Lesley C. Dinwiddie, MSN, RN, FNP,CNN
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1 The Vascular Access Coordinator: A Patient and Treatment Team s Best Friend Lesley C. Dinwiddie, MSN, RN, FNP,CNN
2 Greetings and Thanks to Network 14 for this exciting opportunity!
3 Purpose The purpose of this webinar is to promote the use, and expand the practice, of Vascular Access Coordinators to improve AVF rates and patient outcomes by identifying suitable roles and providing tools and resources. Topics include qualifications, training, role of the coordinator and team in the dialysis center, access center, and hospital setting as well as trending and tracking results.
4 The Genesis &Impetus is from FFBI Change Concept 1 Routine CQI review of vascular access 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.
5 My Story (circa early 1995) Wanted: one nurse practitioner with extensive nephrology, especially HD, experience to help out in the nephrology division and acute unit with continuity of care especially vascular access whatever is best for the patient just call Lesley and just who are you?
6 The Rest of My Story The evolution of my workweek calendar and the concomitant responsibilities The culmination of an extraordinary experience Writing and presentations Invitations to committees and workgroups A career in consulting An enduring philosophy of access advocacy through patient centered care
7 Access Advocacy The overriding principle of: what is best for the patient promotes assertive communication with colleagues dictates persistent patient and staff education (not nagging) drives the relentless search for innovative solutions reinforces the use of process (CQI) and the interdisciplinary team approach
8 It s always about the Patient!
9 Model Vascular Access Algorithm Early referral from nephrologist Assessment including vessel mapping Referral to surgeons for assessment/plan Access creation Post op followup Ongoing monitoring Troubleshooting/referral for appropriate care
10 VAC Model Responsibilities Assess new and established patients VA status and needs and organize appropriate interventions as per nephrologists orders Patient and staff teaching/support Interact with dialysis staff (especially the designated vascular access manager) to assure ongoing access monitoring Oversee data collection and management Organize and maintain CQI process that involves all members of the VA collaborative interdisciplinary team
11 VAC Role Attributes patient advocate teacher (patients and colleagues) liaison (communicator extroadinaire) flexible and mobile assertive and accountable manager (CQI) researcher collaborator
12 Different Programs/Different Needs Some vascular access programs are directed by the surgeons who do all access placement In some academic programs the access care is dictated by the hospital CQI or the nephrology division Some large dialysis organizations have coordinators covering several dialysis units but all have the same goal - better outcomes!
13 Vascular Access Coordinator Role CC1 Reports to: : Facility Administrator, Medical Director, VA Team Purpose of Vascular Access Coordinator Role: Primary source of vascular access information and care coordination for designated facility (provider) Focus on vascular access care and management to increase access longevity Maintain vascular access data to assure tracking and trending of dialysis therapy and outcomes Provide leadership and communication among caregivers Oversee and direct vascular access planning for current and future accesses SUMMARY OF BASIC Role: Collection of accurate and complete vascular access data. Coordination of the care and management of patients vascular accesses. Communication and collaboration with the Multidisciplinary Access Care Team Role Qualifications: Experienced hemodialysis professional Certification in nephrology or hemodialysis preferred Demonstrated proficiency in vascular access care and management Demonstrated commitment to continuous quality improvement (CQI) Excellent communication, writing, and organization skills Empowered by the facility administrator, medical director and Multidisciplinary Access Care Team
14 Vascular Access Coordinator Role CC1 ESSENTIAL JOB FUNCTIONS: 1. Collaborate with medical director, facility administrator et al to identify and continuously re-evaluate the members of the Multidisciplinary Access Care Team. 2. Proactively collect and report accurate and complete data and assessments of the accesses to facility, teammates, patients and other care providers (the Multidisciplinary Access Care Team) for baseline and ongoing outcomes. 3. Educate teammates, provider partners, and hemodialysis patients in the care and management of vascular accesses, with particular attention to opportunities for improvement. 4. Monitor vascular access and hemodialysis care delivery with particular focus on identifying access dysfunction and opportunities to increase arteriovenous fistulas (AVFs) and reduce catheters. 5. Facilitate process of referral for diagnosis for accesses with dysfunction or other pathology. 6. Support referral for Interventional or surgical treatment appropriate for diagnosed vascular access dysfunction. 7. Ensure documentation of care and outcome, and communicate vascular access-related outcomes and status. 8. Participate in Continuous Quality Improvement of Vascular Access care and management to improve patient and facility outcomes. 9. Facilitate routine Multidisciplinary Access Care Team meetings to identify opportunities for vascular access- related improvements. 10 Complete other vascular access-related tasks as directed.
15 Why does Vascular Access Care need to be Coordinated in the Dialysis Unit? Because infection of vascular access is the leading cause of hospitalization in our patients. Coordination of care increases awareness and infection prevention? Because prevention is far superior to treatment and the best method of prevention is the creation and maintenance of fistulas!
