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QUALITY

IMPROVEMENT STUDY

“DELAYED VASCULAR ACCESS PLANNING RESULTING TO

HIGH INCIDENCE OF CATHETER – RELATED

COMPLICATIONS AT THE HEMODIALYSIS UNIT OF

UNCIANO COLLEGES AND GENERAL HOSPITAL, INC.

FROM JANUARY 2016 TO MAY 2016”

PREPARED AND PRESENTED BY: HEMODIALYSIS UNIT

ROMEO A. LAZARTE JR., RN, CNN

HEAD NURSE

STAFF NURSES:

KYLIE ZARLA A. ESCALONA, RN, CNN

EMMANUEL M. GILLA, RN

NOELLE M. MARZO, RN, CNN



JOHN LOUIE S.T. SOLITARIO, RN



INTRODUCTION

The majority of dialysis patients use hemodialysis (HD) for renal

replacement therapy. At any given time, a patient will have one or more

vascular access in place. Still a large percentage of patients start dialysis with a dialysis catheter in place and, often times, no other vascular

access. An organized approach to the management of vascular access

has been found to be effective in reducing the amount of time a patient

has a catheter in place. Creating a plan for vascular access management

is the best way to ensure an organized approach that will lead to catheter

freedom for your patients.

When an access plan has been created this will decrease the use of

HD catheters and preserve existing accesses for continued use. While the

primary focus of vascular access planning is for patients who are new tohemodialysis, it is also important to work with all patients on HD who do

not have an access plan or are dialyzing with a catheter. The dialysis care

team (DCT) must create an access plan and checking, using routine

access monitoring that supports early intervention when access

problems are identified. This will decrease the use of HD catheters and

preserve existing accesses for continued use. An access event requiring

intervention or changes to the access plan may provide an opportunity

for the DCT to explore different treatment options with the patient.

Health status and other factors may limit the options available for anindividual patient, but taking the time to evaluate these choices is

recommended. Choices may include:

• Peritoneal dialysis (PD) - a home dialysis method.

• Kidney transplant- receipt of a kidney from a living or deceased

donor.

The DCT should provide information and arrange for the necessary

referrals in support of patients who want to explore other options.

A vascular access is a hemodialysis patient’s lifeline. It makes life-

saving hemodialysis treatments possible; it should be in place weeks or

months before the first hemodialysis treatment. Patients should set up a

vascular access well before starting hemodialysis, as AV fistulas and AV

grafts both need time to mature before they are ready for use.



If kidney disease has progressed quickly, a patient may not have

time for placement of an AV fistula or AV graft before starting

hemodialysis treatments. Venous catheters are not ideal for long-term

use. With a venous catheter, a patient may develop a blood clot, an

infection, or a scarred vein, causing the vein to narrow.

This quality improvement study focuses on the underlying factors

regarding high incidence of catheter complications in the hemodialysis

unit, having the delayed vascular access planning as our main cause. We

also aim to formulate strategies to provide an efficient treatment and

promote patient’s safety and satisfaction as well, by means of developing

a reliable and effective access plan, for those who are newly diagnosed

with End Stage Renal Disease and regular hemodialysis patients.

ABSTRACT

The course of this study is ranging from January to May 30, 2016

at Unciano Colleges and General Hospital, Inc., Dialysis Unit (2nd Floor)

at Antipolo City.

The scope of this study focused on determining the underlying

factors regarding the high incidence of catheter related hemodialysis

complications, which leads us to come up with the topic“Delayed

Vascular Access Planning Resulting to High Incidence of Catheter-related

Hemodialysis Complications” at Hemodialysis Unit of Unciano Colleges

and General Hospital, Inc.

This quality improvement study also focused on improving the

awareness of patients and relatives regarding the importance of having a

permanent vascular access as soon as primary option for maintaining

hemodialysis treatment.

