List of interventions

Taken from the CMS QIP AVF template for Increasing AVFs in Hemodialysis Patients

11/01

There are several interventions that the following groups can use to help improve their systems:

Nephrologists

¨ Establish collaborative working relationships and regular communication with surgeons in the community who recognize the importance of appropriate access placement, always placing an AVF as the primary access, if at all possible.

¨ Logs can be used to monitor patients with impending renal failure and ensure that they are referred and seen by vascular surgeons in ample time for an AVF to mature.

¨ Assess the patient’s arm veins manually or by Doppler duplex study before an access is placed to help in determining where an AVF should be placed and to have as a baseline measurement.

¨ Monitor the education provided to all patients upon the diagnosis of CRF.

¨ Educate and strongly encourage patients to seek AVF as a permanent access.

¨ Develop reminders in the form of chart stickers and posters to serve as “alerts” to the timing for education and/or referral.

¨ Pamphlets can be included with consultation letters sent to referring primary care physicians regarding the recommended timing for nephrology referral, protecting the arm for future access sites, and access referral and the timing of dialysis initiation.

¨ Develop a form for nephrologists to use that would indicate that a patient is being referred to a surgeon for AVF placement. This would include instructions for the surgeon to call the referring nephrologist to discuss any patient in whom an AVF is not thought plausible.

¨ Develop a referral form that would go to the intervention radiologist from the nephrologist and/or the surgeon relaying the patient information needed to do a specific intervention. The form could include a checklist and place for documentation of the results of the intervention. This would help ensure that the vascular access mapping done will provide the information necessary to make a determination about the best type and location of access for each referred patient.

¨ Provide pre-ESRD patients with cards they can carry in their wallets or purses that alert health care providers for their need to preserve arm veins, reminding them to draw blood and start IVs in the patient’s hand if at all possible. Current patient cards would alert these healthcare providers to use the arm opposite the one with the access in it for drawing blood or to start IVs and to never use anti-cubital veins.

¨ Lead and participate in efforts to have staff consistently well trained in cannulation techniques necessary for working with new and troublesome AVFs

Surgeons

¨ Utilize pre-surgical (baseline) vein mapping to maximize access outcomes.

¨ Logs can be used to monitor education provided to patients both pre-operatively and post-operatively.

¨ Provide a diagram of the access post-surgically to the dialysis facility for the patient’s vascular access record.

¨ Use of reminder stickers or cards to help the surgeon or the surgical staff remember to send a copy of the operative report to the dialysis unit for the VA record.

¨ Develop a referral form for the intervention radiologist from the nephrologist and/or the surgeon relaying patient information needed to do a specific intervention. The form could include a checklist and place for documentation of the results of the intervention. This would help ensure that the vascular access mapping done would provide the information necessary to make a determination about the best type and location of access for each referred patient.

¨ Provide pre-ESRD patients with cards they can carry in their wallets or purses that alert health care providers for their need to preserve arm veins, reminding them to draw blood and start IVs in the patient’s hand if at all possible. Current patient cards would alert these healthcare providers to use the arm opposite the one with the access in it for drawing blood or to start IVs and to never use anti-cubital veins.

¨ Act as a resource for vascular access education for dialysis facility staff, and participate in quality improvement projects.

Intervention radiologists

¨ Provide or document on a tool that facilitates communication between nephrologists, surgeons and the radiologist. This tool will provide important patient information to all.

¨ Provide a checklist and place for documentation of the results might ensure that vascular access mapping provides information that the surgeon needs to make the best decision for each patient regarding the type and location of access to be placed.

Dialysis Facilities

¨ Utilize logs to monitor patient education efforts.

¨ Utilize a log to ensure that the facility staff is consistently educated about dialysis access issues.

¨ Develop, modify, or adopt protocols and algorithms for the management of new or fragile AVFs, the use of clamps, preservation and maintenance of existing AVFs.

¨ Ensure that the access-monitoring program includes provisions for prompt follow-up of abnormal findings.

¨ Develop helpful “tips and techniques” for patients to refer to regarding their new and developed access maintenance and care. Refer to these in your day-to-day conversations/evaluations with the patients.

¨ Develop a self-cannulation program and inform the patients of the benefits of this program to preserve their access.

¨ Designate a Vascular Access Manager who can serve as liaison between the various individuals involved and can oversee the implementation of programs in that facility.

¨ Provide on-going education for patients on preventive measures that increase access longevity. Encourage patients to seek AVF as a permanent access if they do not have one. Use posters, newsletters, patient education seminars, patient support group speakers, and videos to continually reinforce the self-care message.

Hospitals

¨ Establish protocols for IVs, central lines and blood drawing that maximally protect future access sites in patients with renal failure or impending renal failure.

¨ Establish protocols for IVs, central lines and blood drawing that maximally protect the current and potential secondary access sites in patients who currently have an access in place.

¨ Along with these protocols, reminders for the charts, the doors to the patients’ rooms, the bedsides, and /or on the patients themselves could be used.

¨ Provide dialysis units a copy of all surgical and intervention reports to help update the patient’s chart and/or access log.