1. Why Vascular Access Coordinator (VAC)
Samiha Hindi, RN, CNC
Hemodialysis Unit
KFSH & RC. Riyadh

2. Objectives Why the need for vascular access coordinator (VAC)?.
What is the role of the vascular access coordinator?.
What is the best outcome?.
Conclusion.

3. Introduction
The role of the vascular access coordinator (VAC) is a highly specialized role, it has been developed because of the complexity of hemodialysis vascular access and the episodic nature of the complication that arise over time.

4. Why the Need for Vascular Access Coordinator?
Because of:
“Creation, Preservation and maintenance of adequate
vascular access for patients with end stage renal failure is
critical to the successful outcome of hemodialysis”
CARI Guidelines
evidence-based project to improve the quality of care and outcomes
Australian and New Zealand

5. Why the Need for Vascular Access Coordinator?
Increase morbidity:
20-30% of HD patients hospitalization is due to
VA creation or problems.
- Secondary access creation
- Declotting
- Revision
- CVC insertion
Hakim RM, Breyer et-al Effects of dose of dialysis on morbidity and mortality
Centers for Medicare & Medicaid Services: 2003 Annual Report

6. Why the Need for Vascular Access Coordinator?
Increase cost.
The cost of vascular accesses maintenance is
$18,000/pt. /year
- CVC $6000/year.
- Fistula $2800/year
- Graft $6300/year
Healthcare system – Medicare USA data 2006

7. Why the Need for Vascular Access Coordinator?
Toronto Hospital Study 1999:
When a full-time vascular access coordinator was responsible for all aspects of vascular access care:
The vascular access Cost was a significantly reduced.
Hospitalization length Reduced,
KALMAN P.G(1) POPE m(1) et al

8. Why the Need for Vascular Access Coordinator?
Allon M, Bailey R, Ballard et al. Feb 1998:
To improve outcomes and reduce the cost of hemodialysis access procedures a multidisciplinary approach was developed, involving nephrologists, access surgeons, radiologists, and A full-time dialysis access coordinator
Department of Radiology, University of Alabama at
Birmingham, USA Feb

9. Why the Need for Vascular Access Coordinator?
The major changes were:
Native A-V fistula construction in new dialysis patients increased from 33% to 69%.
Elective arteriovenous (A-V) grafts was changed from a three-day inpatient hospitalization to outpatient procedure. The A-V grafts increased from 16% to 81%.
Surgical complications of new A-V graft was decreased from 25% to 11%.
Department of Radiology, University of Alabama at
Birmingham, USA Feb

10. Why the Need for Vascular Access Coordinator?
The major changes—cont
4. Clotted grafts approach was changed from an inpatient surgical procedure to an outpatient radiological procedure. The success rate of graft declots increased from 48% to 69%
5. Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year.
Department of Radiology, University of Alabama at
Birmingham, USA Feb

11. Why the Need for Vascular Access Coordinator?
Study conclusion:
A full-time VA. Coordinator with multidisciplinary approach markedly reduced in:
- access surgical complications
- vascular access failures.
These improvements occurred despite a marked decrease in:
- hospitalization
- cost.
Department of Radiology, University of Alabama at
Birmingham, USA Feb

12. What is the Role of the Vascular Access Coordinator?
Communications:
VAC acts as a link between Nephrologists, Surgeons, Radiologist & patients/Family to:
Facilitate early access placement.
Emphasizing on fistula placement whenever possible.
Accommodate radiology intervention.

13. What is the Role of the Vascular Access Coordinator?
Communications—cont:
Communicate with hospital staff & discuss issues related to vascular access problems:
- Infection.
- Cannulation.
- Clotting.

14. What is the Role of the Vascular Access Coordinator?
Education:
a. Patients/ family education.
Patient & family education should start early when GFR is <30ml/min (CKD Stage 4)
Explain to the patient/ family the modality of treatment such as:
- kidney Transplantation.
- Peritoneal Dialysis
- Hemodialysis

15. What is the Role of the Vascular Access Coordinator?
a. Patients/ family education—cont
Educate patients to “Save Their Veins”
Explain to the Pt./Family the value of AV Fistula creation even if patient chooses PD..
Answer their questions Patients often have difficulty accepting vascular access creation.

