Fistula First Catheter Last (FFCL) Change Package

Dialysis facilities should incorporate vascular access into their continuous quality improvement (CQI) processes. Planning and care for vascular access spans many disciplines and settings; breakdowns in communication put patients at risk for sub-optimal treatment. In order to identify patients who will benefit from secondary arteriovenous (AV) fistula placement, facilities need processes that facilitate multidisciplinary communication, assign responsibility for vascular access information coordination, and regularly collect and use data to identify problems and opportunities for improvement.

• Designate staff member in dialysis facility (RN if feasible) responsible for vascular access CQI.
• Assemble multi-disciplinary vascular access CQI team in facility or hospital.
• Minimally: Medical Director and RN (VA CQI Coordinator).
• Ideally: Representatives of all key disciplines including access surgeons and interventionalists.
• Investigate and track all non-AVF access placements, and AVF failures.

Changes for Improvement

Designate a Vascular Access Coordinator

Designate a staff member in the dialysis facility who will be responsible for vascular access. Designate a registered nurse (RN) if possible; if not, choose any renal care professional.

Assemble a Multidisciplinary Vascular Access Team

Assemble a multidisciplinary vascular access CQI team in your facility or hospital. At a minimum, this team should include the medical director and vascular access coordinator. Ideally, representatives from all disciplines, including access surgeons and interventionalists, should be on the team.

Vascular Access CQI Team

1. Nephrologist must become informed, take lead role in AVF initiative, encourage patients, and develop relationship with surgeons.
2. Access Manager needs to be empowered by Medical Director and team.

Resources

AVG Assessment and Intervention Algorithm
This tool will assist facilities to improve consistency of AVG assessment and intervention, as well as communication efforts with surgeons, nephrologists, and interventionists.  

Vascular Access Management: A Toolkit for Medical Directors 
This tool defines the role of the Medical Directors with vascular access and is designed as a requested, filed document for any provider of nephrology care with patient privileges at the dialysis center.

Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria.

• Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.
• Establish meaningful criteria for PCPs who may not perform GFR or creatinine clearance testing.
• Nephrologist documents AVF plan for all patients expected to require renal replacement therapy.
• Designated nephrology staff person educates patient and family to protect vessels, when possible using bracelet as reminder.

Changes for Improvement

Educate Primary Care Physicians to Utilize Pre-End Stage Renal Disease/Chronic Kidney Disease Referral Criteria

The new Kidney Disease Outcomes Quality Initiative (K/DOQI) Chronic Kidney Disease (CKD) Guidelines provide a clear standard for classification and management of patients with kidney disease.  Primary care physicians (PCPs) should use these guidelines to evaluate, manage, and refer their patients with evidence of kidney disease. Referral to a nephrologist should be made for all patients with evidence of CKD, but certainly before the glomerular filtration rate (GFR) falls below 30 ml/minute (Stage 4 CKD) for nondiabetics or below 60 ml/minute (Stage 3 CKD) for diabetics.

Ideally, the PCP’s regular laboratory will convert serum creatinine measurements to GFR.  If not, office staff or the PCP can easily use an online GFR calculator to do the conversion.

Document an AVF Plan

Document an AV fistula plan for all patients expected to require renal replacement therapy (RRT), regardless of the type of RRT being considered.

Educate Patients and Families on the Benefits of AVFs and on Protecting Vessels

Prepare the patient and the family for an AV fistula before they see a surgeon. Designate a nephrology staff person to educate patients and families on the benefits of AV fistulae and protecting vessels.

Veins should be protected as soon as there is any evidence of possible kidney disease, since ruining them compromises the opportunity and choices for a native AV fistula.

At the first sign of kidney disease, the physician should tell the patient and his or her family that hemodialysis may be required. The physician should examine the patient’s arms and advise the patient to protect his or her veins. The patient should also be encouraged to request that the dorsum of the hand be used for blood draws or IVs and to avoid using the forearm veins (unless in an emergency situation) in order to preserve them for future access. Patients should consider wearing a medical alert bracelet as a reminder to ensure vessel protection. When the patient is in the hospital, a sign should be placed at the bedside to remind staff about vessel preservation.

