why vascular access coordinator (vac) samiha hindi, rn, cnc hemodialysis unit kfsh & rc. riyadh...

Why Vascular Access Coordinator (VAC)

Samiha Hindi, RN, CNC

Hemodialysis Unit

KFSH & RC. Riyadh

E-mail-shindi@kfshrc.edu.sa

Objectives

1. Why the need for vascular access coordinator (VAC)?.

2. What is the role of the vascular access coordinator?.

3. What is the best outcome?.

4. Conclusion.

Introduction

The role of the vascular access coordinator (VAC) is a highly specialized role, it has been developed because of the complexity of hemodialysis vascular access and the episodic nature of the complication that arise over time.

Why the Need for Vascular Access Coordinator?

Because of:

1. “Creation, Preservation and maintenance of adequate

vascular access for patients with end stage renal failure is

critical to the successful outcome of hemodialysis”

CARI Guidelines

evidence-based project 1999 .to improve the quality of care and outcomes

Australian and New Zealand

Why the Need for Vascular Access Coordinator?

2. Increase morbidity:

20-30% of HD patients hospitalization is due to

VA creation or problems.

- Secondary access creation

- Declotting

- Revision

- CVC insertion

Hakim RM, Breyer et-al Effects of dose of dialysis on morbidity and mortality

Centers for Medicare & Medicaid Services: 2003 Annual Report

Why the Need for Vascular Access Coordinator?

3. Increase cost.

The cost of vascular accesses maintenance is

$18,000/pt. /year

- CVC $6000/year.

- Fistula $2800/year

- Graft $6300/year

Healthcare system – Medicare USA data 2006

Why the Need for Vascular Access Coordinator?

Toronto Hospital Study 1999: When a full-time vascular access coordinator was responsible

for all aspects of vascular access care:

1. The vascular access Cost was a significantly reduced.

2. Hospitalization length Reduced,

KALMAN P.G(1) POPE m(1) et al

Why the Need for Vascular Access Coordinator?

Allon M, Bailey R, Ballard et al. Feb 1998:

• To improve outcomes and reduce the cost of hemodialysis access procedures a multidisciplinary approach was developed, involving nephrologists, access surgeons, radiologists, and A full-time dialysis access coordinator

Department of Radiology, University of Alabama at

Birmingham, USA. mallon@nrtc.dom.uab.edu 1998 Feb

Why the Need for Vascular Access Coordinator?

The major changes were:

1. Native A-V fistula construction in new dialysis patients increased from 33% to 69%.

2. Elective arteriovenous (A-V) grafts was changed from a three-day inpatient hospitalization to outpatient procedure. The A-V grafts increased from 16% to 81%.

3. Surgical complications of new A-V graft was decreased from 25% to 11%.

Department of Radiology, University of Alabama at Birmingham, USA. mallon@nrtc.dom.uab.edu 1998 Feb

Why the Need for Vascular Access Coordinator?

The major changes—cont

4. Clotted grafts approach was changed from an inpatient surgical procedure to an outpatient radiological procedure. The success rate of graft declots increased from 48% to 69%

5. Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year.

Department of Radiology, University of Alabama at Birmingham, USA. mallon@nrtc.dom.uab.edu 1998 Feb

Why the Need for Vascular Access Coordinator?

Study conclusion: • A full-time VA. Coordinator with multidisciplinary approach

markedly reduced in:

- access surgical complications

- vascular access failures.

These improvements occurred despite a marked decrease in:

- hospitalization

- cost.

Department of Radiology, University of Alabama at

Birmingham, USA. mallon@nrtc.dom.uab.edu 1998 Feb

What is the Role of the Vascular Access Coordinator?

Communications:

VAC acts as a link between Nephrologists, Surgeons, Radiologist & patients/Family to:

• Facilitate early access placement. • Emphasizing on fistula placement whenever possible.• Accommodate radiology intervention.

What is the Role of the Vascular Access Coordinator?

Communications—cont:

Communicate with hospital staff & discuss issues related to vascular access problems:

- Infection.

- Cannulation.

- Clotting.

What is the Role of the Vascular Access Coordinator?

Education:

a. Patients/ family education.

Patient & family education should start early when GFR is <30ml/min (CKD Stage 4)

• Explain to the patient/ family the modality of treatment such as:

- kidney Transplantation.

- Peritoneal Dialysis

- Hemodialysis

What is the Role of the Vascular Access Coordinator?

a. Patients/ family education—cont

• Educate patients to “Save Their Veins”

• Explain to the Pt./Family the value of AV Fistula creation even if patient chooses PD..

• Answer their questions Patients often have difficulty accepting vascular access creation.

What is the Role of the Vascular Access Coordinator?

a. Patients/ family education—cont

• Encourage the patient to bring a family member and/or friends they can :

- provide emotional support.

- Primary care providers.

- Transportation.