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18 Why does Vascular Access Care need to be Coordinated in the Dialysis Unit? The fistula first experience of Networks 5 & 11 Implementation of a multifaceted intervention including a vascular access nurse and an algorithm to prioritize surgery significantly increased the proportion of patients starting dialysis therapy with an AVF by improving the overall coordination of the surgical waiting list. Polkinghorne et al. AJKD 2009
19 Change in all-cause & cause-specific hospitalization rates, by modality Figure 16 p.218 Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort. Vascular access hospitalizations are pure inpatient vascular access events, as described in Appendix A. New vascular access codes for peritoneal dialysis patients appeared in late 1998; therefore, peritoneal dialysis vascular access values are shown as changing since 1999 rather than 1993.
20 Why does Vascular Access Care need to be Coordinated in the Dialysis Unit? Care Coordination can promote: early referral for access creation/preservation; access monitoring and surveillance timely referrals for access dysfunction increased patient self-management*.
21 Why does Vascular Access Care need to be Coordinated d in the Dialysis Unit? VA Care Coordination can reduce: care errors; delayed or missed appointments; failed accesses; catheter dysfunction.
22 The Duties of the In-Center VA Care Coordinator The in-center coordinator* is responsible for: interfacing with the external vascular access coordinator (VAC) and the vascular access team (VAT) to assure continuity & consistency of VA care; organization of staff and patient teaching re VA; oversight of vascular access data collection; participating on the VAT and in-center CQI
23 The Duties of the In-Center VA Care Coordinator The in-center coordinator is responsible for interfacing with the external vascular access coordinator (VAC) and the vascular access team (VAT) to assure continuity and consistency of care through: Prompt patient referrals for access creation and preservation* Being the onsite clinician overseeing monitoring and surveillance and reporting events
24 The Duties of the In-Center VA Care Coordinator The in-center coordinator is responsible for organization of staff and patient teaching re VA including: Updates from the literature Reports from presentations from professional meetings New product information CQI event-related goals
25 The Duties of the In-Center VA Care Coordinator The in-center coordinator is responsible for oversight of vascular access data collection/management including: Average flow rates per treatment/bvp. Average arterial and venous pressures. Adequacy labs. Monitoring and surveillance data. Number and type* of events. Number and type of interventions to correct events
26 The Attributes of the In-Center VA Care Coordinator The in-center coordinator is responsible for participating on the VAT and in-center CQI.Therefore he/she must possess the following attributes: - knowledgeable and experienced in HD - possess excellent management and communication skills - be a team player/mentor/mentee - be an ASSERTIVE patient advocate!
27 Being ASSERTIVE!
28 It Takes a Team coordinated by a Nephrology Nurse! and A Continuous Quality Improvement (CQI) Process for Better Outcomes for Patients and their Vascular Access!
29 Collaborative Care of Vascular Access Nurses have a pivotal role as vascular access advocates through: assertive preservation of existing access patient & staff education interaction with radiologists and surgeons promoting expert cannulation & self-cannulation persistent preservation of remaining access sites minimizing central catheter access minimizing venous cannulation in virgin limbs
30 Collaborative Care of Vascular Access Nephrologists have a leading role in access creation and continuity of care through: early vein preservation (as soon as CRF dxd) early referrals to nurse educators & surgeons strong recommendations for appropriate access selection to the patient & team post procedure follow-up and ongoing oversight of access adequacy and care
31 Collaborative Care of Vascular Access Surgeons have a role as vascular access advocates through: Creating/placing access in an accessible location diagramming new accesses & labelling arterial anastomosis communicating specific access orders directly to the nurses visiting the dialysis units to do patient & staff education and to familiarize staff c surgeon s point of view be readily accessible for consultation
32 Collaborative Care of Vascular Access Interventional Nephrologists/Radiologists have a role as vascular access advocates through: restoring access patency promptly to prevent CVC placement sending report of procedure with findings, recommendations, & catheter lumen volumes communicating specific access orders directly to the nurses visiting the dialysis units to do patient & staff education and to familiarize staff c IVR s point of view be readily accessible for consultation
33 Collaborative Care of Vascular Access Patients and their families must be heard as their own vascular access advocates through: including them in the discussions for decision making at their level of comprehension making written materials and videos easily accessible educating them about new products and techniques such as self-cannulation respecting the fact that it is their lives, their bodies, their time -----their choice!
34 Their Lives Their Choice
35 What is the Goal of a Team?
36 It Takes a Team! The Chairside Nurse has the primary responsibility for treatment-to-treatment assessment, vascular access care, and documentation. However, she should be able to consult with the: vascular access manager/coordinator. nephrologist and/or APN (a nurse with higher education and expanded duties) interventionalists and surgeons. clinic manager/administrator. social worker (transportation etc). dietitian (adequacy, infection/nutrition) And collaborate with dialysis technicians That s what CQI is all about! The collaborative care and responsibility for vascular access to improve outcomes.
