….. modifiable factor that can improve experience and outcomes.
The National Kidney Care Audit Vascular Access Report 2011 was published today. This vascular access audit has not been easy to conduct. We had policy drivers and widely endorsed clinical audit measures developed by the Renal Association and Vascular Society of Great Britain and Ireland but, the way local systems are configured, how data is recorded and where it is held, differed between units. In addition, the way teams share responsibilities between disciplines and over time varies considerably. In total 60 of a possible 63 kidney units participated and the quality of the returns was high. This is testament to the leadership and skills of the audit team and the dedication and hard work of the individual kidney care teams in each of these units. They all recognise both the importance of best possible access as a modifiable factor that can improve patient experience and outcome and the central role national comparative audit plays in driving up quality and adding value to direct clinical care.
Creating vascular access for dialysis is a complex process. Planning for dialysis is both culturally and technically challenging. The timing of conversations, decisions, consent and surgery need to take into account the views, attitudes and aspirations of the individual with progressive kidney disease; the often unpredictable rate of decline of kidney function and the coordination of imaging, surgery and medical teams. Successful maturation of an arteriovenous fistula requires care and nurture. There is as yet no standard recipe for monitoring and fistula management to guarantee longevity of access. We do however increasingly recognise the importance of team work – patient, dialysis nurse, nephrologist, radiologist and surgeon, in achieving this goal. Good outcomes therefore require both reliable systems and attention to the human factors upon which success is based. No wonder the audit had been difficult to deliver.
But deliver it has. This report provides valuable insights for all participating kidney care teams and the results are the basis for continuing to involve local patients in quality improvement; small tests of change within units for discussion, debate and sharing best practice within and between kidney care networks providing a platform for future work including the routine collection of dialysis access information by the UK Renal Registry. Improving vascular access is an end in itself. Even more than that, a focus on preparation and choice in the 12 months before renal replacement therapy should also facilitate patient engagement in shared decision making and care planning and accelerated rehabilitation for those who commence dialysis as an emergency. It therefore has the potential to increase live donation and pre-emptive transplantation, promote patient preference in type and place of dialysis and support better conservative kidney care for those who choose the “no dialysis” option. It would be a perverse unit that did not capitalise on the added value opportunities all the hard work on vascular access presents. I look to the kidney services to use this knowledge now to improve care for your patients this year. Also to retain the audit’s know-how so that future patients can benefit from all the efforts that have gone into it. For many people with end stage renal failure better vascular access is the single most important modifiable factor in improving outcomes. Better access leads to fewer infections and as this reporting shows directly correlates with a reduction in the burden of dialysis. This audit is a big step in the right direction. All involved should be congratulated. I am truly impressed by the coverage gained, but don’t be complacent. Getting the best vascular access for every single haemodialysis patient remains a challenge but some teams have shown it is achievable.
60 out of 63 units in England, Wales and Northern Ireland took part in the audit which included 2,078 patient records.
Late referrals (less than 90 days from seeing a renal physician to dialysis) accounted for around one quarter of patients nationally, although this varied across networks.
At first dialysis, 39 per cent of patients had a tunnelled line, 20 had a non-tunnelled line, 1 per cent had an arteriovenous graft (AVG) and 40 per cent an arteriovenous fistula (AVF).
After 3 months, the majority of patients on AVG, AVF and tunnelled lines were using the same access. Those who started on non-tunnelled lines were more likely to have moved to another type of access (most commonly as tunnelled line – 67 per cent)
Late referrals were less likely to have had definitive access (i.e. AVF or AVG) at first dialysis and were less likely to have been referred to a surgeon.
16 per cent of haemodialysis patients had a bacteraemic episode in the six months following first dialysis.
Bacteraemias were more common in patients on venous catheters compared to definitive access – 24 episodes per 100 patients for an AVF, 45 for a non-tunnelled venous catheter and 33 for tunnelled catheters.