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Vascular Access Assessment,

Monitoring, and Surveillance

Svetlana (Lana) Kacherova, ESRD Network 18, QI Director

WebEx session, December 18, 2008

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Special Acknowledgement forSpecial Acknowledgement forContent Contributions:Content Contributions:

RMS Lifeline, Inc.RMS Lifeline, Inc.DaVita, Inc.DaVita, Inc.

John White, RN, Manager, John White, RN, Manager, Outreach and EducationOutreach and Education

Irina Goykhman, RN, MBAIrina Goykhman, RN, MBALynda K. Ball, RN, BSN, CNNLynda K. Ball, RN, BSN, CNNQI Director, ESRD Network 16QI Director, ESRD Network 16

Y. Foli Sekyema, MDY. Foli Sekyema, MDDanville Urologic ClinicDanville Urologic Clinic

Session ObjectivesSession Objectives

Project DescriptionProject Description Increase understanding of vascular access Increase understanding of vascular access

monitoring and surveillance and new CFC monitoring and surveillance and new CFC requirements requirements

Learn something newLearn something new

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Vascular Access Challenges in the Vascular Access Challenges in the US.US.

Major cause of morbidityMajor cause of morbidity Many lost HD hoursMany lost HD hours Most Hospitalizations for HD patientsMost Hospitalizations for HD patients High $ Cost to Health Care SystemHigh $ Cost to Health Care System Current Medicare expenditures for ESRD are in excess Current Medicare expenditures for ESRD are in excess

of $21 billion annually (5-7% of total Medicare of $21 billion annually (5-7% of total Medicare expenditures, for only 1% of Medicare beneficiariesexpenditures, for only 1% of Medicare beneficiaries

Best type least used in the US – AV FistulaBest type least used in the US – AV Fistula

V551: Vascular Access Monitoring V551: Vascular Access Monitoring “ “ The patient’s vascular access must be The patient’s vascular access must be

monitored to prevent access failure, including monitored to prevent access failure, including monitoring of arteriovenous grafts and monitoring of arteriovenous grafts and fistulae so symptoms of stenosis”fistulae so symptoms of stenosis”

““The facility must have an on-going program The facility must have an on-going program for vascular access monitoring and for vascular access monitoring and surveillance for early detection of failure to surveillance for early detection of failure to allow timely referral of patients for allow timely referral of patients for intervention when indications of significant intervention when indications of significant stenosis are present.”stenosis are present.”

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V551: Vascular Access Monitoring V551: Vascular Access Monitoring

Patient education should address self-Patient education should address self-monitoring of the vascular access”monitoring of the vascular access”

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V 551: Monitoring StrategiesV 551: Monitoring Strategies

Physical examinationPhysical examination Observance of changes in adequacy or in Observance of changes in adequacy or in

pressures measured during dialysis, pressures measured during dialysis, difficulties in cannulation or in achieving difficulties in cannulation or in achieving hemostasishemostasis

Precipitating events should also be noted, Precipitating events should also be noted, such as hypotension and hypovolemiasuch as hypotension and hypovolemia

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V 551: Surveillance StrategiesV 551: Surveillance Strategies

Include devise-based methods such as Include devise-based methods such as access flow measurementaccess flow measurement

Direct or derived static venous pressure Direct or derived static venous pressure ratiosratios

Duplex ultrasound, etcDuplex ultrasound, etc

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Documentation Requirements:Documentation Requirements: Medical record should show evidence of Medical record should show evidence of

periodic monitoring and surveillance of periodic monitoring and surveillance of AVG or AVFAVG or AVF

Could be dialysis treatment record, progress Could be dialysis treatment record, progress notes, or a separate lognotes, or a separate log

A member of the facility staff must review A member of the facility staff must review the VA monitoring/surveillance the VA monitoring/surveillance documentation to identify adverse trends documentation to identify adverse trends and take action if indicatedand take action if indicated

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Additional Vascular Access Related Additional Vascular Access Related V-Tags:V-Tags:

V 147 & V 148 – Infection ControlV 147 & V 148 – Infection Control V 551 – Patient assessment – evaluation of V 551 – Patient assessment – evaluation of

dialysis access type for maintenance dialysis access type for maintenance V 633 – QAPI condition addressing V 633 – QAPI condition addressing

vascular access monitoring and surveillancevascular access monitoring and surveillance

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V626 QAPI Condition StatementV626 QAPI Condition Statement

The dialysis facility must develop, implement, The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, maintain and evaluate an effective, data driven, quality assessment and performance improvement quality assessment and performance improvement program with participation by the professional program with participation by the professional members of the interdisciplinary team...members of the interdisciplinary team...

