SERVICE SPECIFICATION 2
Vascular Access
Table of Contents
Page
1
Key Messages
1
2
Introduction & Background
2
3
Relevant Guidelines & Standards
2
4
Scope of Service
3
5
Interdependencies with other specialties & support services
4
6
Markers of Good Practice
5
7
Quality Measures & Audit Criteria
5
Appendices
1 Impact Statement
2
Consultation Record, Document History & Version Control
This document should be read in conjunction with the Common Themes
document which is relevant to all Renal Service Specifications.
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1
Key Messages
 Patients who may require renal replacement therapy should
receive information on options for vascular access at an early
stage and be referred into the vascular access service at time
that allows this to be created prior to commencement of dialysis
 The vascular access service should have a named lead in each
centre who is supported by a full multidisciplinary team (which
includes as a minimum a nurse(s), nephrologists, surgeon(s), a
vascular technician and a radiologist(s))
 Access should be monitored and maintained to allow timely
planning for replacement and to avoid the necessity of
emergency access
 65% of patients should commence haemodialysis using an
arteriovenous fistula (AVF)
 85% of all prevalent haemodialysis patients should receive
dialysis via a functioning AVF
 The annual Staphylococcus aureus bacteraemia rate in the
prevalent haemodialysis population should be less than 2.5
episodes per 100 HD patients and less than 1.0 for MRSA over
2 years
2
Introduction and Background
In Wales, the majority of dialysis access surgery is performed in the five major
Welsh centres (Cardiff, Swansea, Wrexham, Glan Clwyd and Bangor) which
serve their own central renal units and the surrounding satellite units.
A small number of patients cross the border from Flintshire to Arrowe Park
Hospital in the Wirral, from Welshpool to Shrewsbury, and from Llandrindod
Wells. Some patients from mid Wales are treated in Shrewsbury but the
Welshpool dialysis unit, managed by the Wrexham Maelor Hospital based team
manage the majority of patients from North Powys, and new patients will be
expected to have access procedures in Wrexham.
Historically, the three provider LHBs via the five Welsh centres have provided all
diagnostic and surgical services required to establish and maintain access. With
the centralisation of major vascular surgery this may change.
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Relevant Guidelines and Standards
4
Scope of Service
The service starts at the point on the Renal Replacement Therapy pathway from
the decision to opt for haemodialysis and when eGFR has declined to Stage 4, or
in urgent cases when a similar eGFR is reached in acute patients, and ends at
cessation of use of access (e.g. due to change of modality).
Service description
The vascular access service is a multidisciplinary service involving as a
minimum a Vascular Access Nurse (VAN), nephrologists, a vascular access
surgeon(s), a vascular technician(s) and an interventional radiologist(s) who
work together with the patient to achieve optimum dialysis access. The service
will have a named lead in each unit who may be any of the members of the
multidisciplinary team (MDT) and will be supported by the wider MDT.
Planning for vascular access should normally begin at an early enough stage to
allow the creation and maturation of optimal vascular access before dialysis is
required. The precise timing of referral into the vascular access service depends
on the rate of decline of renal function, patient co-morbidities and the local
patient pathway. All patients will require information provision and support to
make an individual decision on their optimal vascular access.
The majority of patients will choose the vascular access which is most reliable
and carries the lowest risk of morbidity. This is nearly always an autologous
arteriovenous fistula (AVF), but alternative options include an arteriovenous
graft (AVG) or a tunnelled Central Venous Catheter (CVC). The creation of an
AVF is possible for the majority of patients, although it not infrequently requires
more than one surgical procedure. The location of the fistula will vary but each
service will be expected to state its policy, report performance, participate in
audit of outcomes and be prepared to alter practice in the light of accepted best
practice.
AVGs may be an alternative for some of the patients where AVF formation has
not been successful and as the first choice vascular access for a small number of
patients. CVCs are essential for most patients requiring haemodialysis as an
emergency but are associated with significantly higher rates of morbidity and
mortality and therefore their use should usually be restricted to as short a
duration as possible. When a CVC is required for longer than two weeks it
should be tunnelled under the skin to reduce the risk of infection.
There will be regular surveillance of access.
Acceptance and Entry to Pathway
As describe above planning for access should commence when patients enter
CKD stage 4. Referral into the service will be made by either specialist Chronic
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Kidney Disease (CKD) nurses or nephrologists, who will have already started the
provision of information to the patient.
