3. vascular access audit 2014 - nhs wales. vascular access audit 2… · vascular access audit 2014...

Vascular Access Audit 2014

Mike Stephens

Chairman All Wales Vascular Access Group

All Wales Vascular Access Group

• Provide a forum for agreeing standards and plans, the sharing

of information, and provide advice to the Renal Network

• Philosophy is to work collaboratively in discussing clinical

practice issues, strategies and policies. practice issues, strategies and policies.

• Meet twice yearly

Renal Association Clinical Practice Guidelines

Vascular Access for Haemodialysis

Fluck and Kumwenda 2011

60%

70%

80%

90%

100%

PERCENTAGE INCIDENT PATIENTS ON FUNCTIONING AVF TO TARGET2010-2011 Q3 & Q4, 2011-2012, 2012-2013 AND 2013-2014

Bangor

Cardiff

Incident patients

0%

10%

20%

30%

40%

50%

Q3 2010

Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013

Glan Clwyd

Swansea

Wrexham

Target 65%

Incident target 65%

60%

70%

80%

90%

100%

PERCENTAGE PREVALENT PATIENTS ON FUNCTIONING AVF TO TARGET2010-2011 Q3 & Q4, 2011-2012, 2012-2013 AND 2013-2014

Bangor

Cardiff

Prevalent patients

0%

10%

20%

30%

40%

50%

Q3 2010

Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013

Glan Clwyd

Swansea

Wrexham

Target 85%

Prevalent target 65%

Audit Objectives

• Agreed during the All Wales Vascular Access Group meetings

• Auditing areas of current interest to the group

• Three areas covered:-

Referral to the access service

Incident patients using CVCs as access for dialysisIncident patients using CVCs as access for dialysis

Distal Fistula

• Data collected by the VANs in each centre

• Data covers 18 months (Jan 2013 to June 2014)

Part 1. Referral to the Access Service

1.1 Does your unit have a formal (i.e. written) pathway for

vascular access assessment?


1.1 Does your unit have a formal (i.e. written) pathway for

vascular access assessment?

NO YES

Wrexham SwanseaWrexham Swansea

Bangor Cardiff

Glan Clwyd


1.2 Does your unit specify an eGFR trigger for referral?


1.2 Does your unit specify an eGFR trigger for referral?

NO YES

Wrexham Cardiff (20)

BangorBangor

Glan Clwyd

Swansea


1.3. Please list the eGFR at referral for each patient referred to

your service for vascular access formation between 1st January

2013 and 30th June 2014.

Number of patients seen for vascular access

assessment per centre

N

242

N

Total 555

59 55 55

139

P<0.001

Median eGFR at referral

Mean eGFR at referral

P<0.001

Referral eGFR vs Incident Target

Wrexham Bangor Glan Clwyd Swansea Cardiff

Incident

patients

fistula

23% 40% 39% 44% 53%

fistula

Median

eGFR at

referral

13 18 11 13 14

Mean

eGFR at

referral

13 17 12 13 14

Incident target 65%

Part 2. Root Cause Analysis of Central Venous

Catheters for Incident Haemodialysis Patients

• Being completed by VANs in all units since January 2013

• Aim was to inform individual units of issues with their

pathwaypathway

• Only relates to patients known to renal services for >90 days

Proportion of Incident Patients Known to renal

Services for <90 days

NN

RCA of patients starting dialysis using CVC

% of all CVC patients

Excludes patients know to renal service <90 days

patients

Incident patients starting dialysis using a CVC

due to late referral

% of all incident incident patients



because AVF not mature




due to change in modality choice




due to patient refusal




due to rapid unexpected decline in function



Part 3. Distal Fistulae

3.1 In your unit do you have an artery or vein size cut-off below

which you would not attempt to use that vessel for an

arteriovenous fistula?


3.1 In your unit do you have an artery or vein size cut-off below

which you would not attempt to use that vessel for an

arteriovenous fistula?

NO YES

Bangor Swansea (2.5mm artery 2.5mm vein)Bangor Swansea (2.5mm artery 2.5mm vein)

Cardiff Wrexham (2mm artery 2.5mm vein)

UNKNOWN

Glan Clwyd


3.2 In your unit do you consider the urgency of requiring vascular

access in your consideration of which location to attempt an AV

fistula formation?


3.2 In your unit do you consider the urgency of requiring vascular

access in your consideration of which location to attempt an AV

fistula formation?

NO YES

Swansea BangorSwansea Bangor

Wrexham

Cardiff

UNKNOWN

Glan Clwyd

Number of first vascular access attempts per

centre

N

205

N

Total 488

45 4635

157

Proportion of first fistula attempts involving a

distal fistula

%

100%

86%73%

%

36%

63%

Outcomes of first fistula attempts

25%30%37%13%62%

Outcomes of first distal fistula attempts

32%30%43%13%81%

Summary

Part 1. Referral for vascular access

• Patients in Bangor are referred for vascular access with

significantly higher eGFRs than in the other units

• No simple correlation between eGFR at referral and overall

success at achieving the incident audit target

Summary

Part 2. Central Venous Catheters in incident patients

• The reason for patients not commencing dialysis by means of an

AVF differs between centres

• Higher proportion of patients in Bangor and Wrexham start HD

using a CVC because their fistula is yet to mature than in other

units

• Patients in North Wales more likely to have a rapid unexpected

decline in renal function than those in the South

Summary


• The centres differ in their approach to distal fistulae

• The first access attempt for all patients in Bangor was a distal The first access attempt for all patients in Bangor was a distal

fistula and the majority were successful (although sometimes

further procedures were required to achieve this)

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