Nearly 2 in 3 kidney patients commence haemodialysis using a venous catheter, failing to meet Renal Association and Vascular Society guidelines.
The second National Vascular Access Report was published on 30 March 2011. We have been awaiting the results for some time but there certainly shouldn’t be any complacency about the findings! It makes uneasy reading.
Quality means different things to different people. What does this mean for people with kidney disease? Well for those with advanced chronic kidney disease it means good preparation and choice. For that the individual needs to be well informed, their views, values and aspirations need to shape the decisions. Patient choice is central to high quality care. Good outcomes need involved patients and well organised services as well as time for discussions to enable shared decision making. Decisions about dialysis must involve discussion about all options for dialysis, transplantation and conservative kidney care. Not everyone is suitable for transplantation but when people aren’t or the risks are high, that needs to be explained and discussed with the patient. The reasons should be clearly written in the patient’s record. Similarly, the conservative kidney care or “no dialysis option” needs to be available to everyone and a significant minority now choose this option.
When dialysis is chosen a whole range of other questions arise. Home or hospital? Peritoneal or haemodialysis? When the patient’s choice is haemodialysis, planning needs to begin and this includes type of access as well as regime and location of treatment. The simple most important modifiable variable for those starting haemodialysis is successful creation of arteriovenous fistula. A good fistula can literally mean the difference between life and death, can be crucial for home haemodialysis and should ensure a smooth start to dialysis as an outpatient.
So for most people choosing haemodialysis the safe, timely and efficient creation of an effective Arteriovenous fistula is a key quality indicator. For those who start dialysis as an emergency we need accelerated procedures to ensure equity of counselling and support so they have the options and choice including type of access when haemodialysis is preferred.
Few people are totally unconcerned about needling, some are quite apprehensive and some have needle phobia. Peer support from other patients, encouragement from skilled staff and occasionally psychological therapies can help reduce this normal apprehension. Patient choice is very rarely a reason to provide dialysis through a central line. But there can be technical reasons why a fistula or even a graft is not possible. For people who need dialysis through a line a zero tolerance approach to infection is a must. MRSA and other blood stream infections in haemodialysis patients have fallen dramatically over the last few years. We need to remain vigilant about infection. Patients in whom successful fistula formation will not be achieved should not be subjected to futile operations. This requires clinical judgement and leadership. The reasons why fistula formation is not possible should be clearly explained to the patient and exception reported in the notes.
This audit has only been possible because of the hard work of the central team, the leadership of Dr Richard Fluck, the support of the Renal Registry and the importance individual clinical units place on vascular access as a marker of high quality care. It shows significant variance – that should cause local teams to pause and consider how they can do better. Resources are limited, they need to be used well, and in some units they may need augmenting. Ambition should not be limited.
I see this audit as a start, in time we will need to collect different things. The introduction of best practice tariff for dialysis via a fistula will, I hope, provide a stimulus for earlier creation of vascular access. We know that experience and outcomes are dependent on team working, unit culture and individual behaviours. The importance of preparation and choice was articulated in the National Service Framework, it is here to stay, and during these difficult times for the NHS ensuring that we offer patients the full range of options and support them in making good choices is key to improving outcomes.
Vascular access is important in its own right but it is also a measure of preparation, patient engagement and can also be the driver for improvement in choice of renal replacement therapy or conservative kidney care.