Thursday, 27 May 2010

Getting vascular access right

The first national vascular access audit was released today. Haemodialysis can provide excellent long term treatment for people with end stage chronic kidney disease. To do so requires repeated connection to an extra-corporeal circuit and high quality vascular access is critical to the success of this modality.

Successful renal replacement therapy also requires preparation and choice. Supporting people with kidney disease to achieve the best possible experience of care and outcomes for them is the overarching aim of the National Service Framework for Renal Services. For those with progressive kidney disease that involves multi-disciplinary care planning and shared decision making including education, psychological preparation, weighing up the pros and cons of the various options and when haemodialysis is chosen, creation of the best possible vascular access. That in itself requires high quality team-working often involving radiology as well as surgical colleagues to ensure timely operation to allow full maturation of the access by the time it’s needed.

Starting haemodialysis with a native arteriovenous fistula provides a significant survival advantage because of the association of other forms of access with infective and thrombotic complications. Dialysis via a fistula will also provide the option of higher blood flows during the procedure resulting in more efficient dialysis. Lines and grafts to access the circulation for dialysis are associated with more and longer inpatient admissions, with more MRSA and MSSA bacteraemias and with higher morbidity and mortality.

Here, as in other aspects of kidney care, the patient plays a key role. Even before the surgery to create the fistula they should be given the responsibility of preserving forearm veins and permission to question anyone who suggests venipuncture or placing lines in these vessels. After dialysis starts, observation, monitoring and care of the fistula during needling for haemodialysis or during hospitalisations remain important components of kidney care.

Not all people who need haemodialysis can have an arteriovenous fistula but the variability and access type between units in the United Kingdom and the international best practice comparisons reveals differences in service organisation, priority given to pre-dialysis care and quality of surgical and radiological support for access salvage. The variance points to a significant quality improvement opportunity.

Improvements in vascular access for haemodialysis is supported by the NSF where it has its own standard and challenging best practice goals; by the professional societies’ recommendations and targets and by an 18 week pathway. Understanding the complexity of access and continuously measuring what the service is providing are crucial if we are to achieve the quality gains that we know are possible. This national audit being undertaken by the Information Centre in partnership with the UK Renal Registry is playing a vital role in establishing reporting systems to provide that understanding and knowledge. The aim is ambitious; universal coverage and embedding into Renal Registry business as usual to drive continuous quality improvement. The prize, marked improvements in patient experience and outcomes, is well worth the considerable effort of all those involved in developing, working with and using this audit.