Each centre will have an individual patient pathway (according to local service
circumstances) which will be both formally documented and regularly audited.
The pathway will allow patients to have the greatest opportunity to commence
dialysis by means of the optimal vascular access, and be sufficiently robust to
not rely on the presence of individual members of the MDT.
Exclusions
All patients who opt for haemodialysis should be referred into the vascular
access service. Every attempt should be made to inform patients who decline to
engage with the service about the options for vascular access including the risks
and benefits of each type of access.
MDT Working
The overall skillset of the MDT will be similar between centres but likely unique
within that centre. Wherever MDT meetings are held these should not be a
substitute to a more reactive or virtual MDT whereby there is a continuous
dialogue between clinicians, often co-ordinated by the Vascular Nurse, to enable
services to be provided in response to changing clinical presentations.
Some of the required roles may be performed by different specialists in each
centre (for example CVC insertion). Each centre will be responsible for ensuring
that all MDT members have been appropriately trained and are supported in
conducting their required roles. The service will also have a role in training
future vascular access specialists and allied professionals.
5
Interdependencies with other specialties & support
services
The provision of a high quality vascular access service requires a truly
multidisciplinary approach with input from a diverse group of allied specialists.
The service in all centres will require input from the nephrology, surgery and
radiology departments. There is also the need for close liaison with all of the
dialysis units to monitor and maintain vascular access and it is imperative that
the providers of the dialysis services are fully engaged with the service.
The provision of vascular access has a significant impact on morbidity, mortality
and emergency admission rates for patients with CKD. To provide a robust
service there is requirement for dedicated access to surgical sessions, the exact
number of which will vary according to the population served by individual
centres. As the majority of vascular access surgical procedures can be
performed under local anaesthetic there is no need for these theatre sessions to
be located within a major vascular centre. However a proportion of patients will
require more extensive surgical procedures and therefore each centre providing
vascular access will also need access to appropriate theatre lists to perform
these.
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The service will require access to a vascular laboratory for vein mapping and
follow-up scanning. There is also a requirement for access to interventional
radiology (IR) vascular support for a proportion of patients which, when
required, needs to be performed promptly to maximise successful outcomes. IR
support may be required in theatre.
6
Markers of Good Practice
 Evidence of written pathways and protocols for the vascular
access programme
 Unnecessary venepunctures and peripheral venous access in
the upper limb intended for creation of access is avoided
 Evidence of the provision of good information to patients and
help provided to reach a consensus on the optimal individual
vascular access
 The agreed pathway is audited regularly and shown to allow the
majority of patients to commence dialysis by means of the
optimum vascular access
 Systematic observation and, when appropriate, advanced
surveillance is employed to predict and prevent access failure
 Regular audit of CVC use, including root cause analysis for
incident haemodialysis patients
 Infections are minimised by avoiding CVCs whenever possible,
using strict aseptic technique, cleaning of catheter exit sites,
hubs and antibiotic locks for CVCs, and early catheter removal
 The proportion of all patients with urgent access related
complications treated according to locally agreed protocols by
the multidisciplinary team is monitored
 The MDT has the appropriate skill mix to provide all of the
necessary vascular access procedures, and reacts promptly to
changed clinical circumstances. When the patient numbers are
too small to allow the development of expertise in certain rarer
procedures (e.g. insertion of hybrid CVC-AVG), referral
pathways exist to allow patients to attend a centre with the
appropriate skills
 Access related ischaemia prompts urgent surgical referral
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Quality Measures and Audit Criteria
Each vascular access centre will collect and submit regular audit data for review
and discussion by the All Wales Vascular Access Network. This network will
include representatives from each centre and will meet twice per year to discuss
issues relating to vascular access in Wales.
 Proportion of incident haemodialysis patients commencing
dialysis by means of an AVF (target 65%)
 Proportion of prevalent haemodialysis patients receiving dialysis
by means of an AVF (target 85%)
 The annual Staphylococcus Aureus bacteraemia rate in the
prevalent haemodialysis population (target less than 2.5
episodes per 100 HD patients and less than 1.0 for MRSA over
2 years)
As WRCN commissions this service adherence to the specification will be
monitored and significant shortcomings reported to the LHB.
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Appendix 1: Impact Statement
This would be a general statement of possible impact and/or a record of what
the impact on each provider is agreed to be. The value of such a statement in
this appendix will be reviewed during 2016 before a statement is included
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Appendix 2: Consultation Record, Document History & Version Control
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Document History
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