OBJECTIVES

At the end of this quality improvement study by the end of June

30, 2016 onwards, the researchers from DIALYSIS UNIT (2nd Floor) of

Unciano Colleges and General Hospital, Inc. aims the following:



1.Identify the contributory factors resulting to the high incidence of

catheter – related infections.

2.Determine the roles of the entire Dialysis Care Team (DCT),

together with the patient, on eradicating the increasing morbidity

and mortality rates concerning catheter – related complications by

means of creating an effective vascular access plan, as well as to

involve the patients in the plan of care.

3.Formulate best strategies to improve the process of vascular access

planning through patient education, strong collaboration of the

entire Dialysis Care Team (DCT), and continuous monitoring and

evaluation of the vascular access of the patients.

I. PROBLEM IDENTIFICATION AND SELECTION

I.A. Identification of Potential Problems

A.Unavailability and Delayed delivery of stocks resulting to delayed

treatments

B.Defective/Outdated Machines affecting Treatment Efficiency

C.Delayed Vascular Access Planning Resulting to High Incidence of

Catheter – Related Complications

I.B. Prioritization and Selection of Problems

Potential

Problem

MI SI Av Ef Fe Id Total

A 1 2 1 1 2 2 9

B 3 2 2 2 1 2 12

C 3 3 2 3 2 3 16

Scale:

3 – High Rating 2 – Medium Rating 1 – Low Rating

Legend:



MI – Medical Importance of the problem

SI – Social Importance of the problem

Av – Availability of safe and effective method for solving the problem

Ef – Effectiveness and efficiency of the currently used method

Fe – Feasibility of carrying out remedial actionsId – Identifiable of the problem

I.C. Selection of the Problem

“Delayed Vascular Access Planning Resulting to High

Incidence of Catheter – Related Complications”

I.D. Statement of the Problem

Based from the data collected, there were 55 total number of

patients admitted from January 2016 to May 2016 at the Dialysis Unit of

Unciano Colleges and General Hospital Inc. During these dates, the

researchers collected the total number of patient awaiting for a vascular

access implant, undecided to undergo the procedure, and the incidence

of catheter – related complications.

From January 2016 to May 2016, there were 16 total number of

catheter – related hemodialysis complications. The highest incidence of

incomplete treatments occurred during January 1-31, 2016, which is 5

(31.25%).

These incidences of catheter – related complications are highly

associated with the delay of having a permanent vascular access in

place. More importantly, these data reflect a combination of factors,

including absent or late placement of the permanent vascular access

(AVF, and AVG) due to late referral of patients for nephrological care,

patient anxiety and resistance to accepting and participating in plans for

renal replacement therapy, lack of funding for patients with the

opportunity to have a vascular access placed before the need for dialysis,

and challenges posed by the inability to precisely predict the occurrence

and timing of imminent dialysis therapy. Other contributory factors



concerned are the delay and failure of the permanent vascular access to

mature and maintain long – term patency.

MONTH

Total

No. of

Census

Total No. of

Patients

Awaiting for

Vascular Access

Implant

Total No. of Patients

Undecided to Undergo Vascular Access Implant

(AVF,AVG)

Total No.

Incidence ofCatheter

Infections

January 47 8 7 5

Februar

y51 7 6 4

March 54 6 6 3

April 55 6 4 2

May 55 4 2 2

TOTAL 31 25 16





I.E. FORMULATION OF THE SYSTEM





II-A. Process of the System

Key Task Standard

Performances

Indicator Target

1. HD NODidentifies the

candidates for

permanent

vascular

access

implant.

HD NODdetermines the

total number of

patients that are

candidate for AVF

or AVG implant.

No. of times HD NODidentifies the candidates

for permanent vascular

access implant / No. of

incidence of catheter –

related complications x

100

100%

2. HD NOD

educates

patient

regarding

advantages,

options, and

process of

obtaining a

permanent

vascular

access.

HD NOD educates

the importance of

having a

permanent access

available for

hemodialysis

therapy.

No. of times HD NOD

educates patient

regarding advantages,

options, and process of

obtaining a permanent

vascular access / No. of



100

100%

3. HD NOD

refers patientto TCVS for

vascular

mapping and

further

surgical

evaluation.

