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NDT Advance Access originally published online on March 29, 2007
Nephrology Dialysis Transplantation 2007 22(6):1628-1632; doi:10.1093/ndt/gfm076
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Implementation of a vascular access quality programme improves vascular access care

M. van Loon1, W. van der Mark2, N. Beukers3, C. de Bruin3, P. J. Blankestijn2, R. M. Huisman3, J. J. Zijlstra4, F. M. van der Sande1 and J. H. M. Tordoir1

1Department of Surgery and Nephrology, University Hospital Maastricht, 2Department of Nephrology, University Medical Center Utrecht, 3University, Hospital Groningen, Department of Radiology and 4Hospital Midden-Twente Hengelo, The Netherlands

Correspondence and offprint requests to: J. H. M. Tordoir, MD, PhD, Vascular surgeon, Department of Surgery, University Hospital Maastricht, P. Debeijelaan 25, PO Box 5800, 6202AZ Maastricht, The Netherlands. Email: j.tordoir{at}surgery.azm.nl



   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Introduction. In the Netherlands an access quality improvement plan (QIP) was introduced by vascular access coordinators (VAC) with the aim to decrease vascular access-related complications by preemptive intervention of malfunctioning accesses. A vascular access QIP was established in 24 centres (46% of all Dutch facilities) and a structural multidisciplinary vascular access meeting was instituted.

In these centres, including 2300 patients, a protocol for enhancement of fistula creation and access surveillance programme was implemented, with instruction of physicians and nurses, and rounds to discuss complications and evaluate vascular access interventions. The number and type of vascular access, permanent catheters, thrombosis rates and number of interventions were evaluated at the start and end of the study period.

Results. After the surveillance programme, the number of autogenous arterio-venous fistulas (AVFs) had increased significantly from 69 to 77% (P < 0.01), while the use of temporary subclavian vein catheters declined (34% vs 11%) (P < 0.01), with a substantially higher percentage of jugular vein catheters (from 23 to 35%). Interventional treatment of malfunctioning accesses by percutaneous transluminal angioplasty (PTA) (from 0.39 to 0.50 patient/year; P < 0.001)) and surgical revisions (from 0.06 to 0.12 per patient/year; P < 0.001) also increased.

Conclusion. These data demonstrate that a vascular access QIP resulted in placement of more autogenous AVFs, increased number of PTAs and surgical interventions. These findings suggest that a vascular access care QIP is worthwhile to improve dialysis patients’ care and access morbidity.

Keywords: arteriovenous fistula; preemptive intervention; surveillance; vascular access



   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Preservation of vascular access is critical in the successful management of haemodialysis (HD) patients. An adequately functioning access is a prerequisite to dialyse effectively, and therefore, of vital importance for the HD patient. In 2006, in the Netherlands, 5259 patients with end-stage renal disease (ESRD) relied on renal replacement therapy, of which 3907 patients depended on HD. As in most other countries, the number of patients with cardiovascular comorbidities, diabetes mellitus and older age continues to increase, which makes the creation and maintenance of a well-functioning vascular access more difficult. Vascular access complications continue to be a leading cause for hospitalization and morbidity in patients with ESRD. These complications have a negative effect on the quality of life of dialysis patients and may have a major impact on mortality.

To improve quality of life, the Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines for Vascular Access (update 2006) recommended an increased use of autogenous arterio-venous fistulas (AVFs) and prevention of access dysfunction by surveillance and preemptive intervention [1]. The reason for this is the longevity and fewer complications of AVFs as compared with grafts and central vein catheters.

The Dialysis Outcomes and Practice Pattern Study (DOPPS) estimated an 80% autogenous AVF rate in Europe compared to 24% in the USA [2]. In the Netherlands overall, 61% of the prevalent HD patients were dialyzed through an AVF [3].

Although the necessity of structural vascular access management has been recognized, there is a substantial variation among individual facilities in the Netherlands (52 dialysis facilities) concerning the care of the vascular access. Most of the dialysis facilities have no uniform vascular access surveillance programme, education and information for caregivers and patients, and database to register access creation, surveillance and intervention rates.

The aim was to improve the quality of vascular access care by implementing a quality improvement programme (QIP). The programme was meant to firstly, increase awareness and commitment to vascular access of all parties involved, and secondly, to monitor outcome parameters, to quantify the effectiveness of the initiative.



