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Kidney Dialysis Vascular Access: A Vascular Surgeon and CNC-led Access Clinic

Prince of Wales Hospital
Project Added:
6 January 2016
Last updated:
20 January 2016

Kidney Dialysis Vascular Access: A Vascular Surgeon and CNC-led Access Clinic

Summary

A vascular clinic with an integrated health approach was established, to address the high number of emergency procedures and prolonged hospitalisations incurred by haemodialysis patients. 

Aim

To improve vascular access outcomes for haemodialysis patients.

Benefits

  • Reduces inpatient length of stay.
  • Reduces inpatient waiting time from the date of admission to surgery.
  • Reduces the number of patients requiring emergency surgical intervention.
  • Delivers cost efficiencies to local health district.
  • Increases patient and staff satisfaction.
  • Delivers a positive impact on patients’ quality of life.

Background

Vascular access management is the leading cause of morbidity and hospitalisation for patients with chronic kidney disease. Previously, patients would often require emergency surgery to resolve acute arteriovenous fistula problems. They also experienced post-operative complications and spent a significant amount of time in hospital. Subsequently, bed occupancy rates and emergency operating list use for these patients were high. Along with the negative effects on quality of life and health outcomes for these patients, there were also significant financial consequences for the hospital.

Implementation 

A vascular access team, led by a dedicated vascular surgeon and vascular access clinical nurse consultant, established a vascular clinic to address the high number of emergency procedures and prolonged hospitalisations incurred by haemodialysis patients.

Most clinics are disease based, however this clinic takes a new and different approach by combining the skills and knowledge required from nephrology, vascular surgery and diagnostic vascular ultrasonography. The multidisciplinary approach involves collaboration with patients and staff from nephrology, surgery and haemodialysis. This approach allows the analysis of multiple clinical and dialysis parameters, leading to an accurate diagnosis and subsequent management of haemodialysis dysfunction. Services are delivered to the patient via a ‘one-stop shop’ concept. Both staff and patients are empowered by the Vascular Clinic, as they are able to refer and self-refer respectively. 

This approach is pre-emptive, as the team are constantly monitoring and screening the patients to detect any issues before they become clinically relevant. This approach prevents emergency presentations and loss of dialysis time. It keeps patients out of hospital, reducing the impact of renal failure on patients’ quality of life.

Access clinic patient with sugrical management, nephotologist, dialysis staff, vasuclar surgeon, diagnostic ultrasound and patient
Figure 1: The ‘one-stop shop’ concept

Key dates

  • Pre-clinic group: January 2011 to December 2012.
  • Post-clinic group: January 2013 to December 2014.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business. 

Lead organisation

Department of Nephrology, Prince of Wales Hospital, SESLHD

Implementation site

Prince of Wales Hospital, SESLHD 

Results

  • A retrospective cohort study was performed to establish a baseline. Data from a pre-clinic group (patient outcomes two years prior to the establishment of the clinic) was collected and compared with data from a post-clinic group.
    A total of 322 clinical reviews occurred in the two years since the establishment of the vascular clinic. Between 2011 and 2014 there has been a:
    • reduction in inpatient length of stay from 10.7 to 3.13 days
    • reduction in inpatient wait time for surgery (date of admission to operation) from 3.23 to 0.7 days
    • reduction in number of patients requiring emergency surgical intervention from 54.5% to 25.4%
    • increased patient and staff satisfaction
    • positive impact on patients’ quality of life.
  • The pre-clinic group cost $4.89 million for surgical admissions, compared with $1.53 million for surgical admissions in the post-clinic group. Cost efficiencies for the SESLHD has been $3.31 million since the introduction of the clinic.
  • It began as a once a month clinic, but due to its success it now operates weekly. Sustainability issues were identified and resulted in the allocation of a dedicated vascular access clinical nurse consultant.

Awards

  • 2014 SESLHD Quality Award.

Lessons Learnt

When it was identified that the problem was two-fold, collaboration with the patients and staff from nephrology, surgery and haemodialysis departments took place and a multidisciplinary approach to solving problems was undertaken. The clinic is fundamentally about stakeholders in several departments working together to improve patient outcomes.

By fostering a multidisciplinary and multifaceted clinical encounter, the clinic has a preventative rather than reactive approach and empowers patients to be partners in their care. The success of the clinic model speaks volumes for a collegial approach in delivering cost-effective patient care.

Further Reading

National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. American Journal of Kidney Disease 2006; 48(1): 322.

Contact

Dr Shannon D. Thomas
Vascular, Endovascular and Renal Transplant Surgeon
Prince of Wales Hospital
South Eastern Sydney Local Health District
Phone: 02 9650 4981
Sdthomas.vascular@gmail.com
 

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