Vascular access

The KidneyCare Audit

The challenge of vascular access –Renal National Service Framework

Standard 3“All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

Overall 13,343 (77%) of prevalent patients were having dialysis therapy delivered by definitive access.Centres varied from 52% to 95%.For HD patients only, definitive access was used in 69%, range from 44% to 94%.

Renal Registry Vascular access survey – incident cohort

Patient survival, HD starters, by access type

0%

20%

40%

60%

80%

100%

0 50 100 150 200 250 300 350 400Days

Su

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rob

ab

lity

AVF+AVG

Temp line + Tunnel line

Infection: aetiology

Morbidity and mortality

Causes of death in dialysis patients

USRDS 1996 Annual Data Report

10.2%16.9%

16.1%5.5%

12.6%

3.5% 15.6%

19.6%

Venous catheters and morbidityVenous catheters and morbidityUK Vascular access survey 2005UK Vascular access survey 2005

No of venous access vs Staph aureus episodes

R2 = 0.4035

0

20

40

60

80

100

120

0 50 100 150 200

Total venous access (n)

No of venous access vs Inpatients

R2 = 0.5193

0

10

20

30

40

50

60

0 50 100 150 200Total venous access (n)

Year 2004: 1547 Staph. Aureus infections (462 (29%) related to MRSA)in haemodialysis population

One third of bed days in HD population related to catheter related problemsCost of a single episode of bacteraemia: £6209

Infection pathways and access

Further information

• www.ic.nhs.uk• kidneycare@ic.nhs.uk

The National Kidney Care AuditThe National Kidney Care Audit

Audit Question Standard/Best Practice Reference Associated Measures Impact of non-achievement

Does the proportion of patients starting haemodialysis with functioning permanent access meet the Renal Association and Vascular Society

Guidelines for permanent vascular access?

No patient on dialysis, including those patients who present late, should wait more than four weeks for fistula construction

(Clinical Practice Guidelines for Haemodialysis, UK Renal Association, 4th Edition, 2006)

Number of days spent in hospital to establish first functioning permanent vascular access

At risk of infection especially MRSA

Number of operations and other interventions (eg. angioplasty, revision surgery) to establish first functioning permanent

access.

No time to prepare or make informed choice, educate and empower

 A proxy for failure to pre-emptively transplant list and

therefore long await time for transplantation

Patients should undergo fistula creation between 6 and 12 months before haemodialysis is expected to start to allow time

for adequate maturation of the fistula or time for a revision procedure if the fistula fails or is inadequate for use (source as

above)

Percentage of catheter starters who have functioning permanent access established within three and twelve months

Repeated admissions for percutaneous lines

Increased crash landing

At least 65% of patients presenting more than three months before initiation of dialysis should start HD with a usable native

Arteriovenous fistula (source as above).

Percentage of Haemodialysis patients starting with permanent access

Inadequate dose of dialysis delivered

Percentage of Haemodialysis patients starting with catheter access

Poor correction of metabolic abnormalities - legacy of poor care impact on long term adaptation to dialysis and adverse

clinical outcomes

Checksum of these two measures should equal 100%  

 Percentage of Haemodialysis patients starting with temporary access due to late referral (known to the renal service for less

than 3 months before starting dialysis)

Higher ESA (erythropoietin stimulating agent) requirements

Worse transplant outcomes

What are the hospital-acquired infection rates associated with vascular access in the maintenance of the haemodialysis population and how

does this compare with the national average and the best performance?

No avoidable HCAI in dialysis patients and an overall reduction in MRSA by 50 % by 2008 (Department of Health)

Percentage of RRT patients diagnosed with hospital acquired infection including complications relating to vascular access,

eg. line-related sepsis, clotted graft

The number of Staphylococcal systemic infections per annum varies from 2.3 to 33.8, average 13, the figures for

MRSA alone being from 0 to 21.5, average 4.

