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Vascular Access

As the "lifeline" of the patient on hemodialysis, vascular access should be a primary focus of quality improvement activities. While efforts are underway to improve vascular access outcomes by increasing the use of AV fistulas (see Fistula First), the majority of patients in Network 8 continue to dialyze with AV grafts or central venous catheters. Dialysis facility staff and other vascular access team members must work together to:

These goals may be accomplished through better communication, education, vascular access monitoring, early referral for intervention, and utilization of proper procedures.

CMS and the ESRD Networks currently collect data and monitor the following vascular access clinical performance measures:

Clinical Performance Measures Quality Improvement Project - Decreasing Catheters

Network 8 utilizes vascular access data from the 2728 form and the Fistula First data collection to select nephrologists and facilities to participate in the quality improvement project to reduce central venous catheter use. 2728 data analysis(add link to chart below) revealed that >60% of Network 8 patients initiated dialysis with catheter as only access in recent years, and Fistula First data indicate 16% have catheter as only access.

Project goal: Nephrologists, hospitals and dialysis providers will utilize practices to ensure timely permanent access placement. The Network provides support to project participants through methods such as:

Click here to view the 2728 Form - Vascular Access Data Analysis Chart. (link opens in new browser)

Clinical Focus on Vascular Access Surveillance

Each year, CMS and the ESRD Networks collect Clinical Performance Data (CPMs) to measure and report the quality of renal dialysis services provided under the Medicare program. In the past, these have been collected by paper form on a national random sample of patients. With the full implementation of CROWNWeb, these data will be collected on 100% of patients throughout the US, with each dialysis provider entering data at the facility level or through batch download from corporate headquarters.

Vascular access monitoring and surveillance are now requirements of the Conditions for Coverage, as specified in the Interpretive Guidance (noted below), and will be included in the CROWNWeb data collection.

  1. On-going program for vascular access monitoring: physical exam, observance of changes in adequacy or access pressures during dialysis, cannulation problems, or prolonged bleeding after needle removal. In addition, patient education should address self-monitoring of access.
  2. On-going program for vascular access surveillance, such as access flow measurements, static venous pressure ratios, Doppler flow studies, or dilution-technique studies such as Transonics Ò or CritLine ™ done on a routine basis.

In recent years, CPM data have indicated that stenosis monitoring was performed on only 61 – 72% of AV Graft patients, in the Network 8 region. 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, surveillance, and reporting.

The 2006 Update to KDOQI Clinical Practice Guidelines for vascular access define monitoring as physical exam and surveillance as tests that may involve special instrumentation, both used to detect access dysfunction. The following are surveillance techniques currently in use.

Access flow surveillance methods

Venous pressure surveillance methods

Clinical assessments that ARE NOT routine surveillance methods include:

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. Please refer to the 2006 KDOQI Vascular Access Clinical Practice Guideline 4 and Clinical Recommendation for Guideline 4 for further detail. As always, the QI staff at Network 8 is available for assistance with form questions or vascular access surveillance efforts.

Tools and Resources

 

 

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