Introduction
                     Role of a Dialysis
                     Access                                          ...
Role of the VAM                                        Role of the VAM
                                                   ...
Education of Pre- ESRD                                     AV Fistulas Need to
                         Patients          ...
No Access in Place for
                     Dialysis Start - Options                                      Next Steps:
    ...
What’s Important to                                                              VA Pt tracking tool
                     ...
AV Fistula Readiness
                                                                                                     ...
Wallet card                                        Long Term Care of the
                                                 ...
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Role of a Dialysis Access Coordinator

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Role of a Dialysis Access Coordinator

  1. 1. Introduction Role of a Dialysis Access Goal: Help the Dialysis Community see the value a Coordinator Vascular Access Manager (VAM) can bring as a member (Vascular Access Manager) of the team. Carolyn Barclay, RN, CNN Adapted by 9/18/2006 1 9/18/2006 2 Ideal Renal Team It Takes a Team Renal Pharmacist Patient/Patient’s Family Renal Dietician Nephrologist (office staff) Social Worker Vascular Surgeon (office RN Nephrology Care staff) Managers Interventional Radiology Transplant Coordinator Dialysis Staff Dialysis Access Dialysis Access Coordinator/VAM Coordinator/VAM 9/18/2006 3 9/18/2006 4 Topics of Discussion Topics Role of the Access Coordinator/ Tracking Data VAM Identifying Pre-ESRD population Access Problems: What to report? Education key for Early Referral for Dialysis Access Education Tools for Patients Saving Veins 9/18/2006 5 9/18/2006 6 Role of a Dialysis Access Coordinator 1
  2. 2. Role of the VAM Role of the VAM Collaborates with dialysis unit staff, hospital staff, surgical staff. Provides ongoing patient support, oversight and education related to vascular access. Maintains Access History Facilitates early access placement Participates in QA activities related with emphasis on fistula placement to Access whenever possible. Serves as a resource on Access issues 9/18/2006 7 9/18/2006 8 Early Referral to Early Referral to Nephrologist Nephrologist Screen patients at high risk: Primary Care M.D.’s need Age >60, education Goal is for early fistula creation African-American, We must get patients referred to Native American, Nephrologist before they can be Diabetes, referred to surgeon Hypertension Timing of referrals can improve if Refer to nephrologist if stable or Primary Care M.D. knows when to rising Creatinine >1.5 female, >2.0 refer male Proteinuria > 2 gm/day 9/18/2006 9 9/18/2006 10 Glomerular Filtration When to Refer for Rate Hemodialysis Access Nephrologist should direct when When GFR <30 (CKD Stage 4) and patient chooses hemodialysis, patient gets referred for dialysis nephrologist should refer to surgeon for access. AV fistula consultation. GFR is widely accepted as the Best for AV fistula to be created 6 months to 1 year prior to dialysis start to best overall measure of kidney allow for maturation time. function. Goal should be to avoid hemodialysis GFR Calculator is on Nephron.com catheter whenever possible. If patient is not a candidate for an AV fistula, nephrologist may want to wait until GFR lower before graft placement. 9/18/2006 11 9/18/2006 12 Role of a Dialysis Access Coordinator 2
  3. 3. Education of Pre- ESRD AV Fistulas Need to Patients Be Created Early! Education should start when GFR is Helpful if patient understands process <30ml/min (CKD Stage 4). Referral to surgeon Modality choices need to be presented Ultrasound mapping may be necessary before appropriate access referral can before surgery can be scheduled be made. Important patient have follow-up Consider AV Fistula creation even if post AV fistula creation to monitor patient chooses peritoneal dialysis. development of AV fistula. Educate patients to An AV fistula attempted and not “Save Their Veins” successful should not be considered a failure! An AV fistula attempted is better than a graft. 9/18/2006 13 9/18/2006 14 Provide Realistic Referral for Dialysis Expectations Access Access may take maintenance Vascular access coordinator can angiography, angioplasty, facilitate referral: thrombectomy, revision. Send appropriate patient Grafts clot much more often than records, labs, medication lists, fistulas allergy list to surgeons office. AV Fistulas can be fragile and can infiltrate AV Fistulas can clot - and can be successfully de-clotted. 9/18/2006 15 9/18/2006 16 Referral for Access: Call patient to let them know they Best Outcome: are being referred. Allow them time to ask questions. Patient starts first dialysis treatment with a functioning Follow up: Patients often have AV fistula. difficulty accepting it’s time for an access. VAM acts as liaison between nephrologist and surgeon’s office. 9/18/2006 17 9/18/2006 18 Role of a Dialysis Access Coordinator 3
