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The Vascular Access Coordinator Role:
An Interview With Donna Carlton
Donna Carlton, BSN, RN, is
Nephrology Dialysis Access Coordinator, Department of Medicine,
Nephrology Section, University of Alabama-Birmingham (UAB) Health
Services Foundation, Birmingham, AL. She is a member of the Hazel
Taylor Chapter of ANNA.
Betsy King, MSN, RN, CNN, is
Clinical Service Specialist, DaVita, White Plains, NY. She is the
leader of ANNA’s hemodialysis SIG, and a member of the Northeast
Tri-State Chapter of ANNA.
| In
this article, the the role of the vascular access coordinator role is
examined in detail through an interview with Donna Carlton, BSN, RN,
Nephrology Dialysis Access Coordinator at the University of
Alabama-Birmingham (UAB) Health Services Foundation. Carlton discusses
how this role evolved at UAB, the challenges and rewards affiliated
with the role, and how the Vascular Access Coordinator has
successfully integrated into the UAB access program. This interview was
conducted by Betsy King, MSN, RN, CNN, Hemodialysis Special Interest
Group (SIG) leader for the American Nephrology Nurses’
Association. |
Role of Vascular Access Coordinator
Q: What is a Vascular Access Coordinator?
A: This
really depends on the role of the person to whom you are responsible
and the role description given to the coordinator. Some coordinators
may only schedule procedures if a surgeon or service performing
procedures employs them. They may or may not follow up on patient
outcomes. Other coordinators may be employed by a corporation and be
responsible for following an identified patient caseload. They will be
able to see the outcomes for the outpatients at their dialysis clinics
but may have limitations on obtaining reports and feedback from the
procedures. Our set-up is unique at the University of
Alabama-Birmingham (UAB), where we have access to information at the
medical center and our dialysis clinic information. We follow patients
from the chronic kidney disease (CKD) clinic, hospital admissions, and
the dialysis clinics.
Q: How was the role established at UAB?
A: One
of our nephrologists believed the access scheduling and follow-up
should be centralized and managed in one area instead of each unit or
physician having a different person doing the scheduling.
Q: Are you involved with continuity of care from the hospital setting to dialysis clinics?
A: When
information is shared with us about the dialysis patient, we share this
with the dialysis unit. Since we also follow an antibiotic lock
protocol for catheters here at UAB we very often share information
about cultures and antibiotics between/among the dialysis unit(s) and
our hospital staff. We communicate with several areas as our patients
move through the access process. The information is shared with anyone
involved in their care such as the CKD clinic staff, nurse
practitioner, nephrologists, and dialysis units. Since all calls about
access come through our office, it is convenient and easy to forward
information to all caregivers involved.
History of Role at UAB
Q: How long has this role been a part of the nephrology program at UAB?
A: We started our access program here at UAB in 1996.
Q: Were you the first access coordinator? If so, what were some of the barriers you encountered in establishing this role?
A: I
was not the first coordinator; a physician’s assistant (PA) started
this role at UAB. Our nephrologist set up meetings with the different
departments that would be involved in this role (e.g., surgeons,
radiologists, nephrologists, and dialysis unit managers) to make them
aware of the new role. The PA then had to introduce himself to the
other staff involved in making this role work, that is, staff and
secretaries in all of these areas. When I assumed this position prior
to the PA’s retirement in 1998, he took me on walking rounds to meet
the key people I might need to contact to urgently schedule something.
Q: What were some of the immediate benefits to patients, staff, and physicians?
A: An
immediate benefit to all is one contact number to obtain any
information on patients for whom access care has been provided.
Benefits realized later are in the outcomes, for example, increased
fistula placement, faster follow-up on problems noted by the
radiologists, and the ability to identify specific problems related to
vascular access that need to be addressed.
Common and Lesser-Known Functions of Role
Q: List some of the common functions of this role.
A: The
person in this role acts as a liaison among the nephrologists,
surgeons, radiologists, dialysis nurses and the patients. All access
calls come through our office. I schedule all access appointments and
provide relevant clinical information to radiology and surgery for
appointments that are scheduled. It also includes follow-up on all
vascular access procedures performed and relaying this information to
the nephrologists and dialysis units. Maintaining a prospective
computerized database allows us to track all vascular access procedures.
Q: What are some of the lesser-known functions of this role?
A: We
do whatever it takes to get patients in for appointments, for example,
call them at home, call their children, call them at the dialysis unit,
and send messages to the clinics at which they will be seen. We
occasionally encounter obstacles in patients getting to access
appointments. Our calls and involving other caregivers in talking with
patients about why they need a procedure can sometimes yield a positive
result. It is that level of involvement that can make a difference.
Access Management and Medical Records
Q: What are some of the changes in access management that can be associated with this role?
A: We
have been able to streamline the scheduling process for vascular access
procedures. We can make a rapid implementation change in procedures
since it is just the coordinator involved in the scheduling process. We
do not need to have lengthy education sessions about changes in our
scheduling process since the actions only involve the decision making
of an individual. The coordinator can provide a uniform approach to
vascular access problems, rapidly assessing outcomes and efficacy of
changes. Communication has improved among the disciplines; for example,
the surgeons just call us instead of trying to page a doctor who may be
unavailable. We can immediately take care of issues or relay this
information to the responsible physician and dialysis unit.