Resources

Vein Preservation and Hemodialysis Fistula Protection
A one page paper with instructions for health care providers on vein preservation and hemodialysis fistula protection including directions for protection of forearm veins, for patients with working hemodialysis access and for patients with chronic kidney disease (CKD) or at-risk for CKD.

Recommendations for the Avoidance of Radial Artery Access for Procedures
This document discusses avoidance of the radial artery as an access vessel for cannulation in patients with CKD stage 4, 5 or ESRD due to possible loss of upper extremity vasculature.

Recommendations for the Minimal Use of PICC Lines
Fistula First Breakthrough Initiative white paper recommending that Peripherally Inserted Central Catheter (PICC) lines not be placed in anyone identified as having mid-Stage 3 CKD, Stage 4 and 5 CKD or ESRD with instructions to obtain Glomerular Filtration Rate (GFR) estimates for all patients with high serum creatinine levels, and to defer a PICC line decision until it is clear that the patient does not have CKD.

When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation. Studies show that mapping vessels can significantly increase the incidence of successful AV fistulae. Establish the understanding with your surgeons that they will contact you before placing anything other than an AV fistula. Where timing is such that a temporary access must be placed (e.g., catheter), arrange for evaluation (and placement, if feasible) of an AV fistula during the initial hospitalization. Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.

• 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

Refer Patients for Vessel Mapping

Nephrologists should refer patients for vessel mapping (identification of vessel anatomy) where feasible, ideally prior to surgery referral.  Doppler ultrasound or alternate technique should be used to search for suitable vessels that may be too deep to be identified on physical exam.  Numerous studies have shown that vessel mapping identifies vessels suitable for an AV fistula in the majority of patients where physical exam alone classified the patient as not being a candidate for an AV fistula.

Schedule Surgery with Sufficient Lead-Time for AVF Maturation

In order to schedule surgery with sufficient lead-time for AV fistula maturation, nephrologists should refer patients to surgeons for “AVF only” evaluation no later than Stage 4 CKD (GFR<30).

Communicate AVF Expectations (including Vessel Mapping) to Surgeons

Nephrologists should establish an understanding with surgeons that all patients should be fully evaluated for the possibility of an AV fistula, including vessel mapping where necessary.

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.

Surgeons who are skilled in vein transposition techniques are able to create successful AV fistulae in a substantially greater number of patients. These options require vein mapping and a surgeon’s willingness to put in the additional time and effort. Make sure surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation.

• Surgeons utilize current techniques for AVF placement including vein transposition.
• Surgeons ensure mapping is performed for any patient not clearly suitable for AVF based only on physical exam.
• Surgeons work with nephrologists to plan for and place secondary AVFs in suitable AV graft patients.

Changes for Improvement

Utilize Current Techniques for AVF Placement, including Vein Transpositions

Surgeons should utilize current techniques for AV fistula placement including vein transpositions.

Perform Mapping When Suitable Vessels Are Not Found on Physical Exam

Surgeons should ensure mapping is performed for any patient who is not deemed suitable for AV fistulae based solely on physical exam.

Evaluate graft patients for placement of a secondary AV fistula. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when the graft begins to fail. This avoids the need for a catheter or missing an AV fistula opportunity when the graft fails and there is urgency for an immediate usable access. Note particularly that the outflow vein from a graft is an already matured arterialized vein that could be connected and used right away.

• Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion, including mapping as indicated, and document the plan in the patient’s record.
• Dialysis facility staff and/or rounding nephrologists examine outflow vein of all graft patients (“sleeves up”) during dialysis treatments (minimum frequency, monthly). Identify patients who may be suitable for elective secondary AVF conversion in upper arm and inform nephrologist of suitable outflow vein.
• Nephrologists refer to surgeon for placement of secondary AVF before failure of AVG.

Changes for Improvement

Evaluate Every AV Graft Patient for Possible Secondary AVF

Nephrologists should evaluate every arteriovenous (AV) graft patient for possible placement of a secondary AV fistula, including mapping as indicated, and document the plan in the patient’s record. AV fistula evaluation of graft patients should include an updated history relevant to vascular access, physical exam with tourniquet, and vessel mapping if suitable vessels are not identified on physical exam. A secondary AV fistula plan should be documented in the chart and discussed with the patient, family, staff, and nephrologists and surgeon in anticipation of AV fistula construction on the earliest evidence of graft failure.