……The dialysis facility must maintain and The dialysis facility must maintain and demonstrate evidence of its quality demonstrate evidence of its quality improvement and performance improvement improvement and performance improvement program for review by CMSprogram for review by CMS

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Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The Progress: The Progress:

Stenosis Monitoring Project: Inclusion Stenosis Monitoring Project: Inclusion Criteria for Participating Facilities:Criteria for Participating Facilities:

Based on the results of the 2008 Stenosis Based on the results of the 2008 Stenosis Monitoring ScanMonitoring Scan

Facilities that either do not perform Facilities that either do not perform monitoring and surveillance or perform monitoring and surveillance or perform dynamic venous pressure only (N= 15)dynamic venous pressure only (N= 15)

Facilities that did not respond to the scanFacilities that did not respond to the scan

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Monitoring and Surveillance:Monitoring and Surveillance:

Access DevelopmentAccess Development Infection rateInfection rate ThrombosisThrombosis Other ComplicationsOther Complications

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Benefits of Access Monitoring Benefits of Access Monitoring and Surveillanceand Surveillance

Reduce incidence of thrombosisReduce incidence of thrombosis Extended access use-lifeExtended access use-life Reduce time lost from HemodialysisReduce time lost from Hemodialysis Reduce patient morbidity/hospitalizationsReduce patient morbidity/hospitalizations Improve quality of lifeImprove quality of life Reduce health care costsReduce health care costs

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Surveillance TechnologySurveillance Technology Intra Access Flow Intra Access Flow TransonicsTransonics Static Venous HD PressureStatic Venous HD Pressure Dynamic Venous HD PressureDynamic Venous HD Pressure Access recirculationAccess recirculation Unexplained Decrease Delivered HDUnexplained Decrease Delivered HD Doppler UltrasoundDoppler Ultrasound Physical Exam of AccessPhysical Exam of Access ( (arm swelling, prolonged arm swelling, prolonged

bleeding, increased + venous pressure or – arterial bleeding, increased + venous pressure or – arterial pressurepressure

ScheduleSchedule

Infection Incidence – dailyInfection Incidence – daily Developing Access – every weekDeveloping Access – every week Vascular Access Conference – every monthVascular Access Conference – every month Transonics Flow – each 1-2 monthsTransonics Flow – each 1-2 months Team Meeting – every 2-3 monthsTeam Meeting – every 2-3 months External expertise - periodicExternal expertise - periodic

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Action points:Action points:

Decreased Transonics Flow – FistulogramDecreased Transonics Flow – Fistulogram Access Infections?Access Infections? Increased Attention to Detail by all HD staff !!!!Increased Attention to Detail by all HD staff !!!! Identify Needs for More TrainingIdentify Needs for More Training Identify Potential Physician TrendsIdentify Potential Physician Trends Identify Potential HD Facility TrendsIdentify Potential HD Facility Trends Allow Objective comparison with Regional and Allow Objective comparison with Regional and

National AveragesNational Averages

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K-DOQI GuidelinesK-DOQI Guidelines

Kidney Disease Outcomes Quality Initiative Kidney Disease Outcomes Quality Initiative launched in 1995launched in 1995

Evidence-Based Clinical Practice Evidence-Based Clinical Practice Guidelines for patients and health care Guidelines for patients and health care providersproviders

First Guidelines – 1997First Guidelines – 1997 Currently 22 topicsCurrently 22 topics Three-stage review processThree-stage review process

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Guideline 2: Selection and Placement Guideline 2: Selection and Placement of Hemodialysis Accessof Hemodialysis Access

2.1.1- Preferred: AV Fistulae (AVF)2.1.1- Preferred: AV Fistulae (AVF) 2.1.2- Accepted – AV Graft (AVG)2.1.2- Accepted – AV Graft (AVG) 2.1.3- Avoid if possible: Long-Term 2.1.3- Avoid if possible: Long-Term

CathetersCatheters

Fistula First Breakthrough Initiative (FFBI) Fistula First Breakthrough Initiative (FFBI) goal: 66% of hemodialysis patients goal: 66% of hemodialysis patients utilizing AVF by June 30, 2009utilizing AVF by June 30, 2009

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Guideline 4: Detection of Access Dysfunction: Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing.Monitoring, Surveillance and Diagnostic Testing.

