3. vascular access audit 2014 - nhs wales. vascular access audit 2… · vascular access audit 2014...
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Vascular Access Audit 2014
Mike Stephens
Chairman All Wales Vascular Access Group
All Wales Vascular Access Group
• Provide a forum for agreeing standards and plans, the sharing
of information, and provide advice to the Renal Network
• Philosophy is to work collaboratively in discussing clinical
practice issues, strategies and policies. practice issues, strategies and policies.
• Meet twice yearly
Renal Association Clinical Practice Guidelines
Vascular Access for Haemodialysis
Fluck and Kumwenda 2011
60%
70%
80%
90%
100%
PERCENTAGE INCIDENT PATIENTS ON FUNCTIONING AVF TO TARGET2010-2011 Q3 & Q4, 2011-2012, 2012-2013 AND 2013-2014
Bangor
Cardiff
Incident patients
0%
10%
20%
30%
40%
50%
Q3 2010
Q4 2010
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
Q1 2013
Q2 2013
Q3 2013
Q4 2013
Glan Clwyd
Swansea
Wrexham
Target 65%
Incident target 65%
60%
70%
80%
90%
100%
PERCENTAGE PREVALENT PATIENTS ON FUNCTIONING AVF TO TARGET2010-2011 Q3 & Q4, 2011-2012, 2012-2013 AND 2013-2014
Bangor
Cardiff
Prevalent patients
0%
10%
20%
30%
40%
50%
Q3 2010
Q4 2010
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
Q1 2013
Q2 2013
Q3 2013
Q4 2013
Glan Clwyd
Swansea
Wrexham
Target 85%
Prevalent target 65%
Audit Objectives
• Agreed during the All Wales Vascular Access Group meetings
• Auditing areas of current interest to the group
• Three areas covered:-
Referral to the access service
Incident patients using CVCs as access for dialysisIncident patients using CVCs as access for dialysis
Distal Fistula
• Data collected by the VANs in each centre
• Data covers 18 months (Jan 2013 to June 2014)
Part 1. Referral to the Access Service
1.1 Does your unit have a formal (i.e. written) pathway for
vascular access assessment?
Part 1. Referral to the Access Service
1.1 Does your unit have a formal (i.e. written) pathway for
vascular access assessment?
NO YES
Wrexham SwanseaWrexham Swansea
Bangor Cardiff
Glan Clwyd
Part 1. Referral to the Access Service
1.2 Does your unit specify an eGFR trigger for referral?
Part 1. Referral to the Access Service
1.2 Does your unit specify an eGFR trigger for referral?
NO YES
Wrexham Cardiff (20)
BangorBangor
Glan Clwyd
Swansea
Part 1. Referral to the Access Service
1.3. Please list the eGFR at referral for each patient referred to
your service for vascular access formation between 1st January
2013 and 30th June 2014.
Number of patients seen for vascular access
assessment per centre
N
242
N
Total 555
59 55 55
139
P<0.001
Median eGFR at referral
Mean eGFR at referral
P<0.001
Referral eGFR vs Incident Target
Wrexham Bangor Glan Clwyd Swansea Cardiff
Incident
patients
fistula
23% 40% 39% 44% 53%
fistula
Median
eGFR at
referral
13 18 11 13 14
Mean
eGFR at
referral
13 17 12 13 14
Incident target 65%
Part 2. Root Cause Analysis of Central Venous
Catheters for Incident Haemodialysis Patients
• Being completed by VANs in all units since January 2013
• Aim was to inform individual units of issues with their
pathwaypathway
• Only relates to patients known to renal services for >90 days
Proportion of Incident Patients Known to renal
Services for <90 days
NN
RCA of patients starting dialysis using CVC
% of all CVC patients
Excludes patients know to renal service <90 days
patients
Incident patients starting dialysis using a CVC
due to late referral
% of all incident incident patients
Excludes patients know to renal service <90 days
Incident patients starting dialysis using a CVC
because AVF not mature
% of all incident incident patients
Excludes patients know to renal service <90 days
Incident patients starting dialysis using a CVC
due to change in modality choice
% of all incident incident patients
Excludes patients know to renal service <90 days
Incident patients starting dialysis using a CVC
due to patient refusal
% of all incident incident patients
Excludes patients know to renal service <90 days
Incident patients starting dialysis using a CVC
due to rapid unexpected decline in function
% of all incident incident patients
Excludes patients know to renal service <90 days
Part 3. Distal Fistulae
3.1 In your unit do you have an artery or vein size cut-off below
which you would not attempt to use that vessel for an
arteriovenous fistula?
Part 3. Distal Fistulae
3.1 In your unit do you have an artery or vein size cut-off below
which you would not attempt to use that vessel for an
arteriovenous fistula?
NO YES
Bangor Swansea (2.5mm artery 2.5mm vein)Bangor Swansea (2.5mm artery 2.5mm vein)
Cardiff Wrexham (2mm artery 2.5mm vein)
UNKNOWN
Glan Clwyd
Part 3. Distal Fistulae
3.2 In your unit do you consider the urgency of requiring vascular
access in your consideration of which location to attempt an AV
fistula formation?
Part 3. Distal Fistulae
3.2 In your unit do you consider the urgency of requiring vascular
access in your consideration of which location to attempt an AV
fistula formation?
NO YES
Swansea BangorSwansea Bangor
Wrexham
Cardiff
UNKNOWN
Glan Clwyd
Number of first vascular access attempts per
centre
N
205
N
Total 488
45 4635
157
Proportion of first fistula attempts involving a
distal fistula
%
100%
86%73%
%
36%
63%
Outcomes of first fistula attempts
25%30%37%13%62%
Outcomes of first distal fistula attempts
32%30%43%13%81%
Summary
Part 1. Referral for vascular access
• Patients in Bangor are referred for vascular access with
significantly higher eGFRs than in the other units
• No simple correlation between eGFR at referral and overall
success at achieving the incident audit target
Summary
Part 2. Central Venous Catheters in incident patients
• The reason for patients not commencing dialysis by means of an
AVF differs between centres
• Higher proportion of patients in Bangor and Wrexham start HD
using a CVC because their fistula is yet to mature than in other
units
• Patients in North Wales more likely to have a rapid unexpected
decline in renal function than those in the South
Summary
Part 3. Distal Fistulae
• The centres differ in their approach to distal fistulae
• The first access attempt for all patients in Bangor was a distal The first access attempt for all patients in Bangor was a distal
fistula and the majority were successful (although sometimes
further procedures were required to achieve this)