Question: We are constantly dealing with inadequate blood flows from percutaneous central venous catheters or thrombosed AV grafts in our dialysis unit. What is being done about this problem?

Answer:  In an effort to address the long standing problems associated with vascular access, in April 2004, the Centers for Medicare and Medicaid Services(CMS) launched a national initiative to increase the use of native arterio-venous fistulas (AVF) in patients requiring hemodialysis. This program is known as “Fistula First” and is being funded by CMS and administered through the 18 ESRD networks. The primary goal is to attain the rate of fistula use recommended by the National Kidney Foundation’s Dialysis Outcomes Quality Initiative (K/DOQI). The recommendation suggests AVF placement in 50% or more of new patients and to maintain an AVF rate of 40% or more for those already on hemodialysis (NKF, 1997). This program and the recommendations have been endorsed by the American Nephrology Nurses Association (ANNA).

The renal community recognizes that the AVF is the preferred vascular access. Fistulas are less prone to thrombosis and infection and 65%-75% of fistulas continue to function after 3 years (NKF, 1997). Several surgical options are available to create an AVF, but late referral and the lack of surgical expertise often hamper the success of AVF placement. In addition, the AVF surgery reimbursement is less than that of a graft, and the fistula creation is technically more complicated and time consuming. It has also been stated that dialysis clinic staff are not properly trained to cannulate and care for fistulas (Neumann, 2004).

Despite the barriers to achieve the goals set forth by these initiatives, one network had already accomplished the objectives, reinforcing the fact that the goals were attainable. As a result, based on the best practices, 11 changes in practice have been recommended to assist dialysis facilities in reaching the Fistula First goals.

1. Routine CQI review of vascular access. Establish a vascular access CQI process that ideally would include representatives from all disciplines, including surgeons and interventionalists.
2. Timely referral to nephrologists. Referral prior to CKD stage 4 allows patient education, having patient protect the designated arm from venipunctures, and timely referral to the surgeon.
3. Early referral to surgeon for “AVF only” evaluation and timely placement. Allows time for vein mapping and maturation time for the vascular access.
4. Surgeon selection based on best outcomes, willingness, and ability to provide access services. Ideally outcomes data will be tracked.
5. Full range of appropriate surgical approaches to AVF evaluation and placement. Surgeons utilize current techniques including vein transpositions.
6. Secondary AVF placement in patients with AV grafts. May be considered in those grafts with repeated problems.
7. AVF placement in patients with catheters where indicated.
8. Cannulation training for AVF. Identify most skilled staff and best teaching tools for staff training. Offer self-cannulation option to patients.
9. Monitoring and maintenance to ensure adequate access function. Adopt standard procedures for monitoring, surveillance, and appropriate referral for failing access.
10. Education for caregivers and patients. Continuing education on a routine basis should be provided.
11. Outcomes feedback to guide practice. Track and report vascular access related outcomes on a quarterly basis. (Mid-Atlantic Renal Coalition, 2004).
    

The Fistula First initiative requires commitment and diligence among a multi-disciplinary team in order to be successful. The suggested roles for nurse leadership in this effort include: