Vascular access. The KidneyCare Audit

Transcription

1 Vascular access The KidneyCare Audit

2 Renal National Service Framework The challenge of vascular access Standard 3 All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.

3 Overall 13,343 (77%) of prevalent patients were having dialysis therapy delivered by definitive access. Centres varied from 52% to 95%. For HD patients only, definitive access was used in 69%, range from 44% to 94%.

4 Renal Registry Vascular access survey incident cohort Patient survival, HD starters, by access type Survival probablity 100% 80% 60% 40% AVF+AVG Temp line + Tunnel line 20% 0% Days

5 Infection: aetiology

6 Morbidity and mortality

7 Causes of death in dialysis patients 3.5% 15.6% 12.6% 5.5% 19.6% 10.2% 16.1% 16.9% USRDS 1996 Annual Data Report

8 Venous catheters and morbidity UK Vascular access survey 2005 No of venous access vs Inpatients No of venous access vs Staph aureus episodes R 2 = R2 = Total venous access (n) Total venous access (n) Year 2004: 1547 Staph. Aureus infections (462 (29%) related to MRSA) in haemodialysis population One third of bed days in HD population related to catheter related problems Cost of a single episode of bacteraemia:

9 Infection pathways and access

10 The National Kidney Care Audit Further information

11 Audit Question Standard/Best Practice Reference Associated Measures Impact of non-achievement Number of days spent in hospital to establish first functioning permanent vascular access At risk of infection especially MRSA No patient on dialysis, including those patients who present late, should wait more than four weeks for fistula construction Number of operations and other interventions (eg. angioplasty, revision surgery) to establish first functioning permanent (Clinical Practice Guidelines for Haemodialysis, UK Renal access. Association, 4th Edition, 2006) No time to prepare or make informed choice, educate and empower A proxy for failure to pre-emptively transplant list and therefore long await time for transplantation Repeated admissions for percutaneous lines Patients should undergo fistula creation between 6 and 12 months before haemodialysis is expected to start to allow time Percentage of catheter starters who have functioning for adequate maturation of the fistula or time for a revision permanent access established within three and twelve months procedure if the fistula fails or is inadequate for use (source as above) Does the proportion of patients starting haemodialysis with functioning permanent access meet the Renal Association and Vascular Society Guidelines for permanent vascular access? Increased crash landing At least 65% of patients presenting more than three months before initiation of dialysis should start HD with a usable native Arteriovenous fistula (source as above). Percentage of Haemodialysis patients starting with permanent access Inadequate dose of dialysis delivered Percentage of Haemodialysis patients starting with catheter access Poor correction of metabolic abnormalities - legacy of poor care impact on long term adaptation to dialysis and adverse clinical outcomes Checksum of these two measures should equal 100% Higher ESA (erythropoietin stimulating agent) requirements Percentage of Haemodialysis patients starting with temporary access due to late referral (known to the renal service for less than 3 months before starting dialysis) Worse transplant outcomes What are the hospital-acquired infection rates associated with vascular Percentage of RRT patients diagnosed with hospital acquired The number of Staphylococcal systemic infections per annum No avoidable HCAI in dialysis patients and an overall reduction access in the maintenance of the haemodialysis population and how infection including complications relating to vascular access, varies from 2.3 to 33.8, average 13, the figures for MRSA in MRSA by 50 % by 2008 (Department of Health) does this compare with the national average and the best performance? eg. line-related sepsis, clotted graft alone being from 0 to 21.5, average 4.

12 Content Patient Transport Vascular access Stream 1 Prevalent Patient Access Data Stream 2 Comorbidity In patient utilisation Infection Stream 3 Process measures (based on NRDS)

13 Part 1:Prevalent recording

14 MESS data England April 07 Mar (4.4) 188 (4.2) o Not shared 29 (15) 29 (15) o Shared, not completed 78 (40) 70 (38) o Shared & completed 89 (45) 89 (47) 4438

15 Table 2: Modality of dialysis in patients in established renal failure where record shared and completed Modality Modality of dialysis No. (%) MRSA bacteraemia Haemofiltration 3 (3.4) Haemodialysis 84 (94.4) 2 (2.2) 89 (100) Unknown All

16 Table 3: Type of renal access in patients in established renal failure where record shared and completed Access type Renal access type AV- simple No. (%) MRSA bacteraemia 23 (26) AVG 3 (3.4) Non-tunnelled femoral 6 (6.8) Non-tunnelled - jugular 4 (4.5) Tunnelled femoral 5 (4.7) Tunnelled - Jugular 47 (53) All 89 (101.9)