What is the Role of the Vascular Access Coordinator?

b. Staff education:

• To save the patients Veins: avoid veins puncture • Vascular access care: post Op care pre & post HD VA. Care

• Cannulation technique & VA. assessment

• Prevention of access infection: following sterile/aseptic technique

What is the Role of the Vascular Access Coordinator?

Develop Critical Pathway:

What is the Role of the Vascular Access Coordinator?

Develop a critical pathway –cont :

In Vanderbilt University Medical Center critical pathway was followed for 18 months, after critical pathway :

1. The outpatient access procedures were increased by 95%

2. The cost was decreased to $4,000 and $5,000 from $10,000 to $20,000

Vanderbilt University Medical Center1997 Feb;24(1):70-6; quiz 77.

What is the Role of the Vascular Access Coordinator?

Ongoing monitoring and surveillance.

• perform vascular access assessment.

• Follow surveillance guidelines.

What is the Role of the Vascular Access Coordinator?

• Inspection

• Palpation

• Auscultation

• Examine for Erythema, swelling, gangrene, aneurysm formation, collaterals

• Feel for intravascular pressure, • Check for quality of pulse/thrill• Check for elevated temperature• Check for pain caused by finger pressure.

• Check for low-frequency bruit with systolic & diastolic component

• Examine for high-frequency bruit—due to stenosis

Vascular Access assessment

What is the Role of the Vascular Access Coordinator?

Flowing Surveillance Guidelines:

• Monthly access study.

• Access study post radiology/surgical intervention

• Baseline Study: >600 ml/min AVF > 500 ml/min AVG

• Repeat access study if there is a drop in access flow.

• Send Pt. for radiology intervention if access flow trend dune by 25%.

What is the Role of the Vascular Access Coordinator?

Flowing Surveillance Guidelines:

What is the Role of the Vascular Access Coordinator?

Documentation:

• Type of vascular access: AVF/G/CVC • Access Problems: -Cannulation -Infection -Clotting

• Changes in arterial / venous pressure.

• Prolonged bleeding

• Decrease in Kt/v and URR

What is the Role of the Vascular Access Coordinator?

Documentation—cont

• Change in bruit/ flow

• Swelling, redness, pain.

• Patient with CVC:

creation date—location—flow

infection history—location—date—action

catheter dwell volume—type

What is the Role of the Vascular Access Coordinator?

Tracking Access History. • Surgical access history: - Primary access—date—type—location—MD - Secondary access—number of accesses - Thrombectomies—date—frequency—factors

• Radiology access history: - angiography—angioplasty - throbolisis—emobilization

• Infection history: - date—site—action taken

What is the Role of the Vascular Access Coordinator?

Organize & maintain continues quality improvement (CQI) that involves all member of VA team:

• Nephrologist.• Vascular access surgeon.• Interventional Radiologist.• Dialysis staff.• Vascular access coordinator.

What is the Role of the Vascular Access Coordinator?

Participate in quality assurance (QA) for vascular access:

Based on QA evaluation — fined a room for improvement

implement new protocols

putting guidelines

What is the Best Outcome

The Best Outcome is:• Patient starts first dialysis treatment with functioning AV

fistula.

• If no access in place for dialysis:

- Tunneled hemodialysis Catheter + AV fistula placed.

- If patient choose peritoneal dialysis AV fistula, tunneled

catheter + PD Catheter placed.

Fistula-First

Dooqi Guidelines

What is the Best Outcome

• Minimize CVC insertion—increase AVF creation

• Protect AVF until maturation.

• Reduce hospitalization by reducing access comorbidity: infection—clotting.

• Reduce VA cost.

• Minimize missed treatment by keeping the access patency.

Conclusion

Vascular Access coordinator does play a beneficial role in helping patients, nephrologists, surgeons and dialysis staff in the coordination of VA access creation, care & monitoring.

Vascular Access Coordinator play a central role in coordination of the services necessary to maintain patent vascular access and make it a truly-Life-Line for each dialysis patient.

• It would be possible for every dialysis facility to have a designated staff member (preferably RN) who would stay on-a-top of vascular access needs of ESRD patients.

Conclusion

“I believe the intrinsic value of a vascular access coordinator is not just in the individual talents and commitment, but in the collaborative commitment and support from the team. The question is not, “can we afford to implement the role of the vascular access coordinator?” but “ are we willing to form the team?” and if so, “ How can we afford Not to have a vascular access coordinator?”

LESLEY C, DINWIDDIE, MSN,RN,FNP,CNN

The Value of a Vascular Access Coordinator

Nephrology & Issues. May 2003

University of North Carolina

References

• www.esrdnet17.org/QI/c1b.pdf Vascular Access Coordinator Role

• www.esrdnet15.org/QI/jobdes.pdf Example: Job Description Vascular Access Nurse Coordinator

• www.fistulafirst.org/pdfs/NNI_dinwiddie.pdf• Barelay.C Role of a dialysis Access

Coordinator(Vascula Access Manager) Kaiser Permante.USA • The Value Vascular Access Coordinator