WHAT’S NEW IN

VASCULAR ACCESS?Katie Fielding,

Chair, BRS VA SIG

Professional Development Advisor –Haemodialysis, Derby Teaching Hospitals NHS Foundation Trust

What is present practice development

aimed at?

Promoting AVF use

• Lowest complication rate

• Associated with the best

outcomes

• Primary failure rate is

high

• Require maturation

period

• Cannulation can be

challenging

Kidney Health: Delivering Excellence

• Developed with bKPA, NKF, BRS + other organisations

• 16 ambitions for kidney services• What patients should expect

• What healthcare providers should be providing

Ambition 6: People approaching ESRD given time, and support to prepare for RRT and choose correct RRT

Pre-emptive transplantation, timely VA and PD catheter insertions … are available to all patients, so that no-one commences dialysis with emergency access where it is avoidable.

http://www.kidneyresearchuk.org/file/media/Kidney-Health-Delivering-Excellence-1709-15-Oct.pdf

Variation in VA in the UK

Taken from UK Renal Registry 18th Annual Report

Caskey F, Castledine C, Dawnay A, Farrington K, Fogarty D,

Fraser S, Kumwenda M, MacPhee I, Sinha MD, Steenkamp

R, Williams NEPHRON 2016;132 (suppl1)

60% of all incident (new) HD patients

80% of all prevalent (existing) patients

have dx via AVF, AVG or Tenckhoff

catheter (Kumwenda et al, 2015)

Focus of Developments in the UK

• Need to increase of AVF and AVG use

• Prepare VA for HD start

• Use of PD / transplantation to avoid need for VA for HD

• Variation in VA care

• How do we reduce?

Scottish Haemodialysis Vascular Access

Appraisal• Completed in 2014/2015

• Scottish Renal registry project

• Reponses to variation in AVF use across centres in Scotland

• Visited 10 units in Scotland, including paediatric unit

• Interviewed patients as well as staff from nephrology, vascular surgery and radiology

• Examined VA outcomes in time period

• http://www.srr.scot.nhs.uk/ Projects/Projects3.html#SVAA

Recommendations

• Service development needs to consider and measure

patient experience of VA

• Patients need educating about VA – not just one off but on

going intervention

• Examined pathways for creation of VA – important for

timely creation of VA

• Patients should have personalised VA strategy

• Maintenance of VA function – pathways and MDT

involvement

• Dialysis unit staff trained in AVF assessment

• VA co-ordinator role

Scottish Haemodialysis Vascular Access

Appraisal

• Created following recommendations

• Allows units to appraise their own VA services

• Identify areas for development

• Various sections• Governance

• Service provision

• Education

Within the UK …..

• National survey of VA services

• Not as detailed as Scottish project

• Survey for VA nurses to complete

• Piloted with top performing units in UK

• Identify what leads to success

• Why there might be variation

• Will be coming to all other units imminently ……

Focus of Developments in the UK

• Need to increase of AVF and AVG use

• Prepare VA for HD start

• Use of PD / transplantation to avoid need for VA for HD

• Variation in VA care

• How do we reduce?

• Structure of VA service and service provision

• Staff are key

• Patient experience

• xx

British Renal Society Vascular Access

Special Interest Group• Created in December 2015

• Focus is care of VA once in place

• Preservation of VA

• Reduce complications

• Improved patient experience

• 2 sets of recommendations• Buttonhole cannulation

• Life Threatening Haemorrhage

What is Buttonhole Technique?• Cannulate A-V Fistula vein in exactly the

same place, each cannulation

• Enter the skin through the same site

• Enter the vein in same direction and depth

• Remove the scab prior to cannulation

• Track development phase

• Develop a track of scar tissue and entry

point on vein

• Using sharp needle with same cannulator

over number of sessions

• Once track developed, use blunt

needles to cannulate

Benefits of Buttonhole Cannulation

• Prolonging A-V fistula lifespan• Less stenosis formation

• Prevention and reduction of aneurysm development

• Reduction of infiltrations and haematoma formation

• Promotes self-cannulation

• Feasible on tortuous and short AVF veins

• ? Less painful

• ? Shorter bleeding times

• Higher infection risk

• More missed cannulations

The start ….

• Meeting in Manchester – March 2015

Identified

• Using BH correctly is key to success • Reduces infections

• Cannulation practice has room for improvement

• Skill of cannulation needs to be valued

• Patients need to be informed, involved and engaged

• Staff need good quality training

Buttonhole Recommendations

• Collated between:• Evidence from research / expert

opinion

• Experience of units – success with BH / overcome challenges

• 10 units involved

• 6 sections• Key aspects of care

• Each section consists of:• Recommendations

• Rationale for recommendations, with reference to evidence

• Points for future consideration• Require clarification

6 Sections

A. Screening and Selection of Patients

B. Track Development & Cannulation

C. Disinfection and Scab Removal

D. Mupirocin use

E. Patient Engagement

F. Staff Training

http://www.britishrenal.org/NewsLinks/Buttonhole-

Technique-Cannulation-Clinical-Practice.aspx

Cannulation Recommendations

• Developing further to incorporate all cannulation

• Define cannulation techniques

• Choosing cannulation technique

• Assessment pre-cannulation

• How best to perform each technique

• How best to cannulate

• Tools to support implementation

• More in the cannulation workshop ….

Cannulation Recommendations Change

PackageTools

• Decision making tool – cannulation type

• Assessment of AVF / AVG

Education

• ELearning – BRS education committee

• Awareness posters

• National competency package

• Out to pilot imminently

Measurement

• What and how do we audit our cannulation practice?

• How does that impact practice development?

Life-Threatening Haemorrhage

Recommendations• Prevention is key

• Correct management, when it occurs

• Brief and simple

http://www.britishrenal.org/NewsLinks/HHD-Guidance/Recommendations-for-Managing-Life-Threatening-Haem.aspx

Prevention and Management

Prevention

• Detect and escalate early warning signs• Non-healing wound

• Aneurysms increasing in size

• Signs of infection

• Prolonged bleeding post HD

• Shiny thin skin

• Skin integrity issues

• Awareness of early warning signs• HC staff, patients and carers

Management

• Dial 999 immediately

• Attempt to stop bleeding• Use flat, small rigid object

• Not a towel

Measure number of incidents

• Mortality

• Near – misses

• Warning signs

Planned Package for LTH

• Patient Information

• Bleed from AVF / AVG

• CVC dislodgement

• Assessment Tool for AVF / AVG

• Staff Training & Awareness

• PowerPoint / Elearning

• Posters

Focus of Developments in the UK

• Need to increase of AVF and AVG use

• Prepare VA for HD start

• Use of PD / transplantation to avoid need for VA for HD

• Variation in VA care

• How do we reduce?

• Structure of VA service and service provision

• Staff are key

• Patient experience

• Improving VA care once established

• Cannulation of AVF / AVG

• Preventing complications

• Patient experience of VA

KQuIP – Vascular Access

• Kidney Quality Improvement Partnership

• Joint BRS and RA project, supported by UK renal Registry

• Part of the Think Kidneys programme

• Promote and support quality improvement in the renal community

3 Key priorities:

• Transplantation

• Home Therapies

• Vascular Access

https://www.thinkkidneys.nhs.uk/kquip/

Focus of Developments in the UK

• Need to increase of AVF and AVG use• Prepare VA for HD start

• Use of PD / transplantation to avoid need for VA for HD

• Variation in VA care• How do we reduce?

• Structure of VA service and service provision• Staff are key

• Patient experience

• Improving VA care once established• Cannulation of AVF / AVG

• Preventing complications

• Patient experience of VA

• Quality Improvement