2010
QAPI Vascular Access TOOL
Provider Number/Name:
Date
completed:
/ /10
1. Total number of AVF’s that are patent (whether being used or not) ____
A.
of #1 above, number of patent AVF’s > 2 months old that have never been used
successfully
B. Enter the number of reasons why patent AVFs > 2 months old have never been used:
AVF not adequately mature by 2 months. Of these:
Number that have been referred back to surgeon
Number that have been referred to radiologist
AVF still not usable and:
Instructed by doctor to wait longer and/or continue to exercise arm
Patient not referred for evaluation of AVF failing to mature
Patient refuses to have AVF evaluated or revised
AVF that was failing to mature had intervention and needs more time to
heal or mature
AVF appeared mature but vein “blew” on cannulation and required
additional time to rest
AVF was cannulated but there was inadequate blood flow for dialysis
Other (please explain): ____________________________________
AVF usable but not used because:
Patient refuses to have AVF cannulated
Patient refuses to stop using Catheter
Doctor likes to wait longer than 2 months before cannulating an AVF
Doctor wants to continue to use an AVG that is still functioning
Doctor wants to continue to use a Catheter that is still functioning
Patient with new AVF not tracked to ensure timely cannulation
AVF too deep or poorly located to be safely cannulated
Other (please explain): __________________________________
1
2010
QAPI Vascular Access TOOL
Provider Number/Name:
2.
Date
completed:
/ /10
Total number of AVG’s in use ____ of these how many:
A.
Have not been de-clotted, revised or had angioplasty in the past 3 months
B.
Had only one de-clotting, revision or angioplasty in the past 3 months
C.
Had two or more de-clotting, revisions or angioplasty in the past 3 months
1. Number of “C” that had:
a. _____ Arterial and venous mapping
b. _____ Vascular Access Plan completed for the next time the AVG needs work
c. _____ Patient educated that the AVG is failing and will soon need to be replaced
3.
Total number of catheters in use ______
A.
Total number of catheters in use < 90 days; of these, number that:
1. _____New patients awaiting placement of fistula/graft
a.____ No insurance coverage to pay for placement
b.____ Placement is scheduled
c. ____ Has coverage, but placement not scheduled
2. ___ New patient awaiting maturation/healing of fistula or graft
3. ___ Patient refused placement of permanent access
4. ___ Established patient with failed fistula/graft
a. ____ new fistula/graft planned
b. ____ awaiting maturation/healing of new access
5. ____Medically unsuitable for permanent access

Unable to tolerate increased cardiac output induced by a fistula/graft due to cardiac condition
(i.e. severe CAD) or CHF
2

Severe peripheral vascular disease precludes fistula/graft placement

All possible graft/fistula access sites exhausted and unable to do peritoneal dialysis

Severe vasculitis precludes graft/fistula placement or use until (if) condition improves.
2010
QAPI Vascular Access TOOL
Provider Number/Name:

Date
completed:
/ /10
Dermatologic condition involving extremities precludes graft/fistula placement or use (i.e.
scleroderma, calciphylaxis, etc.)
6. ____Awaiting a scheduled living donor transplant
7.____Peritoneal dialysis patient requiring a short-term course of hemodialysis therapy
B.
Total number of catheters in use > 90 days
1. ___ New patients awaiting placement of fistula/graft
a.____ No insurance coverage to pay for placement
b.____ Placement is scheduled
c. ____ Has coverage, but placement not scheduled
2. ___ New patient awaiting maturation/healing of fistula or graft
3. ___ Patient refused placement of permanent access
4. ___ Established patient with failed fistula/graft
a. ____ new fistula/graft planned
b. ____ awaiting maturation/healing of new access
5. ____Medically unsuitable for permanent access

Unable to tolerate increased cardiac output induced by a fistula/graft due to cardiac condition (i.e.
severe CAD) or CHF

Severe peripheral vascular disease precludes fistula/graft placement

All possible graft/fistula access sites exhausted and unable to do peritoneal dialysis

Severe vasculitis precludes graft/fistula placement or use until (if) condition improves.

Dermatologic condition involving extremities precludes graft/fistula placement or use (i.e.
scleroderma, calciphylaxis, etc.)
6. ____Awaiting a scheduled living donor transplant
3