Vascular Access Assessment, Monitoring, and Surveillance Svetlana Lana Kacherova, ESRD Network 18, QI Director WebEx s .

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Vascular Access Appraisal, Observing, and Reconnaissance Svetlana (Lana) Kacherova, ESRD System 18, QI Executive WebEx session, December 18, 2008. Extraordinary Affirmation for Substance Commitments: RMS Help, Inc. DaVita, Inc. John White, RN, Director, Effort and Training
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Vascular Access Assessment, Monitoring, and Surveillance Svetlana (Lana) Kacherova, ESRD Network 18, QI Director WebEx session, December 18, 2008

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Special Acknowledgment for Content Contributions: RMS Lifeline, Inc. DaVita, Inc. John White, RN, Manager, Outreach and Education Irina Goykhman, RN, MBA Lynda K. Ball, RN, BSN, CNN QI Director, ESRD Network 16 Y. Foli Sekyema, MD Danville Urologic Clinic

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Session Objectives Project Description Increase comprehension of vascular get to observing and observation and new CFC prerequisites Learn something new

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Vascular Access Challenges in the US. Real reason for dreariness Many lost HD hours Most Hospitalizations for HD patients High $ Cost to Health Care System Current Medicare consumptions for ESRD are in abundance of $21 billion yearly (5-7% of aggregate Medicare uses, for just 1% of Medicare recipients Best sort slightest utilized as a part of the US – AV Fistula

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V551: Vascular Access Monitoring " The patient\'s vascular get to must be checked to avert get to disappointment, including observing of arteriovenous unions and fistulae so manifestations of stenosis" "The office must have an on-going project for vascular get to checking and reconnaissance for early discovery of inability to permit convenient referral of patients for intercession when signs of critical stenosis are available."

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V551: Vascular Access Monitoring Patient training ought to address self-checking of the vascular get to"

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V 551: Monitoring Strategies Physical examination Observance of changes in sufficiency or in weights measured amid dialysis, troubles in cannulation or in accomplishing hemostasis Precipitating occasions ought to likewise be noted, for example, hypotension and hypovolemia

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V 551: Surveillance Strategies Include devise-based techniques, for example, get to stream estimation Direct or determined static venous weight proportions Duplex ultrasound, and so forth

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Documentation Requirements: Medical record ought to show proof of intermittent checking and observation of AVG or AVF Could be dialysis treatment record, advance notes, or a different log An individual from the office staff must survey the VA observing/reconnaissance documentation to recognize antagonistic patterns and make a move if demonstrated

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Additional Vascular Access Related V-Tags: V 147 & V 148 – Infection Control V 551 – Patient appraisal – assessment of dialysis get to sort for support V 633 – QAPI condition tending to vascular get to checking and reconnaissance

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V626 QAPI Condition Statement The dialysis office must create, execute, keep up and assess a compelling, information driven, quality evaluation and execution change program with investment by the expert individuals from the interdisciplinary group... … The dialysis office must keep up and exhibit proof of its quality change and execution change program for audit by CMS

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Interdisciplinary Team: Show Me The Progress:

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Stenosis Monitoring Project: Inclusion Criteria for Participating Facilities: Based on the aftereffects of the 2008 Stenosis Monitoring Scan Facilities that either don\'t perform checking and reconnaissance or perform dynamic venous weight just (N= 15) Facilities that did not react to the sweep

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Monitoring and Surveillance: Access Development Infection rate Thrombosis Other Complications

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Benefits of Access Monitoring and Surveillance Reduce rate of thrombosis Extended get to utilize life Reduce time lost from Hemodialysis Reduce persistent bleakness/hospitalizations Improve personal satisfaction Reduce social insurance costs

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Surveillance Technology Intra Access Flow Transonics Static Venous HD Pressure Dynamic Venous HD Pressure Access distribution Unexplained Decrease Delivered HD Doppler Ultrasound Physical Exam of Access ( arm swelling, delayed dying, expanded + venous weight or – blood vessel weight

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Schedule Infection Incidence – day by day Developing Access – consistently Vascular Access Conference – consistently Transonics Flow – every 1-2 months Team Meeting – each 2-3 months External aptitude - occasional

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Action focuses: Decreased Transonics Flow – Fistulogram Access Infections? Expanded Attention to Detail by all HD staff !!!! Recognize Needs for More Training Identify Potential Physician Trends Identify Potential HD Facility Trends Allow Objective examination with Regional and National Averages

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K-DOQI Guidelines Kidney Disease Outcomes Quality Initiative propelled in 1995 Evidence-Based Clinical Practice Guidelines for patients and medicinal services suppliers First Guidelines – 1997 Currently 22 points Three-organize survey handle