Patient is referred

to TCVS for vascular mapping

and further

surgical

evaluation

regarding

choosing the

applicable

permanent

vascular access.

No. of times HD NOD

refers patient to TCVS for vascular mapping and

further surgical

evaluation / No. of



100

100%

4. HD NOD

monitors the

vascular

access for

signs of

infection and

HD NOD performs

vascular access

monitoring and

assessment to

check for any

signs of infection

No. of times HD NOD

monitors vascular access

integrity and

maturation / No. of



100%



maturation and maturation of

the access.

100

5. HD NOD

educates

patientregarding

proper care of

vascular

access

HD NOD educates

the patient

regarding theproper self –

monitoring and

care of their

vascular access.

No. of times HD NOD

educates patient

regarding vascular accesscare / No. of incidence of

catheter – related

complications x 100

100%

6. HD NOD

plans for the

removal of

catheter

together with

the patient

HD NOD plans the

timetable for the

removal of

catheter of the

patient

No. of times HD NOD

plans for the removal of

catheter / No. of



100

100%

7. HD NOD

follows

cannulation

protocol and

permanent

vascular

access

monitoring

andsurveillance.

HD NOD follows

the algorithm for

cannulation

procedures and

permanent

vascular access

monitoring and

surveillance.

No. of times HD NOD

follows cannulation

protocol and permanent

vascular access

monitoring and

surveillance / No. of



100

100%

8. HD NOD

Re-evaluates

the vascular

access for full

integrity and

maturity.

HD NOD reassess

the readiness of

the vascular

access for

permanent usage

by inspecting full

maturity after 3

consecutive

successfulcannulations.

No. of times HD NOD Re-

evaluates the vascular

access for full integrity

and maturity / No. of



100

100%

9. HD NOD

performs

catheter

removal

aseptically.

HD NOD performs

the removal of

catheter

aseptically.

No. of times HD NOD

performs catheter

removal aseptically / No.

of incidence of catheter –


100%



100

III. PROBLEM ANALYSIS

III-A. Verification of the Problem

KEY TASK

TOTAL NO. OF

INCIDENCE OF

CATHETER

RELATED –

COMPLICATIONS

NO. OF

INCIDENCEMEASUREMENT TARGET

1. HD NOD

identifies the

candidates for

permanent

vascular access

implant.

16 7(7/16) x 100

= 43.75 %100%

2. HD NOD

educates patient

regarding

advantages,

options, and

process ofobtaining a

permanent

vascular access.

16 8(8/16) x 100

= 50 %100%

3. HD NOD refers

patient to TCVS

for vascular

16 6 (6/16) x 100

= 37.5 %

100%



mapping and

further surgical

evaluation.

4. HD NOD

monitors the vascular access

for signs of

infection and

maturation

16 0(0/16) x 100

= 100 %100%

5. HD NOD

educates patient

regarding proper

care of vascular

access

16 13(13/16) x 100

= 81.25 %100%

6. HD NOD plansfor the removal of

catheter together

with the patient

16 0(0/16) x 100

= 100 %100%

7. HD NOD

follows

cannulation

protocol and

permanent

vascular accessmonitoring and

surveillance.

16 8(8/16) x 100

= 50 %100%

8. HD NOD Re-

evaluates the

vascular access

for full integrity

and maturity.

16 6(6/16) x 100

= 37.5 %100%

9. HD NOD

performs

catheter removalaseptically.

16 4

(4/16) x 100

= 25% 100%



III-B. Verification of Factors Causing the Problem

III-B.1. Balloon Chart



III-B.2. Ishikawa Diagram



III-C. Validation of Probable Cause

III-C.1. Data Collection

Frequency Distribution of Root Causes of Delayed Vascular Access

Planning Resulting to High Incidence of Catheter – Related Complications At The Hemodialysis Unit of Unciano Colleges And General Hospital, Inc.

ROOT CAUSES

FREQUE

NCY

PERCENTA

GE

Cumulativ

e %

A.Patient undecided to

have Permanent Vascular

Access

1. Financial Constraints

2. Low Socio-economic

status

3. Unemployment

1 6% 6%

B. Contamination of

Central Venous Catheters

1. Exposure of CVC to

external environment

2. Dressing dressing comes

off/manually removed

3. Dressing gets wet due to

sweat/when taking a bath;

Activity or during sleep

2 13% 19%

C. Patient anxiety &

resistance to

accept/participate in HD

Treatment

1. Patient is unprepared to

have HD

2. Patient still in denial of

their present condition

1 6% 25%

D. Failure of PVA’s

(AVF/AVG) to mature

1. Encountered Vascular

access complication (e.g.

thrombosis

2. Due to comorbid

conditions (e.g. DM)

3. Improper PVA care &

monitoring

2 13% 38%

E. Delayed referral to

Nephrologist

1. Patient unaware of their

present condition

2. Lack of Knowledge aboutHD Treatment

1 6% 44%

F. NOD breaks aseptic

technique

during catheter dressing

1. Improper handwashing

and not wearing/changing

PPE’s

2. Time cramming and

inavailability of stocks

3 19% 63%



G. Defective

Extracorporeal Circuit

1. Cracked/ improperly

fitted caps

2. Manufacturer defect

1 6% 69%

H. Clotted catheters

1. Catheter is not properly

heparinized

2. Patients are known

clotters

1 6% 75%

I. Contaminated Supplies

1. Exposure to air

2. Not properly sterilized or

covered well

3. Lack of time

management

1 6% 81%

J. Accumulation of dirt &

hair

around the drressing

1. Improper hygiene/

Presence of pets at home

2. Lack of patienteducation

1 6% 88%

K. Presence of Airborne

Pathogens within the

facility

1. Contaminated

circulating air around the

premises

2. Irregular terminal

cleaning or sanitation of

the entire unit

1 6% 94%

L. Presence of Airborne

Pathogens

inside the Pt’s house

1. Contamination of

Patient’s

belongings2. Unclean home

1 6% 100%

TOTAL 16 100%



IV. OBJECTIVE SETTINGS

Target Setting:

To decrease the incidents of catheter related complications, researchers

targets to aim the following by the end of June 2016, in the Dialysis Unit (2nd

Floor) of Unciano Colleges and General Hospital, Inc.:

IV-A. Formulation of Solutions

A. BRAIN STORMING

B. ALTERNATIVE SOLUTIONS

C. SELECTION OF SOLUTIONS

Scale:

3 – High Rating 2 – Medium Rating 1 – Low Rating

Legend:

MI – Medical Importance of the problem



SI – Social Importance of the problem

Av – Availability of safe and effective method for solving the problem

Ef – Effectiveness and efficiency of the currently used method

Fe – Feasibility of carrying out remedial actions

Id – Identifiable of the problem

IV-B. Most Probable Solutions

ROOT CAUSES Potential Solutions

M

I

S

I

A

v

E

f

F

e

I

d

TOT

A

A.Patient

undecided to have

Permanent Vascular Access

1. Financial

Constraints

2. Low Socio-economic

status

3. Unemployment

1. Provide referrals to

social serv

ice assistance and

politicians.

2. Encourage to find

alternative means of

gaining income.

1 3 1 1 2 1 9

B. Contamination of

Central Venous

Catheters

1. Exposure of CVC to

external environment

2. Dressing dressing

comes off/manually

removed

3. Dressing gets wet

due to sweat/whentaking a bath; Activity

or during sleep

1. Educate patient and

relatives to keep catheter

dressing intact and dry.

2. Advice patient to refrain

from sleeping on the side

where catheter is inserted

3. Educate patients

regarding maintaining the

catheter site dry and intactat all times and

encouraged to have sponge

bath near the affected

area.

3 3 3 3 3 3 18

C. Patient anxiety &

resistance to

accept/participate

in HD Treatment

1. Patient is +

unprepared to have HD

2. Patient still in denial

of their present

condition

1. Patient education

regarding importance of

HD.

2. Assist patient to

accepting present

condition by reality

presentation.

2 3 1 1 1 2 10



D. Failure of PVA’s

(AVF/AVG) to

mature

1. Encountered

Vascular access

complication (e.g.

thrombosis

2. Due to comorbidconditions (e.g. DM)

3. Improper PVA care &

monitoring

1. Referral to nephrologist

or TCVS for appropriate

medical/surgical

intervention

2. Referral to attending

physician for management

of other conditions

3. Educate patient

regarding proper care and

regular monitoring of their

vascular access

3 3 3 3 3 3 18

E. Delayed referral

to Nephrologist

1. Patient unaware of

their present condition

2. Lack of Knowledge

about HD Treatment

1. Early consultation and

referral to nephrologist to

determine their current

health condition.

2. Patient education

regarding the benefits of

complying withhemodialysis treatment.

3 3 2 2 3 3 16

F. NOD breaks

aseptic technique

during catheter

dressing

1. Improper

handwashing and not

wearing/changing

PPE’s

2. Time cramming and

inavailability of stocks

1.NOD must observe and

comply on proper hand

washing and wearing /

changing PPE’s at all

times

2. Practice time

management at all times

and notify manufacturers

ahead of time.

3 3 3 3 3 3 18

G. Defective

Extracorporeal

Circuit

1. Cracked/ improperly

fitted caps

2. Manufacturer defect

1. NOD to double check

caps to be used

2.abruptly inform

suppliers about defective

supplies

3 2 3 2 3 3 16

H. Clotted catheters

1. Catheter is not

properly heparinized

2. Patients are known

clotters

1. NOD must always check

proper heparinization of

catheters.

2. Referral to nephrologist

for medical intervention.

3 2 3 3 3 3 17

I. Contaminated

Supplies

1. Exposure to air2. Not properly

sterilized or covered

well

3. Lack of time

management

1. Ensure that all supplies

were covered or sealed

properly.

2. Proper sterilization or

disinfection of supplies.

3. Practice time

management at all times.

3 1 3 2 3 2 14



J. Accumulation of

dirt & hair

around the

drressing

1. Improper hygiene/

Presence of pets at

home

2. Lack of patient

education

1. Encourage maintenance

of proper hygiene and

minimize exposure to pets.

2. Educate patients

regarding proper care of

their central venous

catheters.

1 3 1 1 1 3 10

K. Presence of

Airborne Pathogens

within the facility

1. Contaminated

circulating air around

the premises

2. Irregular terminal

cleaning or sanitation

of the entire unit

1. Maintain regular air

sanitation by using air

sanitizers or UV lamps.

2. Maintain regular

cleaning and sanitation of

the entire unit.

1 3 3 3 3 3 16

L. Presence of

Airborne Pathogens

inside the Pt’s

house

1. Contamination of

Patient’s

belongings

2. Unclean home

1. Encourage patients to

regularly clean or disinfect

their belongings.

2. Advice patient and

relatives to maintain

cleanliness at home.

1 3 3 3 3 3 16

IV-C. Action Plan

ACTIVITY IMPLEMENTOR TARGET

GROUP

TIME

FRAMEEXPECTED RESULT

Identifying patients that are

possible candidates for an

alternative access.

Attending

Physician,

Hemodialysis

Head Nurse and

Staff Nurses

Patients

May 31,

2016

onwards

Decreased incidence of

catheter infections and

further complications on

HD access.

Routine CKD education:Standard CKD and vascular

access education with

coordinated referral from the

physician’s office for all

patients.

AttendingPhysician,

Hemodialysis

Head Nurse and

Staff Nurses

Patients

May 31,

2016

onwards

Patients will become more

aware of their presentcondition and understand

the importance of access

care and monitoring, as

well as they express their

willingness to be involved

in the treatment plan.



