Change Concept 4: Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services

Collect data on the surgeons in your community to find out who has the skills and interest in placing fistulae. Choose surgeons who are willing and able to do AV fistula construction.

• Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.
• Nephrologist refers for vessel mapping where feasible, prior to surgery referral.
• Nephrologist refers patients to surgeons for “AVF only” evaluation, no later than Stage 4 CKD (GFR<30). Surgery scheduled with sufficient lead-time for AVF maturation.
• Nephrologist defines AVF expectations to surgeon, including vessel mapping (if not already performed).
• If timely placement of AVF does not occur, nephrologist ensures that patient receives AVF evaluation and placement at the time of initial hospitalization for temporary access (e.g. catheter).

Changes for Improvement

Communicate AVF Expectations to Surgeons

Nephrologists should communicate expectations to surgeons regarding AV fistula placement and their ability to use current AV fistula surgical techniques, based on K/DOQI Guidelines and best practices.

Refer to Surgeons Willing and Able to Meet AVF Expectations

Nephrologists should refer to surgeons who are willing and able to meet AVF expectations based on K/DOQI Guidelines and best practices.

Evaluate Surgeons on the Frequency, Quality, and Patency of Access Placements

Data collection and outcomes tracking can be initiated and reported at the dialysis center as part of ongoing CQI processes, and may be aggregated at the ESRD Network level. Nephrologists can also potentially track the data for their patients themselves.