4.1. Physical examination (monitoring)4.1. Physical examination (monitoring) 4.2. Surveillance of grafts (preferred)4.2. Surveillance of grafts (preferred) - Intra-access flow- Intra-access flow - Static venous pressure- Static venous pressure - Duplex ultrasound- Duplex ultrasound Surveillance of grafts (acceptable)Surveillance of grafts (acceptable) - Physical findings- Physical findings Unacceptable:Unacceptable: - Unstandardized dynamic venous pressure - Unstandardized dynamic venous pressure

(DPVs) should not be used(DPVs) should not be used

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Guideline 4: Detection of Access Dysfunction: Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance and Diagnostic Testing.Monitoring, Surveillance and Diagnostic Testing.

Surveillance of fistulae (preferred)Surveillance of fistulae (preferred) - Direct Flow Measurements- Direct Flow Measurements - Physical findings- Physical findings - Duplex Ultrasound- Duplex Ultrasound Surveillance of fistulae (acceptable)Surveillance of fistulae (acceptable) - Recirculation (using non-urea based- Recirculation (using non-urea based dilutional method)dilutional method) - Static pressure, direct or derived- Static pressure, direct or derived

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Look, Listen,Feel

AngioplastyFistulagram

Thrombectomy

Continuum of Vascular Access Care

Assessment

Monitoring and Surveillance

Interventions

Documentation

“Everyday” Every shift,

Every patient

Vascular AccessProgram

QIStatic pressure

DVPRecirculation

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Physical AssessmentPhysical Assessment

Inspection (look)Inspection (look) Auscultation (listen)Auscultation (listen) Palpation (feel)Palpation (feel)

Use all of your senses for assessment and thenUse all of your senses for assessment and thenuse your memory to compare and contrast theuse your memory to compare and contrast the

condition of the access to previous assessmentscondition of the access to previous assessments

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InspectionInspection

RednessRedness DrainageDrainage AbscessAbscess

Skin ColorSkin Color EdemaEdema Small blue Small blue

Purple veinsPurple veins

Hands: cold, painful, Hands: cold, painful, numbnumb

Fingers: discoloredFingers: discoloredInfection

Central or Outflow

Veinstenosis

Steal Syndrome

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Is the Access Working Properly?Is the Access Working Properly?

Clearances (URR) greater than 65Clearances (URR) greater than 65 Access flow greater than 600Access flow greater than 600 Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125 Able to run prescriptionAble to run prescription Other signs and symptoms of access pathologyOther signs and symptoms of access pathology

– RecirculationRecirculation– Difficulty cannulating and pain in the accessDifficulty cannulating and pain in the access– Changes in thrill and bruitChanges in thrill and bruit– Prolonged bleeding post-dialysisProlonged bleeding post-dialysis

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Is New AVF Mature? Use the KDOQI Is New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s”

6 - 8 week Post OpCheck AVF Maturation

Diameter Greater than

66 mm

Depth below skin Approximately

6 6 mm

Access Blood Flow Greater than

600 600 mL/Min

6 cm of straight segment

“ “ Rule of 6’s Rule of 6’s ””

Vein Vein MUSTMUST Mature Mature PRIORPRIOR to the to the FIRSTFIRST cannulation cannulation

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Central Stenosis and Occluded VeinsCentral Stenosis and Occluded Veins

Arm swellingArm swelling Prominent veins in the upper chestProminent veins in the upper chest Prominent veins in the armProminent veins in the arm Swollen neck and faceSwollen neck and face Look for signs of catheter on access sideLook for signs of catheter on access side Look for pacemaker or defibrillatorLook for pacemaker or defibrillator

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What Causes the Stenosis?What Causes the Stenosis?

Scaring at the cannulation sites from poor Scaring at the cannulation sites from poor needle rotationneedle rotation

Scaring the vein from the high arterial flowsScaring the vein from the high arterial flows Scaring from implanted devicesScaring from implanted devices Aneurysm and pseudoaneurism formationAneurysm and pseudoaneurism formation Manipulation of veinsManipulation of veins

– Transpositions, translocationTranspositions, translocation

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Physical Findings of Venous Physical Findings of Venous StenosisStenosis

PARAMETERPARAMETER NORMALNORMAL STENOSISSTENOSIS

ThrillThrill Only at the Only at the arterial arterial anastamosisanastamosis

At the site of At the site of stenotic lesionstenotic lesion

PulsePulse Soft, easily Soft, easily compressiblecompressible

Water-Water-hummerhummer

BruitBruit Low pitch, Low pitch, continuous, continuous, diastolic & diastolic & systolicsystolic

High-pitch, High-pitch, discontinuous, discontinuous, systolic onlysystolic only

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Clinical Indicators of StenosisClinical Indicators of Stenosis

Clotting the system 2 or more times/monthClotting the system 2 or more times/month Difficult needle placementDifficult needle placement Persistently swollen armPersistently swollen arm Increased machine pressuresIncreased machine pressures Difficult achieving hemostasis at the end of Difficult achieving hemostasis at the end of

treatmenttreatment Decreased blood pump speedsDecreased blood pump speeds Decreased Kt/V or URR (due to recirculation)Decreased Kt/V or URR (due to recirculation)

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What is Steal Syndrome?What is Steal Syndrome?