  4. 4. No Access in Place for Dialysis Start - Options Next Steps: Tunneled hemo Catheter + AV Vein mapping (as necessary) fistula placed, if possible. Graft material only if patient not a If patient wants Peritoneal Dialysis good candidate for AV fistula. an acute hemo catheter + PD Nephrologists could consider use Catheter may suffice until PD of peritoneal dialysis while AV training can start. fistula matures if patient is an appropriate candidate for PD Case example 9/18/2006 19 9/18/2006 20 Reporting Access Reporting Problems Problems What’s important to report? Be aware that if patient has Increase in venous pressure significant stenosis - access may Changes in arterial pressure function but labs can get critically Prolonged bleeding out of balance. Decrease in Kt/v and URR Change in bruit Case example: Abnormal transonic/ultrasound flow Fistula examples Swelling, redness, pain, problems with Catheter example cannulation Poorly functioning hemodialysis catheter 9/18/2006 21 9/18/2006 22 Tracking Information What’s Important to Track Access history – very helpful if Needs to be decided by team VAM and/or designated staff Database is useful to track person can keep an updated Primary Placement history on all access events a patient is having. Replacement Access Patient name Thrombectomies Date of procedure Infections Surgeon/radiologist 9/18/2006 23 9/18/2006 24 Role of a Dialysis Access Coordinator 4
  5. 5. What’s Important to VA Pt tracking tool Track Access Incidence and Prevalence Angiography/Angioplasty Information can be tracked by dialysis unit, surgeon, access type 9/18/2006 25 9/18/2006 26 Thrombosis by month PD tracking tool Health Plan # of Hemo Pts Thrombotic Annualized Monthly Total + Pts w/VA # of Thrombosis Episodes/Pt/Mo Episodes/Pt/Year Jan 283 14 0.05 0.88 Feb 284 7 0.02 0.44 Mar 288 7 0.02 0.39 April 271 9 0.03 0.39 May 274 14 0.05 0.44 Jun 281 9 0.03 0.43 July 297 10 0.03 0.42 Aug 304 4 0.01 0.39 Sep 306 12 0.04 0.40 Oct 286 11 0.04 0.41 Nov 304 11 0.04 0.41 Dec 308 9 0.03 0.40 Current Total 2588 117 0.05 9/18/2006 27 9/18/2006 28 Thrombosis Primary Access Thrombotic Episodes - 2000 vs 2001 Summary Primary Insertions by Non-Catheter Access Type: AV Fistula vs Graft for AV Fistula versus Graft 2001 Fistula Graft 2000 2001 100% 87% 120 83% 80% 101 98 botic episodes 100 60% 80 40% 60 # of Throm 17% 40 20% 13% 20 20 10 0% 2000 2001 0 Fistula Graft 9/18/2006 29 9/18/2006 30 Role of a Dialysis Access Coordinator 5
  6. 6. AV Fistula Readiness Infection Tracking 2001-AV Fistula Readiness for 1st Dialysis N=45 Fistula Tracking infections by access type Fistula Catheter Systemic (blood ) or local infection 100% 87% CDC has dialysis surveillance 61% study that individual units can 50% 39% 13% participate in 0% http://www.cdc.gov/ncidod/hip/ Fistula Catheter Fistula Catheter dialysis/dsn.htm 2000 2001 Started with Fistula Also Required Catheter Started with Fistula Also Required Catheter Allows comparison with other participating units in the country 9/18/2006 31 9/18/2006 32 Infections by Month Tools for Access Infections by Vascular Access Type By Month - 2001 Management Referral to Surgeon form Catheter Graft Fistula Referral for Evaluating Problem 8 Infection Tracking 7 7 7 6 6 6 Access Procedure Tracking Tool 5 5 5 “Save Your Veins” card 4 4 3 3 3 3 3 Wallet card with Access Care 2 2 2 2 2 22 Advice and Important Phone 11 1 1 1 1 1 0 0 0 0 0 0 0 00 00 0 0 Numbers for dialysis unit, surgeon, 0 nephrologist Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 9/18/2006 33 9/18/2006 34 Caring for the Care of the New Dialysis Hemodialysis Catheter Access AV Fistula/Graft Educate patient on: Allow enough maturation time ( 2-6 proper handwashing technique weeks for AVG and 2-3 months for AVF) taking a shower without getting the Carefully assess VA before each dialysis catheter wet; session changing the dressing on their own Rotate needles clamping the catheter if it starts to bleed Clamp use vs. no clamps what to do if the catheter falls out Educate patients on s/s of infection, who to call if they have a problem with clotting, and other complications the catheter 9/18/2006 35 9/18/2006 36 Role of a Dialysis Access Coordinator 6
  7. 7. Wallet card Long Term Care of the Hemodialysis Access Routine monitoring and surveillance at the facility level Prompt referral and arly intervention Patient VA history Patient education Self-cannulation 9/18/2006 37 9/18/2006 38 Conclusion Access Manager does play a beneficial role in helping patients, nephrologists, surgeons and dialysis staff in the coordination of access care 9/18/2006 39 Role of a Dialysis Access Coordinator 7

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