what’s new in vascular access? - edtnaerca.org · what is buttonhole technique? •cannulate a-v...
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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