Access “steals” blood from the handAccess “steals” blood from the hand Decreased blood supply to the handDecreased blood supply to the hand Causes hypoxia (lack of oxygen) to the Causes hypoxia (lack of oxygen) to the

tissues of the hand resulting in severe paintissues of the hand resulting in severe pain Neurotic damage to the hand can occurNeurotic damage to the hand can occur Without oxygen tissue dies and necrosis Without oxygen tissue dies and necrosis

occursoccurs

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Is Steal Syndrome Serious?Is Steal Syndrome Serious?

Necrotic tissue can not be “fixed” – it must Necrotic tissue can not be “fixed” – it must be removed (amputated)be removed (amputated)

= Risk for infection= Risk for infection = Risk for hospitalization= Risk for hospitalization = Risk for death!= Risk for death!

The Allen Test (within 3 seconds you The Allen Test (within 3 seconds you should see capillary refill)should see capillary refill)

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Flow Methods in Dialysis AccessFlow Methods in Dialysis Access

Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasound (DDU) Magnetic Resonance Angiography (MRA)Magnetic Resonance Angiography (MRA) Variable Flow Doppler Ultrasound Variable Flow Doppler Ultrasound Ultrasound Dilution (Transonics): UDTUltrasound Dilution (Transonics): UDT Crit-Line III or Crit-Line IICrit-Line III or Crit-Line II Glucose Pump InfusionGlucose Pump Infusion Urea DilutionUrea Dilution Differential Conductivity Differential Conductivity In-line Dialysate (FMC) - DDIn-line Dialysate (FMC) - DD

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Color-Flow DopplerColor-Flow Doppler

Outpatient radiological procedure done Outpatient radiological procedure done quarterlyquarterly

Also called duplex ultrasound or duplex Also called duplex ultrasound or duplex Doppler studyDoppler study

Evaluates access flow patterns as well as Evaluates access flow patterns as well as areas of access stenosisareas of access stenosis

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Ultrasound Dilution Technique Ultrasound Dilution Technique (Transonics)(Transonics)

Conducted quarterly or as necessaryConducted quarterly or as necessary AKA Crit-Line III or Crit-line TKAAKA Crit-Line III or Crit-line TKA Very popular, but not all facilities have Very popular, but not all facilities have

transonics on-sitetransonics on-site

Transonics Flow:Transonics Flow:

AV Graft – once a month, if stable – every AV Graft – once a month, if stable – every 2-3 months.2-3 months.

AV Fistula – every 2-3 monthsAV Fistula – every 2-3 months Flow:Flow:

- < 600 ml/min every month with 15% - - < 600 ml/min every month with 15% - fistulogramfistulogram

- > 1000 ml/min- > 1000 ml/min

- 25% decrease- 25% decrease40

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Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)

Conducted and recorded at the beginning of Conducted and recorded at the beginning of each treatment at a each treatment at a specifiedspecified blood flow rate blood flow rate using specified/consistent needle sizeusing specified/consistent needle size

Non-standardized dynamic venous pressure Non-standardized dynamic venous pressure are considered are considered as unacceptable as unacceptable monitoring monitoring method by the K/DOQI workgroupmethod by the K/DOQI workgroup

Acceptable method for Acceptable method for AVFs only! AVFs only! (KDOQI 2006)(KDOQI 2006)

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Static Venous Pressure (SVP)Static Venous Pressure (SVP)

Following a unit-specific procedure for Following a unit-specific procedure for measurement of venous and arterial measurement of venous and arterial measures at zero blood flowmeasures at zero blood flow

Conducted at least every 2 weeksConducted at least every 2 weeks Measurements plugged into mathematical Measurements plugged into mathematical

formulaformula Ratio > 0.5 is considered abnormalRatio > 0.5 is considered abnormal Refer for fistulagram after 3 abnormal Refer for fistulagram after 3 abnormal

readings readings

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Other MethodsOther Methods

On-Line-Clearance (OLC) – conducted On-Line-Clearance (OLC) – conducted quarterly – Fresenious technology)quarterly – Fresenious technology)