ContentContent

• Patient Transport• Vascular access

– Stream 1 Prevalent Patient Access Data– Stream 2 Comorbidity

• In patient utilisation• Infection

– Stream 3• Process measures (based on NRDS)

Part 1:Prevalent recordingPart 1:Prevalent recording

April 07 – Mar 08 196 (4.4) 188 (4.2) 4438

o Not shared 29 (15) 29 (15)

o Shared, not completed 78 (40) 70 (38)

o Shared & completed 89 (45) 89 (47)

MESS data England

Modality

Modality of dialysis No. (%) MRSA bacteraemia

Haemofiltration 3 (3.4)

Haemodialysis 84 (94.4)

Unknown 2 (2.2)

All 89 (100)

Table 2: Modality of dialysis in patients in established renal failure where record shared and completed

Access type

Renal access type No. (%) MRSA bacteraemia

AV- simple 23 (26)

AVG 3 (3.4)

Non-tunnelled – femoral 6 (6.8)

Non-tunnelled - jugular 4 (4.5)

Tunnelled – femoral 5 (4.7)

Tunnelled - Jugular 47 (53)

All 89 (101.9)

Table 3: Type of renal access in patients in established renal failure where record shared and completed

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AVF - simple AVG Non-tunnelled venous catheter - Femoral/other

Non-tunnelled venous catheter - J/SC Tunnelled venous catheter - Femoral/other Tunnelled venous catheter - J/SC

Not completed

Linkage with Renal Registry

Infection• Bacteraemia

– Staph. Aureus– ?CDT

In patient stats• Bed utilisation• Admissions by code

– Bacteraemia– Pneumonia– Endocarditis– Spinal Abscess

Arteriovenous fistula

Date of AVF The date that the arteriovenous fistula was constructed

To monitor use of arterio-venous fistula Date format

Side of AVF The side of the body used for construction of an arteriovenous fistula

To identify the site used for arteriovenous fistula construction

n

01 Right 02 Left

Site of AVF The artery and vein used for construction of arteriovenous fistula

To identify the site used for arteriovenous fistula construction

n

01 Snuff box 02 Radiocephalic 03 Brachiocephalic 04 Brachiobasilic 05 Ulnacephalic 06 Radioulnar 07 Popliteal to long saphenous 08 Other

Drugs used to prevent thrombosis

The drugs prescribed to prevent thrombosis To monitor use of arteriovenous fistula n

01 Aspirin 02 Dipyridamole 03 Clopidogrel 04 Warfarin 05 Other

Blood pump speed The rate of blood flow through the dialyser during average dialysis

To determine whether there is adequate flow n

01 <100 ml/min

02 100-200 ml/min

03 200-300 ml/min

04 300-400 ml/min

04 >400 ml/min

Procedure

Recurrent dataComplication date Date of development of a complication of

arteriovenous fistulaTo monitor morbidity arising from AVF formation

Date format

Complications Comlications of arteriovenous fistula To monitor morbidity arising fom AVF formation

n

01 AVF stenosis 02 AVF infection 03 AVF aneurysm 04 AVF pseudoaneurysm 05 AVF rupture 06 AVF thrombosis 07 Steal syndrome 08 Heart failure

Surveillance date Surveillance of AVF with one of a number of techniques

To monitor arteriovenous fistula Date format

Surveillance technique Method used to monitor AVF To monitor arteriovenous fistula n

01 Clinical examination 02 Reduction in dialysis adequacy 03 Static venous pressure measurement 04 Blood flow rate assessment 05 Recirculation measurement 06 Duplex ultrasonography 07 Fistulography 08 Other

AVF revision Date of revision of arteriovenous fistula To monitor need for revision of arteriovenous fistula

Date format

AVF revision Type of revision of arteriovenous fistula To monitor revision of arteriovenous fistula n

RADIOLOGICALa. To Fistula 01 Angioplasty 02 Angioplasty with cutting balloon 03 Angioplasty with stent 04 Thrombolysis 05 Otherb. To central veins 06 Angioplasty 07 Angioplasty with cutting balloon 08 Angioplasty with stent 09 Thrombolysis 10 OtherSURGICAL 11 Surgical corection with jump graft 12 Surgical correction with vein patch 13 Banding of arteriovenous fistula 14 Thrombolysis of arteriovenous fistula 15 Ligation of arteriovenous fistula 16 Evacuation of haematoma 17 Pseudoaneurysm repair 18 Refashioning of arteriovenous fistula 19 Drill procedure for STEAL syndrome 20 Other

Start recurring group (for AVF revision)

Start recurring group (for surveillance)

End recurring group (for surveillance)

Start recurring group (for complication of AVF)

End recurring group (for complication of AVF)

What is needed from units

• Prevalent dataset– Electronic coding of access type at each session– Target 80% of units

• Comorbidity datset– HES and HPA linkage

• Process measures– Pilot sites– Use NRD (all ready finished a small pilot)