Improving quality of vascular access care for hemodialysis patients

Because quality of care for patients with end-stage renal disease (ESRD) has improved, they require long-term vascular access for hemodialysis. Construction of a native vein arteriovenous fistula (AVF) on the arm is considered best practice; a prosthetic graft (PG) AVF on the arm is a good alternative, although insertion of a central venous catheter (CVC), the third choice, is sometimes necessary. A quality improvement project was initiated at the dialysis unit of Rijnland Hospital (The Netherlands) to improve quality of vascular access care.

Seventy-four patients were treated from January 2001 through June 2002. The list of preferred access operations was adapted from evidence-based guidelines. The percentages of CVCs and PGs were chosen as quality indicators.

Twelve of 19 patients (34%) appeared to be using CVCs unnecessarily. Actions were taken, and the CVC indicator decreased by 11%. The PG indicator decreased gradually from 24% to 8%.

Reductions in the use of CVCs and PGs suggest that the vascular access improvement project resulted in improvement of long-term vascular access for hemodialysis patients. A considerable decrease in the use of PGs and CVCs was achieved in 2001. However, a decrease of CVCs to < 20% has still not been realized, perhaps because new hemodialysis patients referred to the dialysis unit have already had CVCs inserted.

Considerable improvement, as reflected in the number of hemodialysis patients with CVCs or PGs, can be achieved with a minimum of costs.