Duc Vascular Access Monitoring

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Duc Vascular Access Monitoring

• Y. Foli Sekyema, MD
• Danville Urologic Clinic
• Marc Spring Council Meeting _at_ Fairfax, VA
  05/02/2003

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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

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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

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DUC Vascular Access Experience
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Danville Urologic Clinic
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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

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DUC Vascular Access Analysis

• AV Fistula -- 37 (kDOQI gt40)
• Graft -- 39
• PermCath -- 24 (kDOQI lt10)
• Bacteremia rate 4-11 (1-17)

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Team/Resources

• Vascular Surgeons
• Interventional Radiology
• Nephrologists
• HD Head Nurses
• Pt Care Co-Ordinator
• Vascular Access Co-Ordinator
• Quality Assurance Co-Ordinator

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Monitoring/ Surveillance

• Access Development
• Infection Rate
• Thromboses
• Other Complications

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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

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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!

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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

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Transonics Flow

• PTFE/ GRAFT
• once a month
• if stable, every 2-3mo
• FISTULA
• every 2-3mo
• FLOW
• lt600 ml/min -- fistulogram
• 600 - 1000ml/min q mo w 15 -- fistulogram
• gt1000ml/min
• 25 decrease

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Tracking Forms
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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

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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