Effect of a Vascular Access Nurse Coordinator to Reduce Central Venous Catheter Use in Incident Hemodialysis Patients: A Quality Improvement Report

Background: Starting hemodialysis therapy with an arteriovenous fistula (AVF) is associated with improved patient survival. Clinical audit showed that less than 50% of our patients started hemodialysis therapy with an AVF. Study Design: Quality improvement report, prospective before and after study. Setting & Participants: Tertiary referral hospital with 184 patients starting hemodialysis therapy in 2005 and 2006. Quality Improvement Plan: Situational analysis showed poor overall coordination of surgical waiting lists. Multifaceted intervention included vascular access nurse coordinator and an algorithm to prioritize surgery. Outcomes: Vascular access used at first hemodialysis treatment in patients with pre-end-stage renal disease in the 12 months before and after the intervention. Measurements: Proportions of patients starting hemodialysis therapy with an AVF. Results: Overall, 65% of patients started hemodialysis therapy with an AVF; 2%, with an arteriovenous graft; and 33%, with a catheter. The proportion of patients starting hemodialysis therapy with an AVF increased from 56% preimplementation to 75% postimplementation (P = 0.007). After adjustment for age, sex, late referral, cause of renal failure, and presentation type, patients starting dialysis therapy in the implementation phase were twice as likely to start treatment with an AVF (odds ratio, 2.85; P = 0.008). The total number of catheter-days in the implementation phase was half that of the preimplementation phase (2,833 v4,685 days). Limitations: Nonrandomized study. Conclusions: Implementation of a multifaceted intervention including a vascular access nurse and an algorithm to prioritize surgery significantly increased the proportion of patients starting dialysis therapy with an AVF by improving the overall coordination of the surgical waiting list. Am J Kidney Dis 53:99-106. (C) 2008 by the National Kidney Foundation, Inc.