Examine the Outflow Vein of All Forearm Graft Patients to Identify Suitable Veins for Secondary AVF

Dialysis facility staff and/or rounding nephrologists should examine the outflow vein of all forearm graft patients during dialysis treatments (with a recommended minimum frequency of at least monthly) to identify patients who may have a suitable upper outflow vein for elective secondary AV fistula conversion in the upper arm. If such a suitable vein is found, dialysis facility staff and/or rounding nephrologists should inform the patient’s nephrologist and surgeon of the need to evaluate the identified outflow vein for AV fistula conversion.

Refer to the Surgeon for Evaluation/Placement of Secondary AVF before the Graft Fails

Patients with an AV graft should be evaluated (including vessel mapping) for an AV fistula when the graft shows evidence of dysfunction by monitoring and surveillance. The timing of such surgical intervention to convert the outflow vein of an existing AV graft to an AV fistula, or to construct a new AV fistula in a new location, assuming suitable vessels, should be as soon as feasible but not later than following an intervention for thrombosis or clinically significant stenosis. Any delay in conversion beyond this point is likely to result in loss of the window of opportunity for an AV fistula, since further graft interventions, especially if done as an emergency, are likely to damage or utilize the outflow vein, or the graft will eventually be abandoned (usually after a failed intervention), resulting in a catheter and a new graft in a different location.

Resources 

“Sleeves Up” Protocol to Convert Forearm AV Graft to Upper-Arm AV Fistula
From: Fistula First Breakthrough Initiative Tools and Resources Working Group with assistance from Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group

This protocol is used to identify a suitable outflow vein to convert a forearm arteriovenous (AV) graft to an upper-arm AV fistula, in anticipation of secondary AV fistula construction by the surgeon.

An effective strategy for increasing arteriovenous (AV) fistula prevalence is the planning and construction of AV fistulae in existing AV graft patients prior to graft failure. Although the primary access may currently be a graft, all graft patients should be evaluated and considered (where feasible) for an AV fistula as their next permanent access (secondary AV fistula).

Although evaluation for a secondary AV fistula may require bilateral vessel mapping to identify a suitable vein and artery for AV fistula construction, the simplest opportunity to convert a graft patient to a fistula patient, when present, is the conversion of an arterialized (mature) upper-arm outflow vein of a forearm graft to a direct upper-arm AV fistula. Such a conversion opportunity should be looked for and considered in all forearm graft patients.

“Sleeves Up” Checklist
Checklist for Access Managers

Higher catheter use is associated with increased infection, morbidity, mortality, and hospitalization. Evaluation and mapping of catheter patients is crucial to facilitate the placement of AV fistulae. While catheters are necessary in some circumstances (e.g., while an AV fistula matures), the increasing prevalence of catheters in the United States is a serious health risk to patients. Strategies for reducing the number of catheters include early referral to nephrologists, monitoring and maintenance (so that accesses can be repaired before a catheter needs to be placed), and planning for a permanent access before the patient leaves the hospital.

• Regardless of prior access (e.g. AV graft), nephrologists and surgeons evaluate all catheter patients as soon as possible for AVF, including mapping as indicated.
• Facility implements protocol to track all catheter patients for early removal of catheter.

Changes for Improvement

Evaluate All Catheter Patients for an AVF

Regardless of prior access (e.g., AV graft), nephrologists and surgeons should evaluate all catheter patients as soon as possible for an AV fistula, including mapping as indicated.

Develop a Protocol for Catheter Indications and Removal

Patients with a “catheter only” should be reviewed and discussed by the vascular access team.  A documented plan for permanent vascular access evaluation and placement should be part of the patient’s permanent medical record.

Track All Catheter Patients for Early Removal of Catheters

Develop and implement protocols to track all catheter patients for early removal of catheters.

Prevent fistulae from being destroyed by inexperienced staff. Discuss the basics of needle cannulation with all staff.

