Comprehensive Approach to Improve Quality of Life in Hemodialysis Patients by Early Creation of Arteriovenous Access

Abstract

An arteriovenous fistula (AVF) is the closest to the ideal model of vascular access. Evidence suggests that people who approach end-stage kidney disease may have an arteriovenous fistula surgically created proactively, enabling the elimination of Permcath insertion for dialysis. Consequently, this proactive action will reduce the risk of bacteremia and admissions to inpatient services for this vulnerable population. The current mean waiting time for AVF creation in King Fahd Armed Forces Hospital, Jeddah (KFAFH), was 172 days. The aim of the project was to decrease the adult Chronic Kidney Disease patient mean waiting time for arteriovenous (AV) access creation from a mean of 172 days to less than 10 days within 12 months. The project was carried out in the Chronic Kidney Disease patient population of King Fahd Armed Forces Hospital, Jeddah. The Plan Do Study Act rapid cycles Quality improvement method was used to implement changes. The interventions include a multidisciplinary approach as the base for the new AVF strategy. Identification of CKD Stage IV patients with impending dialysis was booked for early AVF, thereby reducing the need for Permcath. An additional renal clinic was established to update the patients waiting time for AVF creation and to book patients as Day-surgery through fast track. Daily rounds in the dialysis unit were introduced to address issues of new patients on hemodialysis, and the waiting time for each patient was revised and booked to the new renal clinic for AVF creation. This reduced the referral time to the vascular clinic. Centralized approach by requesting early venogram & venous mappings. The addition of a dedicated inpatient bed for advanced access surgery like AV graft, superficialization, and bridging for patients on anti-coagulation was allotted. Addition of a dedicated operating room for at least daily AVF creation apart from the regular operating list. Addition of 1 more day to existing 1 day per week schedule for Day case procedures with 2 day surgery beds for vascular access. During the 1st PDCA cycle, the mean waiting time for AVF Access decreased to 127.75 days; during the 2nd PDCA cycle, the mean time decreased to 34.25 days, and during the 3rd PDCA cycle the project achieved proactive AVF access with the mean waiting time at -7.2 days. None of the patients with newly created AVF access developed steal syndrome during the project period. AV fistulae have a longer median survival, require less costly and invasive intervention to maintain patency and are less likely to become infected than AV graft or Permcath. A multidisciplinary team approach proved to be successful in reducing the mean AVF waiting time for hemodialysis patients. The interventions enable the team to perform proactive AVF creation in a timely manner eliminating the use of Permcaths for newly admitted Hemodialysis patients. Thus, reducing the CLABSI rate.