17 Royal Infirmary Manchester Oxford Radcliffe Hospital Nottingham City Hospital Hull Royal Infirmary Freeman Hospital & Royal Victoria Infirmary Cumberland Infirmary Countess of Chester Hospital Bristol Royal Hospital for Children University Hospital of North Staffordshire University Hospital Aintree Royal Shrewsbury Hospital Queen Alexandra Hospital (Portsmouth) AVG Tunnelled venous catheter - Femoral/other Ipswich Hospital Hope Hospital (Salford) Heartlands Hospital (Birmingham) Colchester General Hospital Sunderland Royal Hospital Royal Liverpool University Hospital Royal Cornwall Hospital (Treliske) Kent & Canterbury Hospital Derriford Hospital Addenbrookes Hospital (Cambridge) St Helier Hospital Royal Free & Middlesex Hospital Lister Hospital Guy's and St Thomas's Hospital Walsgrave Hospital (Coventry) Norfolk & Norwich University Hospital King's College Hospital St Lukes Hospital (Bradford) Southmead Hospital (Bristol) Royal Sussex County Hospital Hammersmith & Charing Cross Hospital Barts and the London Hospital Leicester General Hospital James Cook University Hospital (Middlesbrough) Royal Preston Hospital St James's University Hospital (Leeds) Queen Elizabeth Hospital (Birmingham) AVF - simple Non-tunnelled venous catheter - J/SC Not completed Non-tunnelled venous catheter - Femoral/other Tunnelled venous catheter - J/SC

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19 Linkage with Renal Registry Infection Bacteraemia Staph. Aureus?CDT In patient stats Bed utilisation Admissions by code Bacteraemia Pneumonia Endocarditis Spinal Abscess

20 Procedure Arteriovenous fistula Date of AVF Side of AVF Site of AVF Drugs used to prevent thrombosis Blood pump speed The date that the arteriovenous fistula was constructed The side of the body used for construction of an arteriovenous fistula To monitor use of arterio-venous fistula Date format To identify the site used for arteriovenous fistula construction n The artery and vein used for construction of To identify the site used for arteriovenous arteriovenous fistula fistula construction The drugs prescribed to prevent thrombosis To monitor use of arteriovenous fistula 01 Right 02 Left n 01 Snuff box 02 Radiocephalic 03 Brachiocephalic 04 Brachiobasilic 05 Ulnacephalic 06 Radioulnar 07 Popliteal to long saphenous 08 Other n 01 Aspirin 02 Dipyridamole 03 Clopidogrel 04 Warfarin 05 Other The rate of blood flow through the dialyser To determine whether there is adequate flow n during average dialysis 01 <100 ml/min ml/min ml/min ml/min 04 >400 ml/min

21 Recurrent data Start recurring group (for complication of AVF) Complication date Date of development of a complication of arteriovenous fistula Complications Comlications of arteriovenous fistula To monitor morbidity arising from AVF formation To monitor morbidity arising fom AVF formation Date format n 01 AVF stenosis 02 AVF infection 03 AVF aneurysm 04 AVF pseudoaneurysm 05 AVF rupture 06 AVF thrombosis 07 Steal syndrome 08 Heart failure End recurring group (for complication of AVF) Start recurring group (for surveillance) Surveillance date Surveillance of AVF with one of a number of techniques Surveillance technique Method used to monitor AVF To monitor arteriovenous fistula Date format To monitor arteriovenous fistula n 01 Clinical examination 02 Reduction in dialysis adequacy 03 Static venous pressure measurement 04 Blood flow rate assessment 05 Recirculation measurement 06 Duplex ultrasonography 07 Fistulography 08 Other End recurring group (for surveillance) Start recurring group (for AVF revision) AVF revision Date of revision of arteriovenous fistula AVF revision Type of revision of arteriovenous fistula To monitor need for revision of Date format arteriovenous fistula To monitor revision of arteriovenous fistula n RADIOLOGICAL a. To Fistula 01 Angioplasty 02 Angioplasty with cutting balloon 03 Angioplasty with stent 04 Thrombolysis 05 Other b. To central veins 06 Angioplasty 07 Angioplasty with cutting balloon 08 Angioplasty with stent 09 Thrombolysis 10 Other SURGICAL 11 Surgical corection with jump graft 12 Surgical correction with vein patch 13 Banding of arteriovenous fistula 14 Thrombolysis of arteriovenous fistula 15 Ligation of arteriovenous fistula 16 Evacuation of haematoma 17 Pseudoaneurysm repair 18 Refashioning of arteriovenous fistula 19 Drill procedure for STEAL syndrome 20 Other

22 What is needed from units Prevalent dataset Electronic coding of access type at each session Target 80% of units Comorbidity datset HES and HPA linkage Process measures Pilot sites Use NRD (all ready finished a small pilot)