• Facility uses best cannulators and best teaching tools (e.g., videos) to teach AVF cannulation to all appropriate dialysis staff.
• Dialysis staff use specific protocols for initial dialysis treatments with new AVFs and assign the most skilled staff to such patients.
• Facility offers option of self-cannulation to patients who are interested and able.

Changes for Improvement

• Use Experienced Staff and Teaching Tools to Train All Appropriate Dialysis Staff on AVF Cannulation
• Identify the experienced cannulators on your staff; make sure they are available to cannulate all new fistulae and to train inexperienced staff.  Identify and make available to your staff appropriate teaching tools.
• Use Protocols for Initial Dialysis Treatments with New AVF Patients
• Dialysis staff should develop and use a specific protocol for initial dialysis treatments with new AV fistula patients and assign the most skilled staff to such patients.
• Teach Self-Cannulation to Patients Who Are Interested and Able
• Facilities should offer the option of self-cannulation to patients who are interested and able.

The health care team should establish a process for monitoring and maintenance of AV fistulae to ensure adequate access function. It is extremely important to catch problems with fistulae early. Problems must be caught within 24 hours or the fistula will fail and be irreparable. There is a 20 to 30 percent failure rate for early fistulae.

• Nephrologists and surgeons conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure and refer for intervention as indicated.
• Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF.
• Nephrologists, interventional radiologists, and surgeons adopt standard criteria, and a plan for each patient, to determine the appropriate extent of intervention on an existing access before considering placing a new access.

Changes for Improvement

Conduct a Post-Operative Physical Evaluation of AVFs at 4 Weeks

Nephrologists and surgeons should conduct post-operative physical evaluations of AV fistulae at four weeks to detect early signs of failure and refer for diagnostic study and remedial intervention as indicated.

Adopt Standard Procedures for Monitoring, Surveillance, and Timely Referral for the Failing AVF

The K/DOQI has established recommendations and guidelines for monitoring and surveillance:

Monitoring, which K/DOQI defines as physical examination techniques to detect access dysfunction, has been shown in many studies to be able to identify the majority of patients with AV fistula dysfunction.

Surveillance involves the use of a variety of tests to detect access dysfunction. Intra-access blood flow measurement over time is the best surveillance method available for assessing AV fistula function and detecting dysfunction.

Two other methods offer significant value for AV fistula surveillance:

Pre-pump arterial pressure, which is measured on almost all dialysis machines, indicates the ease or difficulty with which the blood pump is able to draw blood from the access (inflow). A significant restriction of inflow will cause an excessively negative pre-pump arterial pressure. Since most causes of AV fistula dysfunction are inflow problems, an excessively negative pre-pump arterial pressure is often the earliest indication of such a problem.

Access recirculation measurement. An AV fistula may remain patent but not provide enough blood flow to meet the prescribed blood pump flow rate, resulting in under dialysis. If there is any question about adequacy of blood flow for dialysis, or if there is difficulty dialyzing the patient at the prescribed pump rate, a recirculation study will determine if the AV fistula blood flow is not sufficient to meet the prescribed blood pump flow rate.

Note: While physicians commonly use venous pressure measurement to detect access dysfunction, it is of very limited value in AV fistula surveillance. This is because most of the flow-limiting problems in AV fistulae are on the arterial of the venous needle (and often the arterial needle as well) and therefore are not detectable by pressure measurements made at the venous (or arterial) needle, which can only detect an outflow obstruction downstream of the measuring needle(s). In addition, the fistula has tributaries that can dissipate pressure in the presence of an outflow obstruction. Finally, access pressure measurements are not likely to identify centrally located venous obstructions.

Adopt Standard Criteria and a Plan for Each Patient

Nephrologists, intervention radiologists, and surgeons should adopt standard criteria, and a plan for each patient, to determine the appropriate extent of intervention on an existing access before evaluating and mapping for an AV fistula.

Resources

AV Fistula Quick Reference Guide 
An easy-to-use reference document that describes the maturation process, and guidelines for assessment and monitoring of AV fistulas.

To make good decisions about their care, dialysis patients and their caregivers need support and resources, including information about the value of fistulae over other access types, protecting their veins, and advocating for themselves with their health care team.