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Guideline 2: Selection and Placement of Hemodialysis Access 2.1.1-Preferred: AV Fistulae (AVF) 2.1.2-Accepted – AV Graft (AVG) 2.1.3-Avoid if conceivable: Long-Term Catheters Fistula First Breakthrough Initiative (FFBI) objective: 66% of hemodialysis patients using AVF by June 30, 2009

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Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing. 4.1. Physical examination (checking) 4.2. Observation of unions (favored) - Intra-get to stream - Static venous weight - Duplex ultrasound Surveillance of unions (adequate) - Physical discoveries Unacceptable: - Unstandardized dynamic venous weight (DPVs) ought not be utilized

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Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing. Reconnaissance of fistulae (favored) - Direct Flow Measurements - Physical discoveries - Duplex Ultrasound Surveillance of fistulae (adequate) - Recirculation (utilizing non-urea based dilutional strategy) - Static weight, immediate or determined

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Continuum of Vascular Access Care QI Static weight DVP Recirculation Assessment Look, Listen, Feel "Regular" Every move, Every patient Monitoring and Surveillance Vascular Access Program Documentation Interventions Angioplasty Fistulagram Thrombectomy

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Physical Assessment Inspection (look) Auscultation (tune in) Palpation (feel) Use the greater part of your faculties for evaluation and after that utilization your memory to investigate the state of the entrance to past appraisals

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Redness Drainage Abscess Skin Color Edema Small blue Purple veins Hands: cool, difficult, numb Fingers: stained Inspection Infection Steal Syndrome Central or Outflow Vein stenosis

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Is the Access Working Properly? Clearances (URR) more noteworthy than 65 Access stream more prominent than 600 Venous weight at 200 BRF under 125 Able to run medicine Other signs and side effects of get to pathology Recirculation Difficulty cannulating and torment in the get to Changes in excite and bruit Prolonged draining post-dialysis

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Is New AVF Mature? Utilize the KDOQI "Administer of 6\'s" Vein MUST Mature PRIOR to the FIRST cannulation " Rule of 6\'s "

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Central Stenosis and Occluded Veins Arm swelling Prominent veins in the upper trunk Prominent veins in the arm Swollen neck and face Look for indications of catheter on get to side Look for pacemaker or defibrillator

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What Causes the Stenosis? Startling at the cannulation destinations from poor needle turn Scaring the vein from the high blood vessel streams Scaring from embedded gadgets Aneurysm and pseudoaneurism arrangement Manipulation of veins Transpositions, translocation

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Physical Findings of Venous Stenosis

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Clinical Indicators of Stenosis Clotting the framework at least 2 times/month Difficult needle situation Persistently swollen arm Increased machine weights Difficult accomplishing hemostasis toward the finish of treatment Decreased blood pump speeds Decreased Kt/V or URR (because of distribution)

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What is Steal Syndrome? Get to "takes" blood from the hand Decreased blood supply to the hand Causes hypoxia (absence of oxygen) to the tissues of the hand bringing about extreme agony Neurotic harm to the hand can happen Without oxygen tissue passes on and putrefaction happens

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Is Steal Syndrome Serious? Necrotic tissue can not be "settled" – it must be evacuated (severed) = Risk for contamination = Risk for hospitalization = Risk for death! The Allen Test (inside 3 seconds you ought to see fine refill)

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Flow Methods in Dialysis Access Duplex Doppler Ultrasound (DDU) Magnetic Resonance Angiography (MRA) Variable Flow Doppler Ultrasound Dilution (Transonics): UDT Crit - Line III or Crit - Line II Glucose Pump Infusion Urea Dilution Differential Conductivity In-line Dialysate (FMC) - DD

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Color-Flow Doppler Outpatient radiological methodology done quarterly Also called duplex ultrasound or duplex Doppler think about Evaluates get to stream designs and additionally ranges of get to stenosis

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Ultrasound Dilution Technique (Transonics) Conducted quarterly or as essential AKA Crit - Line III or Crit - line TKA Very prominent, however not all offices have transonics on location

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Transonics Flow: AV Graft – once per month, if stable – each 2-3 months. AV Fistula – each 2-3 months Flow: - < 600 ml/min consistently with 15% - fistulogram - > 1000 ml/min - 25% decline

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Dynamic Venous Pressure (DVP) Conducted and recorded toward the start of every treatment at a predefined blood stream rate utilizing determined/predictable needle measure Non-institutionalized element venous weight are considered as unsuitable checking strategy by the K/DOQI workgroup Acceptable technique for AVFs as it were! (KDOQI 2006)

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Static Venous Pressure (SVP) Following a unit-particular method for estimation of venous and blood vessel measures at zero blood fl

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