   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
For the vascular access programme, 27 dialyses facilities (three academic dialysis centres, 21 dialysis centres in general hospitals and three other centres) representing more than 50% of all dialysis facilities in the Netherlands were randomly selected and split into three regions.

A taskforce group was created including representatives of the nephrologists, radiologists, and vascular surgeons together with three nurses trained as vascular access coordinators (VACs). This taskforce defined standardized procedures and developed multidisciplinary protocols for the construction, maintenance and intervention of the vascular access all based on internationally accepted quality standards (K/DOQI). The QIP included two steps. The first step was meant to improve awareness and commitment of all parties involved, i.e. nephrologists, radiologists, vascular surgeons and dialysis staff. The QIP consisted of an analysis of the baseline situation, defining targets for improvement (summarized in an advisory report), organizing regular meetings, and institution of an education programme and of an access surveillance programme, which included physical examination, monitoring pressures and access flow. For the management of the QIP, each dialysis department was asked to identify a Vascular Access Nurse (VAN) interested in being a key member for the execution of the programme. Because the QIP could only be achieved if there was an integrated multidisciplinary approach to vascular access care, every centre was asked to identify a nephrologist, surgeon and interventional radiologist from their staff who could participate in the programme. The VAN was the key member in the improvement programme, with the purpose of streamlining the communication between the dialysis unit, the involved physicians and the VACs. The VAC regularly visited the dialysis centres with the purpose to guide the centre in the programme.

In the second step of the QIP prospective monitoring of outcome variables including type of access in incident patients, surgical and radiological interventions, thrombosis rate and central venous catheter were performed.

Statistical analysis
A comparison between baseline data at the start of the study and data at the end of implementation of the QIP was performed. Data were analysed by SPSS 12.0. A P-value <0.01 is considered significant.



   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
During a three-year period, 27 (51%) of the Dutch dialysis facilities, including more than 2300 patients, participated in the vascular access quality improvement programme. In all centres an advisory rapport was completed and, with support of the VACs, the programme was established. In 24 centres (89%) it was possible to perform a final report/measurement. In three centres, the time since programme initiation was too short to evaluate the effects.

Surveillance programme
During the vascular access improvement programme, in 88% of the centres vascular access monitoring protocols (at baseline 33%) were introduced and implemented. At the end of the programme, in 91% of the centres, complete clinical examination was performed before each cannulation. This was a substantial improvement from baseline: inspection and palpation in 62%, and auscultation in 21% of the centres. Registration of venous and/or arterial pressures during HD treatment at normal dialyser flow was common. To monitor the vascular access function during HD, 88% of the centres used the ultrasound dilution technique (at baseline 58%). All of the HD centres established structural multidisciplinary evaluation meetings (at baseline 79%). In 67% of the centres multidisciplinary pre-dialysis care was instituted including education, preservation of veins, preoperative vein mapping, early fistula creation and a follow-up for fistula maturation (at baseline 21%).

Education
In 88% of the centres an integrated continuous education programme on vascular access care has been established, which improves the knowledge and technical skills of the dialysis staff (at baseline 33%). All centres have developed a variety of teaching methods for patients and their family/caregivers including videos, written instructions and meetings to improve quality of care and outcomes of vascular accesses (at baseline 87%).

Outcome parameters
The baseline period included 14 months of follow-up, and the intervention period was 12 months. The number of newly created autogenous AVFs in incident patients increased significantly, from 69% to 77% (P < 0.01), with 54% forearm, and 23% upper arm AVFs (P < 0.01) (Figure 1). The use of AVFs among prevalent patients increased from 61% to 64% (P < 0.01) (Figure 2). During the programme, the percentage of non-tunnelled subclavian vein catheters decreased from 34% to 11% (P < 0.01), while non-tunnelled catheters in the jugular vein increased from 11% to 21% (P < 0.01) (Figure 3). A significantly greater percentage of the patients were using tunnelled central vein catheters from 22% to 34% (P < 0.01) instead of non-tunnelled catheters (78% vs. 66%) (Figure 3).


Figure 1
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  		Fig. 1. Vascular access creation. AVF: arteriovenous fistula; AVG: arteriovenous graft.

 

Figure 2
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  		Fig. 2. Vascular access use among prevalent HD patients. AVF: arteriovenous fistula; AVG: arteriovenous graft.

 

Figure 3
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  		Fig. 3. Catheter use among HD patients.