• Routine facility staff in-servicing and education program in vascular access.
• Continuing education for all caregivers to include periodic in-services by nephrologists, surgeons, and interventionalists.
• Facilities educate patients to improve quality of care and outcomes (e.g., prepping puncture sites, applying pressure at needle sites, etc.).

Changes for Improvement

Educate Patients to Improve Quality of Care and Outcomes Pre-Dialysis:

• Facilities and/or nephrologists should provide pre-ESRD education for patients and their caregivers to communicate the value of fistulae over other access types and access preparation (e.g., vessel mapping, and vein preservation strategies)

Post-Dialysis

• Facilities should educate patients on practices that can improve the quality of their care and their outcomes (e.g., prepping puncture sites, applying proper pressure at needle sites without clamps).
• Patients should be taught, where feasible, to manage their puncture sites without the use of clamps. If clamp use is necessary, dialysis clinic staff will evaluate and educate the patient and his/her caregiver on the safe use of clamps.  

Provide Continuing Education for all Care Givers

• Provide continuing education for all caregivers to include periodic in-services by nephrologists, surgeons, and interventionalists.

Develop Routine In-Servicing and Education Programs in Vascular Access for Facility Staff

• Facilities should provide routine in-servicing and education programs for all staff to communicate the value of fistulae over other access types and best treatment practices for patients with fistulae.

Resources 

Vascular Access Education 
American Association of Kidney Patients (AAKP) is recognized as the leader for patient-centered education – continually developing high quality, professionally written, edited and reviewed educational pieces covering every level of kidney disease.

Dialysis Patients Speak: A Conversation About the Importance of AV Fistulas
In this 12-minute video, designed for patient audiences old and new, you will see renal professionals and real dialysis patients telling their access stories from the heart. It is humorous, moving and educational. There is major emphasis on placement and use of AVF as a first blood access, and strong cautionary tales about catheters. The conversational style of the video is non-threatening, sincere and candid. Our hope is that your patients see the video and are encouraged to have discussions about vascular access choices.

A How-To Manual: The Art of Teaching Buttonhole Self-Cannulation
An article written by Stuart Mott that is an excellent resource for patients to learn step-by-step how to self-cannulate using the Buttonhole Technique.

Facilities can start by measuring performance on a monthly basis by access type – catheter, AV graft, and AV fistula – since access type is the major determinant of outcomes and directly affects dialysis delivery and adequacy.  It is also important to focus specifically on native AV fistula outcomes and performance, including tracking the monthly AV fistula placement and failure rate in incident as well as prevalent patients.

• Networks work with dialysis providers to give specific feedback to all decision-makers on incident and prevalent rates of AVF, AVG, and catheter use.
• Review data monthly or quarterly in facility staff meetings. Present and evaluate data trended over time for incident and prevalent rates of AVF, AVG, and catheter use.

Changes for Improvement

Provide Specific Outcomes Feedback to All Decision Makers

Provide specific outcomes feedback to all decision makers, including incident and prevalent rates of AV fistula, AV graft, and catheter use. The ESRD Networks are currently working with dialysis providers to collect and provide this information regularly to each facility.

Review Data Monthly or Quarterly in Facility Staff Meetings

Discuss and evaluate data trended over time for incident and prevalent rates of AV fistula, AV graft, and catheter use. Track and disseminate all vascular access-related outcomes.

Early identification, early education, timely referral to nephrology, and coordination with discharge planning will provide patient and family support in making decisions related to renal replacement therapy and vascular access. Hospital stays provide an additional opportunity for early diagnosis of CKD. Early identification of patients with kidney disease can slow the progression of the disease.

• Hospitals develop a comprehensive plan for early identification of patients with kidney disease to allow for interdepartmental coordination for protective measures programs to prevent nephrotoxicity or other causes of further kidney damage, to allow for vessel preservation, patient and family support, and vascular access planning and/or placement.