37 Nurses try to do it All!
38 CQI Process for Better Outcomes for Patients Creation or adaptation of an algorithm to set dialysis unit policy for management of vascular access dysfunction that includes: Identification of vascular access team. Definitions of dysfunction.* Assessment and diagnosis. Appropriate interventions. Documentation CQI data collection and meeting schedule.
39 Sources and Resources IHI.org
40 CQI Process for Better Outcomes for Patients Monthly review of individual data to track trends of labs and events. Monthly review of aggregate facility data and comparison with previous trends. Identification of root causes for events in both the individual and facility. Evaluation of interventions and outcomes. Literature review for research on improved vascular access outcomes.
41 CQI Process for Better Outcomes for Vascular Access Data collection, including: Average flow rates per treatment/bvp. Average arterial and venous pressures. Adequacy labs. Monitoring and surveillance data Number and type of dysfunction events. Number and type of interventions to catheter correct dysfunction, including: Lytic administration. Referrals to interventionalist or surgeon. Bacteremias with positive cultures. Antibiotic therapy.
42 The 2006 KDOQI Updates
43 PG 4. Detection of Access Dysfunction: Monitoring & Surveillance Monitoring: The evaluation of the vascular access by means of physical examination to detect physical signs that suggest the presence of dysfunction. (KDOQI glossary)
44 PG 4. Detection of Access Dysfunction: Monitoring & Surveillance Surveillance: The periodic evaluation of the vascular access by means of tests which may involve special instrumentation, and for which an abnormal test result suggests the presence of dysfunction. (KDOQI glossary)
45 CQI Process for Better Outcomes for Patients! Goal setting to improve outcomes! Education of staff: Dissemination of CQI process findings and goals. Retraining on areas of care where events are occurring. Sharing literature demonstrating evidence-based practice.
46 CQI Process for Better Outcomes for Patients! Education of patient and family: Discussion of patient s current access status (perhaps through a report card -type medium similar to what dietitians use for monthly lab dissemination). Discussion of the data points and their importance that the patient can monitor as well, such as: Actual blood flow = prescribed. Arterial and venous pressure monitors on and limits set. Adequacy data.
47 Effective Teaching!
48 CQI Process for Better Outcomes for Patients Education of patient and family: Discussion of patient s access options (if appropriate). If the events include infection/s: handwashing review catheter dressing care as per unit protocol. review importance of patient and staff adhering to Dialysis Center Precautions when handling or accessing catheter or cannulating fistula/avg. Encourage patient to keep a personal access record (similar to medication record) to track access events.
49 Recommended Infection Control Practices for Hemodialysis Units
50 Issues for the VAC creating/adapting the role networking with other vascular access coordinators printed resources needs assessment - different places/different resources set realistic goals collaborative relationships vs turf wars
51 Facilitators & Barriers to Practice Never losing sight of the fact that the goal of everything you do is doing what is best for the patient Having realistic expectations of/for yourself and communicating that to colleagues and your patients
52 Conclusions More than 80% of patients starting dialysis do so with a catheter so it is up to the HD team to determine & arrange for the best access for every patient Vascular Access infection is the leading cause of hospitalization in hemodialysis patients. The associated morbidity and mortality (and cost) can be reduced with vascular access management by both an internal and external coordinator. A nephrology nurse, knowledgeable and experienced in HD, is ideal to fill the role of the in-center coordinator and liaison to the vascular access team (VAT) It takes a team and a CQI process to manage vascular access and assure better outcomes for the patient!
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54 This is the GOAL - always doing what s best for the patient!
55 Sources and Resources Dinwiddie LC (2007) Overview of the role of a vascular access nurse coordinator in the optimisation of access care for patients requiring haemodialysis. Hong Kong Journal of Nephrology, 9 (2) pgs Dinwiddie LC Investing in the lifeline: The value of a vascular access coordinator, Nephrology News and Issues, May, 2003 Burrows Hudson S. & Prowant B. (2005) Nephrology Nursing Standards of Practice and Guidelines for Care ANNA, Pitman, NJ. NKF manual Elements of Excellence: A Team Approach to CKD Care June, 2008.
56 Sources and Resources /FFBIChangeConcepts/ChangeConcept1.aspx Kalman PG, Pope M, Bhola C, Richardson R, Sniderman KW. A practical approach to vascular access for hemodialysis and predictors of success. J Vasc Surg 30:4: , 1999 King B. The vascular access coordinator role: an interview with Donna Carlton. NNJ, 2005 (6) Polkinghorne KR et al. Effect of a vascular access nurse coordinator to reduce central venous catheter use in incident hemodialysis patients: a quality improvement report. AJKD 2009 Jan;53(1):
57 Too Much Information!
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