to Network 8 via Email, letter or phone. Workgroup members (nephrologists, surgeons, radiologists and nurses) will provide the technical support by phone, e-mail and possibly through face-to-face meetings. Please contact Ann Pridgen with your requests for technical assistance and/or requests for materials ((601) 936-9260 or Email).
Fistula First Resources for Patients
These materials present information on a variety of topics, which should prove beneficial in educating your patients about the advantages of fistulas. These include: preparation and planning for fistula placement, how to self-advocate for a fistula, tackling emotional issues, needle fear and body image, vessel preservation and imaging, monitoring, pre/post surgical care and others. Click here to access the list.
Clinical Focus on . . .Vascular Access Surveillance
Each year, Clinical Performance Measure Data Collection forms are sent to a random sample of dialysis facilities to collect clinical data in the areas of adequacy, anemia, and vascular access. The following passage is taken directly from the Centers for Medicare & Medicaid Services website and explains the purpose of CPMs.
“Section 4558 (b) of the Balanced Budget Act (BBA) required CMS to develop and implement by January 1, 2000 a method to measure and report the quality of renal dialysis services provided under the Medicare program. To implement this legislation, CMS funded the development of clinical performance measures (CPMs) based on the National Kidney Foundation's (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines (formerly known as Dialysis Outcome Quality Initiative).
Data are currently collected annually to calculate the ESRD CPMs on a national random sample of adult (18 years or older) hemodialysis (HD) patients and adult peritoneal dialysis (PD) patients. Although currently these CPMs do not apply to the pediatric age group (under 18 years old), data are also collected on pediatric HD patients in order to profile national patterns of care for these patients.”
For vascular access measures, the main focuses are:
- Maximizing the placement of AVFs—CMS goal: >40% patients with AVF access
- Minimizing the use of catheters as chronic dialysis access—CMS goal: <10% patients with chronic catheter access
- Monitoring AV grafts for stenosis—CMS goal: 100%
In 2000, 63% of patients sampled in the Network 8 region were routinely monitored for graft stenosis. Since then, the network average improved to 76% in 2002—
still considerably below CMS goal. Furthermore, preliminary reports from the 2004 data collection, which contains fourth quarter of 2003 data, reveal a decline in stenosis monitoring.
In review of the CPM forms, it was observed that some facilities might have been confused about acceptable methods of stenosis monitoring, resulting in a falsely low reported rate of stenosis monitoring. It is our hope that clarification will result in both improved monitoring and reporting.
“Routine surveillance”, for purposes of CPM reporting, is defined as “the sequential measurement of access flow OR of venous pressure” and includes the following methods.
Access flow surveillance methods
- In-center access flow measurements—done by reversing bloodlines to induce recirculation. Access flow is then calculated either manually, using mathematical formula, or via computer program. May be done using Transonic ®, Cardiodynamic ®, or similar device or may be accomplished using hemodialysis machine with access flow measurement option. Measurements must be repeated on a routine basis to qualify as surveillance.
- Color-Flow Doppler study every three months. This outpatient radiological procedure may also be referred to as a duplex ultrasound, duplex Doppler study, or Doppler color-flow study This method combines conventional ultrasound, which reveals the structure of vessels, with Doppler ultrasound, which reveals blood flow images.
Venous pressure surveillance methods
- Dynamic venous pressure EVERY HD session during data collection time frame. Though not the first choice of K/DOQI panelists, dynamic venous pressure is often considered to be the most “user-friendly” method of access surveillance. With this technique, venous pressure is recorded at a pump speed of 200 mls/min during the first 2-5 minutes of every dialysis treatment, using the same size fistula needle each treatment, usually 15-guage. While baseline pressures vary with different machines, pressure readings should be close to 125-150 mmHg. Three consecutive readings greater than 150 (or facility specific baseline as determined by medical director) are significant and should prompt further study (fistulagram).
- Static venous pressure (SVP) measured and recorded once every two weeks. SVP monitoring is preferable to dynamic venous pressure monitoring by the K/DOQI workgroup. This method, somewhat more detailed than dynamic monitoring, requires consistency in measurements and use of a simple formula to calculate intra-access pressure ratio. More information on this method is available on the K/DOQI website.
Clinical assessments that ARE NOT routine surveillance methods include:
- Monthly measurement of Kt/V or URR
- Recirculation studies
- Prolonged bleeding after needle removal
- Altered characteristics of thrill or bruit
As technology advances, vascular access surveillance methods are certain to follow. With the increasing use of intra-dialytic clearance monitoring, changes to acceptable stenosis monitoring methods may follow. Updated K/DOQI guidelines are scheduled for release later this year. In the interim, please read and follow CPM data collection form instructions closely. As always, the QI staff at Network 8 is available for assistance with form questions or vascular access surveillance efforts.