Q: How are medical records kept? Are procedure records routinely sent to dialysis facilities?
A: We
do not keep any records in our office. The access database is on a
secured server connection. Any medical records we need access to are
available on the secure web site at UAB.
Cost/Benefits of Role
Q: Are you aware of any cost/benefit studies of this role?
A:
While I do not have data reflecting actual or potential cost savings I
do know that we have been able to decrease hospital admissions, reduce
graft thromboses, and increase the rate of fistula placement. We
recognize the biggest cost now is in the hospital admission, so any
savings there are likely to be significant.
Q: Do you have a role in educating facility staff on cannulation techniques/concerns?
A: I
do not have a direct role since the physicians employ us and our
patients are treated in one of the dialysis corporations’ facilities. I
do assist with difficult cases in our acute unit since our office is
right across the hall. We also see patients in our nephrology clinic
and make recommendations. I have provided in-service education at the
dialysis units in regards to other access concerns.
Challenging and Rewarding Aspects of Role
Q: What is the most challenging aspect of this role?
A: The most
challenging part is to stay on track in spite of all the distractions
and not become overwhelmed if a lot of issues are presented at one time
from different areas. It can get very hectic since we receive
information from several areas. It is very important to prioritize the
problems presented and work through the list.
Q: What is the most rewarding aspect?
A: I enjoy the
success of getting catheters removed after a permanent dialysis access
is in use. Knowing the patients’ outcomes will improve makes it worth
the challenges I face day to day.
Q: What are common misperceptions of this role by facility staff and/or physicians?
A: We are
constantly educating new staff on our role here at UAB and changing the
practice of paging a doctor for any problems. This usually resolves
after meeting with the staff and explaining the services we can provide.
Role in Access Placement
Q: Are you involved with pre-ESRD access placement?
A: We are called about all new patients that need access placement from the clinics.
Q: In this role, are you involved in peritoneal dialysis access placement/intervention?
A: We arrange for
patients to see a surgeon for peritoneal dialysis catheter placement.
We schedule other appointments if intervention for complications is
required.
Q: What are some of the interventions that facilities without a VA coordinator can take to improve vascular access outcomes?
A: The most
important step is to work out a tracking method for all access
procedures. Patients with catheters are a priority for access
appointments and follow-up on patients who have an access that is
maturing is imperative. The biggest pitfall is losing patients in
follow-up. Maintaining communication with nephrologists and nurse
practitioners to begin access planning early for CKD patients is
paramount.
Role in Follow-up
Q: What is your role in follow up?
A: The
CKD clinic or dialysis unit is to notify us if there are issues with
fistula development like extreme swelling, drainage, or fever with
fistula/graft in place. The expectation is for a weekly evaluation of
the fistula by the dialysis unit. I have provided in-service education
at the dialysis unit and CKD clinic about assessment for development of
fistulas. Our work with fistulas is noted in the “Fistula First”
initiative supported by the End Stage Renal Disease Networks (Allon
& Robbin, 2002; Jennings & Spergel, 2005). In this study, the
access coordinators saw patients with fistulas after an ultrasound had
been done but we were blinded to the ultrasound assessment until after
we had done our evaluation of a fistula (Allon & Robbin, 2002).
These assessments were scheduled 4 weeks after fistula creation. The
results of these assessments were compared with the outcomes of
successfully cannulated fistulae at least 6 times for dialysis. We
found that a diameter of greater than 0.4 cm and blood flow of greater
than 500 ml were indicators of successful fistula use. This was found
to be true with 70% of the fistula when these indicators were met. Lisa
Bimbo and I were the nurses in the study (cited as “an experienced
nurse”) along with a nephrologist’s subjective physical examination. I
was told our exam correlated with the ultrasound report in accuracy.
Since subjective assessments can be hard to duplicate, having clear
objective indicators such as the ultrasound for a successful fistula
can be very helpful.
Summary
In
summary, the access coordinator is at the center of our access program
at UAB. The coordinators can make decisions based on the calls we
receive from the nursing staff and reports obtained from procedures.
The ability to relay information to the entire team rather than simply
data entry staff, makes us a central focal area for our access team.
This type of model is working to help us achieve better patient
outcomes. We provide many services but the most important is follow-up.
As a result, we are able to achieve optimal outcomes for our patients.
References
Allon,
M., & Robbin, M.L. (2002). Increasing arteriovenous fistulas in
hemodialysis patients: Problems and solutions. Kidney International,
62, 1109-1124.
Jennings, W., & Spergel, L. (2005). Fistula first. Retrieved October 30, 2005 from http://www.fistulafirst.org/
| The Practice Issues in Nephrology Nursing department
focuses on issues identified by ANNA's Special Interest Groups. Address
correspondence to: Karen Robbins, Associate Editor, through the
Nephrology Nursing Journal; East Holly Avenue/Box 56; Pitman NJ
08071-0056; (856) 256-2320, or by emailing her at kcr_nnj@yahoo.com.
The opinions and assertions contained herein are the private views of
the contributors and do not necessarily reflect the views of the
American Nephrology Nurses' Association. |
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