Preventative access care

Good morning Dr. Agar,
What is the protocol in your program to make sure patients’ accesses are functioning well? Should they need repairs how is it handled?

Dear Jane

You will exhaust me in the 1st month at this rate … still, here we go again …

First, let me be clear about access. In Australia, the patterns of vascular access are quite different to those of the US. From DOPPS II:

Australia had 77% AVF, 13% Grafts and 10% Catheters
Japan had 91% AVF, 6% Grafts and 3% Catheters
Italy/Germany/France had 80+% AVF, 10% Grafts and 10% Catheters
USA had 33% AVF, 41% Grafts and 27% Catheters

In the Australian catheter group, our data suggests that of the catheter group, only about 1/3rd of our catheter group are regarded as ‘permanent’ catheters while the remainder are catheters while waiting fistula access creation or repair. I suspect the same holds true for the European data.

That said, we can still do better in Australia (as, clearly, so can the US) and try to emulate the Japanese and Europeans who are still well ahead of us both in this regard.

Canada lies about half way between the US and ANZ.

DOPPS III showed little major change from DOPPS II in all contributing data bases except the US which, to give it credit, had improved a little to 47%, 28% and 25% respectively … probably largely due to the efforts of the Fistula First program. Eevn so, the US still does lag far behind the rest of the world in fistula creation and use.

This said, I will only now comment on native fistula care as this is our prime access device here in ANZ and is the centre of our major surveillance effort … and, I suspect, the basis for your question.

The first and most important fistula assessment is self-evident. Fistulae should be, always, first assessed using clinical skills.

Look, touch, feel, prod, play, trace upstream, feel for dips and bumps, sense how the pressure ‘feels’, look for aneurysmal change, for needle infection or for inflammatory changes, check adjacent skin for sterilization fluid irritation, excoriation or flaking, lift the arm to see that fistula pressures collapse with elevation … these and more are all part of a day-to-day and ongoing assessment of normal fistula health. In buttonhole fistulae, look especially for signs of para-button redness or early inflammatory or infective change.

We also routinely apply a Transonic QC™ flow monitor to all fistulae in our unit as part of our 3 month routine surveillance program. Each fistula is ‘Transonic’d’ every 3 months. This is described in a brief PPT presentation given by our Vascular Health Nurse at a 3 day Australian National Nurse Cannulation Skills Workshop we established in Geelong in 2008 and which we will run annually from now on in partnership with Deakin University in Geelong. Our Vascular Health Nurse is a full time position in our service, the role being to …

  1. oversee and conduct the surveillance program

  2. coordinate our vascular access surgical program
    liaise with our 3 specialist vascular surgeons

  3. organise and run our monthly fistula review meeting of all patients with identified AVF problems from the previous 3 months surveillance and all patients pending AVF creation. This meeting is attended by all nephrologists, all vascular surgeons and all junior staff and senior dialysis nursing staff and is our key communication session.

  4. Ensure rapid throughput and adequate surgical operating time is available such that fistulae in all patients get rapid attention … remember, we have a universal health-care program here so all are equal and all get done on the basis of and in the order of need.

The criteria we use as ‘ALERTS’ are detailed in her PPT.

As a conclusion, can I make the following observation …

Each dialysis service must (and does) develop their own individual protocols and practices. These must be (and are) locally tailored to suit to local abilities, staffing conditions and available skills. However, these local practices and protocols should be developed with both national and international guidelines in mind.

These guidelines include, but are not limited to, those that are, for example used in …
(1) the US (KDOQI)
(2) the international system in development (KDIGO)
(3) the BRA guidelines of the UK
(4) our own Australian CARI (Caring for Australians with Renal Impairment) guidelines.

Almost all OECD countries now have their own guidelines (in some format) … Canada has its’ set, so do the French, the Italians … all do.

However, these guidelines are nationally constructed to suit local conditions and thus they do differ, country to country, though in truth they do broadly concur on most issues.

For questions such as the one I have just answered here, you will find many of the answers in these guidelines. There are, for example, guidelines for fistula surveillance where a much more extensive answer can be found than the one I have just given.

Most services attempt to follow and be guided by these various national guideline systems … at least, they do so wherever possible. But, and this is an important ‘but’, we are all individuals – and this applies not only the patients, but to the doctors too – and it is not always possible (or even advisable), especially in an individual patient, to always do exactly what the guideline says or try to achieve exactly what the guideline says can be achieved for the majority.

A guideline is just that … it’s a common course applicable to the majority. It is not always the right course for an individual.

A guideline is a guideline, not a rule or a law. There are situations where a guideline will clearly not suit a particular problem. This is where discussion with your team – who knows the individual circumstances – matters so much and sites like this can lead people astray … and that is inevitably so, despite all the goodwill in the world.

The guidelines for AVF care are available at all these national guideline sites. You will find them on the net. I have given you four such sets above. It behooves us all to note them and, when it is sensible and possible to do so, follow them. We try to.

Now - back to my patients …

John Agar