Magnetic Resonance AngiographyMagnetic Resonance Angiography

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KDOQI Guideline 4: When to refer for KDOQI Guideline 4: When to refer for evaluation (diagnosis) and treatment:evaluation (diagnosis) and treatment:

Do not respond to a single isolated episodeDo not respond to a single isolated episode Look for persistent abnormalitiesLook for persistent abnormalities Access flow rate <600 mL.min for AVG Access flow rate <600 mL.min for AVG

and 400 to 500 mL/min in AVFand 400 to 500 mL/min in AVF A venous segment static pressure (mean A venous segment static pressure (mean

pressures) ratio > 0.5 n AVG or AVFpressures) ratio > 0.5 n AVG or AVF An arterial segment static pressure ratio > An arterial segment static pressure ratio >

0.75 in AVG 0.75 in AVG

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Medicare Guidelines for ReferralMedicare Guidelines for Referral Venous outflowVenous outflow

– Elevated venous pressureElevated venous pressure– Prolonged bleedingProlonged bleeding– Decreased URRDecreased URR– Decreased Kt/VDecreased Kt/V– RecirculationRecirculation– Swelling of the extremitySwelling of the extremity– Pulsatile graftPulsatile graft– Loss of thrillLoss of thrill– AneurysmsAneurysms– Difficult or painful Difficult or painful

cannulationcannulation

Arterial inflowArterial inflow– Low pressure in graft when Low pressure in graft when

outflow is occludedoutflow is occluded

– Ischemic changes in Ischemic changes in extremityextremity

– Diminished intra-access Diminished intra-access flow (AKA: arterial pulling flow (AKA: arterial pulling negative)negative)

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How often for Angioplasty?How often for Angioplasty?

Some lesions are elasticSome lesions are elastic Once scar starts to grow, it continuesOnce scar starts to grow, it continues Scar grows at a different paceScar grows at a different pace Acceptable interval is approximately 6 monthsAcceptable interval is approximately 6 months May be more often, depending on the caseMay be more often, depending on the case

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Why Angioplasty?Why Angioplasty?

Improves blood flow for better dialysisImproves blood flow for better dialysis Decreased the rate of thrombosis of the accessDecreased the rate of thrombosis of the access Prevents the need for surgeryPrevents the need for surgery Extend the life of the access (from 2 to 7 years)Extend the life of the access (from 2 to 7 years) There is a finite number of sites for an accessThere is a finite number of sites for an access

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All Patient should be taught how to:All Patient should be taught how to:

Compress a bleeding accessCompress a bleeding access Wash skin over access with soap and water daily Wash skin over access with soap and water daily

and before HDand before HD Recognize s/s of infectionRecognize s/s of infection Select proper methods for exercising fistula arm Select proper methods for exercising fistula arm

with some resistance to venous flowwith some resistance to venous flow Palpate for thrill/pulse dailyPalpate for thrill/pulse daily Listen for bruit with ear opposite access if can’t Listen for bruit with ear opposite access if can’t

palpate for any reasonpalpate for any reason

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All patients should know to:All patients should know to:

Avoid carrying heavy items and wearing occlusive Avoid carrying heavy items and wearing occlusive closing over accessclosing over access

Avoid sleeping on the access armAvoid sleeping on the access arm Be aware of site rotation (unless buttonhole Be aware of site rotation (unless buttonhole

cannulation method is used)cannulation method is used) Be aware of proper skin preparation and Be aware of proper skin preparation and

importance of staff wearing masksimportance of staff wearing masks Report and s/s of infection and absence of Report and s/s of infection and absence of

bruit/thrill to staff bruit/thrill to staff immediatelyimmediately

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In ClosingIn Closing The patient’s dialysis access is his or her The patient’s dialysis access is his or her

lifeline; it is the job of the entire team to try to lifeline; it is the job of the entire team to try to maintain it through routine monitoring and maintain it through routine monitoring and surveillancesurveillance

Team education is keyTeam education is key Patients who are able to should be taught how to Patients who are able to should be taught how to

assess their own accessassess their own access Listen to the patientListen to the patient Follow up on the procedure reportFollow up on the procedure report

Project Timelines:Project Timelines:

To implement accepted monitoring and To implement accepted monitoring and surveillance procedures by April 1, 2009.surveillance procedures by April 1, 2009.

To submit Policy & Procedure to the To submit Policy & Procedure to the Network by April 15, 2009Network by April 15, 2009

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QUESTIONS?QUESTIONS?

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