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Minimizing delays to hemodialysis access maturation: A quality improvement analysis
Andrew S Warren1,2, Hannah Wolf1, Charles J Hillenbrand1
1Division of Vascular Surgery, University of Washington, Seattle, WA, USA.
Insights
Pre-operative vein mapping for hemodialysis (HD) access creation caused significant delays, particularly in outpatients. However, mapping time did not correlate with increased catheter use, suggesting alternative strategies to reduce wait times.
Area of Science:
- Nephrology
- Vascular Surgery
- Health Services Research
Background:
- Optimizing pre-operative processes can reduce healthcare costs and expedite time-to-intervention for hemodialysis (HD).
- Pre-operative vessel mapping is a mandatory step in our practice for HD access creation.
- We hypothesized that vessel mapping causes the longest delay and correlates with increased catheter days.
Purpose of the Study:
- To evaluate pre-operative delays in hemodialysis (HD) access creation.
- To determine the impact of pre-operative vessel mapping on time-to-intervention.
- To assess the correlation between mapping-related delays and the duration of catheter use.
Main Methods:
- Retrospective review of 130 patients undergoing initial HD access creation (01/01/2017-12/31/2021).
- Comparison of pre-operative event times between inpatients and outpatients using Mann-Whitney U test.
- Stratification of outpatients by catheter-based HD initiation time and regression analysis for mapping delay impacts.
Main Results:
- Inpatients experienced shorter referral-to-access maturation times compared to outpatients, driven by reduced referral-to-mapping and mapping-to-pre-surgical evaluation times.
- Pre-surgical evaluation to operating room (OR) time represented the longest pre-operative delay for both groups.
- Tunneled catheter placement post-referral in outpatients increased access maturation time but not pre-operative delays; no correlation found between mapping time and catheter duration.
Conclusions:
- Preoperative vein mapping contributed significantly to referral-to-maturation times but was not associated with increased tunneled catheter duration.
- Tunneled catheter placement impacted access maturation but did not add to pre-operative delays.
- Earlier referrals, reduced outpatient wait times (referral to OR), and increased arteriovenous graft placement may mitigate delays associated with pre-operative vein mapping.
Introduction:
Pre-operative process optimization can expedite time-to-intervention and reduce overall health care costs. We hypothesized that the longest delay to hemodialysis (HD) access creation would be from pre-operative vessel mapping (mandatory in our practice), and that this would be correlated with increased catheter days.
Methods:
One hundred thirty patients (24 inpatients, 106 outpatients) who received initial hemodialysis (HD) access from 01/01/2017 to 12/31/2021, at the Veterans Affairs Puget Sound, Seattle, Washington, were identified. Median time differences between pre-operative events were compared between inpatients and outpatients using the Mann-Whitney U test. Outpatients were then stratified by time of catheter-based HD initiation (no catheter, pre-referral catheter, post-referral catheter) and compared. The impacts of mapping-related delays on catheter use were evaluated using regression.
Results:
Inpatients had shorter referral to access maturation times (125 days inpatient vs 146 days outpatient; p = 0.03). This was driven by shorter referral to mapping (2 days inpatient vs 27 days outpatient; p < 0.01) and mapping to pre-surgical evaluation (1-day inpatient vs 6 days outpatients; p < 0.01) times. Pre-surgical evaluation to OR times represented the longest pre-operative delay in both groups (51 days inpatient vs 29 days outpatient; p = 0.59). Among outpatients, tunneled catheter placement post-referral resulted in longer maturation times (74 days no catheter vs 67 days pre-referral vs 149 days post-referral; p < 0.01) but not additional pre-operative delays. No trend existed between increased mapping times and catheter-based dialysis duration (R2 = 0.08).
Conclusion:
Preoperative vein mapping contributed up to 21% of referral to maturation times but was not associated with increased tunneled catheter duration. While tunneled catheter placement impacted access maturation it did not cause additional pre-operative delays. Earlier referrals for access creation and reduction of outpatient wait-time from referral to OR and increased AV graft placement may minimize catheter days in our system thereby mitigating the added delays caused by pre-operative vein mapping.
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