Automatic education and

referral for vascular mapping

and surgical evaluation upon

admission of catheter patient

to the dialysis facility.

Attending

Physician,

Thoraco-

Cardiovascular

Surgeon (TCVS),

Hemodialysis

Head Nurse and

Staff Nurses

Patients

May 31,

2016

onwards

Patients will become more

aware of the importance of

vascular mapping and

surgical evaluation before

obtaining a permanent

vascular access.

Construct and Implement

Catheter Reduction Program,

involving the patients in the

plan of care.

Attending

Physician,

Thoraco-

Cardiovascular

Surgeon (TCVS),

Hemodialysis

Head Nurse,

Staff Nurses,

and Patients

Patients

May 31,

2016

onwards

All the members of the

Dialysis Care Team (DCT),

as well as the patient, will

be able to achieve

reduction of catheters by

implementing permanent

vascular access implant.

Continuous monitoring and

surveillance of vascular

access use.

Attending

Physician,

Thoraco-

Cardiovascular

Surgeon (TCVS),

Hemodialysis

Head Nurse and

Staff Nurses

Patients

May 31,

2016

onwards

Dialysis Care Team will be

able to assess the

progress of the maturation

and readiness of the

particular vascular access

to be used for long-term

therapy.

Monthly meeting of the

dialysis team.

Hemodialysis

Head Nurse

Hemodialysis

Staff Nurses

Every 4th

Week of the

Month

(May-December,

2016)

All members of the

dialysis team will be able

to assess the strengths

and weaknesses of therecently implemented

program.

Continuous monitoring and

evaluation of the

effectiveness of proposed

activities and

recommendations

Hemodialysis

Head Nurse &

Staff Nurses

Hemodialysis

Head Nurse

and Staff

Nurses

May 31,

2016

onwards

All Staff Nurses will

adhere to the proposed

activities and

recommendations.



IV-D. Gantt Chart



V. BENEFITS OF THE STUDY

After solutions were made to solve problems regarding complications on

hemodialysis access, this quality improvement study have come up withsolutions in decreasing incidence among patients undergoing hemodialysis

treatment which is listed as follows:

1.Constant observance of proper PPE use among dialysis staff decreases

contribution to hemodialysis complications.

2.Continuous health education aids in enforcing proper access care in

order to prevent infections and further complications.

3.The emphasis of proper care of their hemodialysis access leads to better

access patency thus promoting better health status.

4.Regularly updating HD staffs on ways and means to decrease further

catheter complications.

5. Providing patients options on alternative access placement in case the

current access fails thus continuing HD treatment to prevent further

complications regarding their health.

6. Emphasizing compliance on HD medications such as blood thinners,

antibiotics and hypertensive meds that prevents HD access

complications.



VI. INSTITUTIONALIZATION

Upon achieving the study, the entire Dialysis Care team recognized the

importance to be presented for the benefit of the patients of the entire

institution, as well as the staffs of Unciano Colleges and General Hospital, Inc.

The researchers recommended that the prompt implementation of catheter

reduction program by emphasizing the importance of obtaining a permanent

vascular access is the main key to decrease the high incidence of catheter –

related complications. And these goals will be achieved by means of educating

patients regarding the importance of having a permanent access for use, as

well as to involve them to the implementation of catheter reduction program.

Patient education greatly provides awareness to patients on how can

their health status be improved. Regularly updating patients about their health

condition makes them more cooperative and active about their health

management. When patients are well informed they are more likely to

participate in their health care needs and are actively compliant to health

regimens. When patients are aware of the do’s and don’ts in health

management this tends them to have a positive outlook on their health status.

Moreover, it is important as well to recognize patient’s readiness and

acceptance of their health condition so as health management will be effective.

Acceptance from patients plays a vital role in order to proceed to effective

management. It provides them positive views in life and hope to gain an

optimum level of self-worth thus making them actively participate.

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QUALITY-IMPROVEMENT-STUDY-2016-FINAL-Repaired.doc