 
Interventional treatment of malfunctioning accesses by PTA increased from 0.39 to 0.50 interventions per patient/year (P < 0.001) (Table 1), as well as surgical intervention (from 0.06 to 0.12 per patient/year; P < 0.001) (Table 2). At the start of the programme, most centres did not have an adequate registration of vascular access problems. At the end of the programme, all centres did have adequate registration and the prevalence of AVG thrombosis could be calculated to be 0.41 per patient year.


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  		Table 1. Interventional treatment by radiology

 

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  		Table 2. Surgical interventional treatment

 


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
To the best of our knowledge, this is one of the largest initiatives, in terms of number of participating centres and patients, meant to improve quality of vascular access care. The present study shows that introducing and implementing a QIP led, firstly, to more awareness and commitment with those involved in the care of vascular access and, secondly, that this was translated in an improvement of some aspects of quality of care.

The introduction of a vascular access quality improvement programme resulted in placement of significantly more autogenous AVFs in incident patients, and led to a small increase of fistula use among prevalent patients. The latter can be explained by the number of primary failures and the short observation period. The percentage of PTAs and surgical interventions also increased, indicating early diagnosis of significant stenoses by an anticipating surveillance programme.

Various studies have reported a decline in thrombosis rate for arterio-venous graft fistula (AVG) after implementation of a vascular access surveillance programme, if coupled with a programme of elective stenosis correction [4–11]. Summarizing the described results in mentioned studies, AVG thrombosis rates of <0.5 per patient/year should be possible. The AVG thrombosis rate of 0.41 per patient/year in this study underlines these findings. Although the programme was not designed to investigate the effects of outcomes on patency rate and vascular access quality, the results appear promising. Although the thrombosis rate decreased, the number of tunnelled jugular vein catheters increased at the expense of catheters inserted through the subclavian vein route and non-tunnelled catheters. This development is in line with the recommendations of K/DOQI and helps to diminish catheter-related infections and central vein obstruction. On the other hand, we could not establish a decrease in the total number of central vein catheters, as recently have been shown by Asif et al., where the implementation of a QIP reduced the use of tunnelled catheters [12].

At the start of the programme, there was a substantial variation among individual facilities in the Netherlands concerning the care of the vascular access. To improve vascular access care and outcomes it is essential to implement the recommendations of the K/DOQI Clinical Practical Guidelines for Vascular Access and European Guidelines on vascular access [1,13,14]. Because of the multidisciplinary character of vascular access care it was a prerequisite to develop an integrated multidisciplinary approach in all participating facilities. The vascular access quality programme focused on establishing pre-dialysis care, implementing access surveillance to detect problems in an early stage, and an education programme for the patients and their family and caregivers as well as dialysis staff. The updated K/DOQI guidelines published in 2006 [1] underline the importance of a multidisciplinary approach to vascular access-related problems, both in pre-dialysis and in haemodialysis patients in preventing malfunctioning fistulas. Mishler et al. [15] also showed that a dedicated outpatient vascular access centre decreased the number of hospitalizations and dialysis treatments. In addition, the increase in number of AVFs is in agreement with the K/DOQI guidelines [1,13].

The importance and value of the VACs in this project were to realize changes in vascular access care in the studied dialysis centres by developing, implementing, coordinating and managing the process of vascular access surveillance, stimulating and motivating the multidisciplinary taskforces related to surveillance, and streamlining communication and evaluation between professionals involved in vascular access care.

The implementation of such a vascular access quality improvement programme is time demanding, and cost consuming. To continue the programme and study the effects of the investments and efforts, it is required to measure and communicate the effects of this approach. Therefore, it is a crucial factor and prerequisite for individual centres to have a standardized database system to collect prospective data about procedures and complications. These data make it possible to monitor and evaluate outcomes and, if necessary, to make adjustments to the process related to vascular access [1,2,13,14,16].

Although we did not investigate the impact of a QIP on healthcare costs, McCarley et al. [17] did show the cost effectiveness of an access flow-based surveillance programme. They calculated a reduction in the number of thrombosis rates in both AVGs and AVFs, which had a beneficial effect on patient comfort and healthcare costs.

The vascular access quality improvement programme has shown to be successful. It has been the first step towards a wide standardized and uniform approach towards vascular access care, based on international quality standards. The data revealed an important contribution to the process of continuous quality improvement, especially with regard to development and implementation of quality instruments. The next step is to establish a continuous process of evaluation of outcome parameters. For the future, the challenge will be to continue the programme and measure the impact of this quality improvement initiative from a patient's perspective.