Changes for Improvement

Hospitals develop a comprehensive plan of care for patients at risk for or with kidney disease to include:

• Early identification of patients with kidney disease to allow for interdepartmental protective measures programs (pharmacy, radiology) to prevent nephrotoxicity and/or further kidney damage.
• Early identification of patients with kidney disease to allow for interdepartmental coordination (dietary, education, social services, case management) for patient and family support.
• Early identification of patients with kidney disease to allow for vessel preservation measures.
• Hospital care coordination infrastructure (attending physicians, case management, quality improvement, risk management, infection control, discharge planning, social services) to assist patients in arranging necessary care during and after a hospital stay to assure that CKD Stage 3B (eGFR 30 – 44) and CKD Stage 4 (eGRF 15 – 29) patients receive appropriate primary care follow-up and nephrology and/or surgical consults as needed.
• Hospital care coordination infrastructure (attending physicians, case management, quality improvement, risk management, infection control, discharge planning, social services) assists patients during and after a hospital stay in arranging necessary care that ensures CKD Stages 4 (eGFR 15 – 29) and 5 (eGFR <15) patients obtain appropriate vascular access assessment, coordination and placement as well as nephrology follow-up and education regarding renal replacement therapy options.
• Hospital care coordination infrastructure collaborates with local dialysis centers to develop and implement discharge documentation tools that communicate detailed vascular access placement plans for patients who choose hemodialysis as their renal replacement therapy option.

Patient self-management support will increase patients’ skills and confidence in managing their health problems, including goal setting, regular assessment of progress and problems, and problem-solving support.

• Patient achieves optimum treatment outcomes and health status through collaborative knowledge-building related to CKD progression and treatment and through effective application of self-management interventions, such as self-monitoring and decision-making.
• Health care clinicians utilize techniques and strategies for the education of those who participate in vascular access education and management that are designed to encourage, enhance, and support patient self-management. This includes motivational interviewing, health coaching, and other patient empowerment strategies and techniques.

Changes for Improvement

Empower patients with earlier stages of CKD to:

• Know their GFR and Kidney Disease Stage
• Understand the dangers of PICC lines and blood draws and utilize tools and strategies to preserve arteries and veins once diagnosed with CKD
• Actively participate in developing their plan of care
• Understand all treatment modalities available for treatment of ESRD

Empower CKD Stage 4 patients preparing for hemodialysis to:

• Understand what criteria should be used to select the appropriate vascular access (vessel mapping, physical exam, co-morbid conditions)
• Compare the risks and benefits of all vascular access (AV fistulas, AV grafts, catheters)
• Identify and overcome barriers to timely placement of an AV fistula and have an AV fistula placed and matured before initiating hemodialysis
• Participate in developing their vascular access plan
• Know the benefits of self-cannulation and prepare for self-cannulation, i.e. pre-cannulation training

Empower ESRD patients on hemodialysis to preserve their AV fistula by:

• Understanding the need to examine their access several times daily by feeling for a thrill. If a stethoscope is available listen for a bruit and changes in sounds heard.
• Understanding access monitoring and interventional procedures to ensure vascular access patency
• Learning and performing self-cannulation and understanding access depth (deep access = 1¼” needle; very superficial=3/5” needles)
• Learning and performing buttonhole cannulation

Health care facilities, physicians and staff provide support for patient self-management by:

• Understanding and implementing the core concepts of patient self-management, dignity and respect, information sharing, participation, collaboration, and empowerment
• Developing guidelines and protocols to implement patient self-management concepts in all treatment areas including in-center dialysis, should be sensitive to cultural and linguistic competency of patients.
• Assess patient’s health literacy level, use visual aids, easy readability brochures and video tapes to assist patients to understand all aspects of their treatment, to include vascular access planning and care, fluid balance, nutrition, co-morbidities, and treatment modalities.
• Promoting self-management among patients to achieve better outcomes and quality of care

Resources 

How to Have a Good Future with Kidney Disease
A patient-centered Chronic Kidney Disease (CKD) education series in 6 parts.

Some change concepts may involve clinical approaches that are not currently common practice or about which there is a range of opinion. Local clinical guidance is critical to selecting and implementing appropriate strategies. Practitioners and Networks must take into consideration the availability of local clinical resources and expertise in developing their own strategies.

Together, the ESRD Networks, dialysis providers and medical specialists comprise a complex and sophisticated system for serving hemodialysis patients. By working together within a common framework, professionals in the field of hemodialysis can be certain that their efforts will lead to better care and better outcomes for the most important group of stakeholders—ESRD patients.