Duc Vascular Access Monitoring
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  • 1. Duc Vascular Access Monitoring Y. Foli Sekyema, MD Danville Urologic Clinic Marc Spring Council Meeting @ Fairfax, VA 05/02/2003
  • 2. The Access Problem
      • Major cause of Morbidity
      • Many Lost HD Hours
      • Most Hospitalizations for HD pts
      • High $ Cost to Health-Care System
      • Best type Least Used in US-- AVF
  • 3. Access Complications
    • Infection :
          • Poor Personal Hygiene (Patient, Dialysis Staff)
          • New or Inexperienced Dialysis Staff
    • Access Stenosis
    • Access Thrombosis (Clotting)
    • Others
  • 4. kDOQI Recommendations
      • increase # of native avf (fistula) -- early is key!!
      • detect access dysfunction prior to clotting
      • QA program to
        • detect at-risk accesses
        • track complication rates
        • implement efforts to maximize longevity
        • dialysis staff education
        • patient education
  • 5. DUC Vascular Access Experience
  • 6. Danville Urologic Clinic
  • 7. Danville Urologic Clinic
    • Practice of 7 nephrologists and 6 urologists
    • 4 HD units
      • Danville, VA (~190 pts)
      • South Boston, VA (~85 pts)
      • Martinsville, VA (~30 pts)
      • Yanceyville, NC (~30 pts) -- [UNC]
  • 8. DUC Vascular Access Analysis
    • AV Fistula -- 37% (kDOQI: >40%)
    • Graft -- 39%
    • PermCath -- 24% (kDOQI: <10%)
      • Bacteremia rate ~4%-11% (1%-17%)
  • 9. Team/Resources
    • Vascular Surgeons
    • Interventional Radiology
    • Nephrologists
    • HD Head Nurses
    • Pt Care Co-Ordinator
    • Vascular Access Co-Ordinator
    • Quality Assurance Co-Ordinator
  • 10. Monitoring/ Surveillance
    • Access Development
    • Infection Rate
    • Thromboses
    • Other Complications
  • 11. Benefits of Access M/S
    • Reduce Incidence of Thrombosis
    • Extend Access Use-Life
    • Reduce Time Lost from HD
    • Reduce Patient Morbidity/ Hosp
    • Improve Quality of Life
    • ?Reduce Health-Care Cost
    • Indirect Benefit to Practice
  • 12. Infection Control Procedures
      • Catheter care/ manipulation
            • examine cath site q hd for infection
            • change dressing q hd
            • surgical mask/face shield (patient, staff)
            • clean/fresh gloves
            • soak hub caps 3-5min 10% Povidone iodine
      • clean technique for needle cannulation
            • pt wash access site w antiseptic soap x5min
            • 70% etoh (1 min, immediate)
            • 10% povidone iodine (2-3min, let dry)
            • clean/fresh gloves
            • rotate sites!
  • 13. Surveillance Technology
      • Intra-Access Flow -- Transonics
      • Static Venous HD Pressure
      • Dynamic venous HD Pressure
      • Access Recirculation -- Urea Conc
      • Access Recirculation -- Dilution
      • Unexplained Decrease Delivered HD
      • Doppler Ultrasound
      • Physical Exam of Access
        • arm swelling, prolonged bleeding, increased +venous pressure or -arterial pressure
  • 14. Transonics Flow
      • PTFE/ GRAFT
        • once a month
        • if stable, every 2-3mo
      • FISTULA
        • every 2-3mo
      • FLOW
        • <600 ml/min -- fistulogram
        • 600 - 1000ml/min q mo w 15% -- fistulogram
        • >1000ml/min
        • 25% decrease
  • 15. Tracking Forms
  • 16. Schedule
    • Infection Incidence -- daily
    • Developing Access -- q wk
    • Vasc Access Conference -- q mo
    • Transonics Flow -- q 1-2 mo
    • Team Meeting -- q 2-3mo
    • External Expertise -- periodic
        • Dr. Gerald Beathard
        • Dr. W. G ‘Sandy’ Schenk III, UVA
  • 17. Utility
        • Decreased Transonics Flow-- Fistulogram
        • Access Infections?
        • Increased Attention to Detail by HD Staff
        • Identify Needs for More Training
        • Identify Potential Physician Trends
        • Identify Potential HD Facility Trends
        • Allow Objective Comparison with Regional and National averages
        • Resource for policy reviews + to Improve Quality of Care