In conclusion, the data from this study demonstrate that implementation of a vascular access quality improvement programme results in placement of more autogenous AVFs in incident patients, and an increased number of PTAs and surgical interventions. These findings suggest that a vascular access care programme is worthwhile to improve dialysis patients’ care and access morbidity.

Conflict of interest statement. None declared.



   Acknowledgment
 
The authors would like to acknowledge the commitment and cooperation of the participating dialysis centres, without whose dedication, this project would not have succeeded. This project was supported by a grant from the Dutch Kidney Foundation.



   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. NKF-K/DOQI. Clinical practice guidelines for vascular access: update July 2006. Am J Kidney Dis (2006) 48:S187–S277.
  2. Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int (2002) 61:305–316.[CrossRef][Web of Science][Medline]
  3. Ezzahiri R, Lemson MS, Kitslaar PJ, Leunissen KM, Tordoir JH. Haemodialysis vascular access and fistula surveillance methods in The Netherlands. Nephr Dial Transplant (1999) 14:2110–2115.[Abstract/Free Full Text]
  4. Fistula First. National Vascular Access Improvement Initiative. (2005) December 6.
  5. McGill R, Marcus R, Healy D, et al. AV fistula rates: changing the culture of vascular access. J Vasc Access (2005) 6:13–17.[Medline]
  6. Pisoni RL, Young EW, Mapes DL, Keen ML, Port FK. Vascular access use and outcomes in the US, Europe, and Japan: results from the Dialysis Outcomes and Practice Patterns Study. Nephrol News Issues (2003) 17:38–43, 47.[Medline]
  7. Schwab S, Oliver M, Suhocki P, McCann R. Hemodialysis arteriovenous access: detection of stenosis and response to treatment by vascular access blood flow. Kidney Int (2001) 59:358–362.[CrossRef][Web of Science][Medline]
  8. Valj K. Prophylactic angioplasty: is it worthwhile? In: Dialysis Access: A Multidisciplinary Approach.—Gray RJ, Sands JJ, eds. (2002) Philadelphia: Lippincott Williams & Wilkins. 153–156.
  9. Sands J, Jabyac P, Miranda C, Kapsick B. Intervention based on monthly monitoring decreases hemodialysis access thrombosis. ASAIO J (1999) 45:147–150.[Web of Science][Medline]
  10. Smits JH, van der Linden J, Hagen C, et al. Graft surveillance: venous pressure, access flow or the combination? Kidney Int (2001) 59:1551–1558.[CrossRef][Web of Science][Medline]
  11. Allon M, Bailey R, Ballard R, et al. A multidisciplinary approach to haemodialysis access: prospective evaluation. Kidney Int (1998) 53:473–479.[CrossRef][Web of Science][Medline]
  12. Asif A, Gautam C, Merrill D, Cipleu CD, Bri P. Conversion of tunneled hemodialysis catheter-consigned patients to arteriovenous fistula. Kidney Int (2005) 67:2399–2406.[CrossRef][Web of Science][Medline]
  13. NKF–K/DOQI. Clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis (2001) 37:S137–S181.[Medline]
  14. Bakran A, Mickley V, Passlick-Deetjen J. Management of the Renal patient: clinical Algorithms on Vascular Access for Haemodialysis. (2003).
  15. Mishler R, Sands JJ, Ofsthun NJ, Teng M, Schon D, Lazarus JM. Dedicated outpatient vascular access center decreases hospitalization and missed outpatient dialysis treatments. Kidney Int (2006) 69(Suppl 2):393–398.[CrossRef][Web of Science][Medline]
  16. Port FK, Wolf RA, Held PJ, Young EW. Random Sample (DOPPS) versus Census-Based (Registry) Approaches to Kidney Disease Research. Blood Purif (2003) 21:85–88.[CrossRef][Web of Science][Medline]
  17. McCarley P, Wingard RL, Shyr Y, Pettus W, Hakim R, Ikizler TA. Vascular access blood flow monitoring reduces access morbidity and costs. Kidney Int (2001) 60:1164–1172.[CrossRef][Web of Science][Medline]
Received for publication: 1. 1.07
Accepted in revised form: 26. 1.07


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