16. What is the Role of the Vascular Access Coordinator?
a. Patients/ family education—cont
Encourage the patient to bring a family member and/or friends they can :
- provide emotional support.
- Primary care providers.
- Transportation.

17. What is the Role of the Vascular Access Coordinator?
b. Staff education:
To save the patients Veins:
avoid veins puncture
Vascular access care:
post Op care
pre & post HD VA. Care
Cannulation technique & VA. assessment
Prevention of access infection:
following sterile/aseptic technique

18. What is the Role of the Vascular Access Coordinator?
Develop Critical Pathway:

19. What is the Role of the Vascular Access Coordinator?
Develop a critical pathway –cont :
In Vanderbilt University Medical Center critical pathway was followed for 18 months, after critical pathway :
The outpatient access procedures were increased by 95%
The cost was decreased to $4,000 and $5,000 from $10,000 to $20,000
Vanderbilt University Medical
Center1997 Feb;24(1):70-6; quiz 77.

20. What is the Role of the Vascular Access Coordinator?
Ongoing monitoring and surveillance.
perform vascular access assessment.
Follow surveillance guidelines.

21. What is the Role of the Vascular Access Coordinator?
Vascular Access assessment
Examine for Erythema, swelling, gangrene, aneurysm formation, collaterals
Feel for intravascular pressure,
Check for quality of pulse/thrill
Check for elevated temperature
Check for pain caused by finger pressure.
Check for low-frequency bruit with systolic & diastolic component
Examine for high-frequency bruit—due to stenosis
Inspection
Palpation
Auscultation

22. What is the Role of the Vascular Access Coordinator?
Flowing Surveillance Guidelines:
Monthly access study.
Access study post radiology/surgical intervention
Baseline Study: >600 ml/min AVF
> 500 ml/min AVG
Repeat access study if there is a drop in access flow.
Send Pt. for radiology intervention if access flow trend dune by 25%.

23. What is the Role of the Vascular Access Coordinator?
Flowing Surveillance Guidelines:

24. What is the Role of the Vascular Access Coordinator?
Documentation:
Type of vascular access: AVF/G/CVC
Access Problems: -Cannulation
-Infection
-Clotting
Changes in arterial / venous pressure.
Prolonged bleeding
Decrease in Kt/v and URR

25. What is the Role of the Vascular Access Coordinator?
Documentation—cont
Change in bruit/ flow
Swelling, redness, pain.
Patient with CVC:
creation date—location—flow
infection history—location—date—action
catheter dwell volume—type

26. What is the Role of the Vascular Access Coordinator?
Tracking Access History.
Surgical access history:
- Primary access—date—type—location—MD
- Secondary access—number of accesses
- Thrombectomies—date—frequency—factors
Radiology access history:
- angiography—angioplasty
- throbolisis—emobilization
Infection history:
- date—site—action taken

27. What is the Role of the Vascular Access Coordinator?
Organize & maintain continues quality improvement (CQI) that involves all member of VA team:
Nephrologist.
Vascular access surgeon.
Interventional Radiologist.
Dialysis staff.
Vascular access coordinator.

28. What is the Role of the Vascular Access Coordinator?
Participate in quality assurance (QA) for vascular access:
Based on QA evaluation — fined a room for improvement
implement new protocols
putting guidelines

29. What is the Best Outcome
The Best Outcome is:
Patient starts first dialysis treatment with functioning AV fistula.
If no access in place for dialysis:
- Tunneled hemodialysis Catheter + AV fistula placed.
- If patient choose peritoneal dialysis AV fistula, tunneled
catheter + PD Catheter placed.
Fistula-First
Dooqi Guidelines

30. What is the Best Outcome
Minimize CVC insertion—increase AVF creation
Protect AVF until maturation.
Reduce hospitalization by reducing access comorbidity:
infection—clotting.
Reduce VA cost.
Minimize missed treatment by keeping the access patency.

31. Conclusion
Vascular Access coordinator does play a beneficial role in helping patients, nephrologists, surgeons and dialysis staff in the coordination of VA access creation, care & monitoring.
Vascular Access Coordinator play a central role in coordination of the services necessary to maintain patent vascular access and make it a truly-Life-Line for each dialysis patient.
It would be possible for every dialysis facility to have a designated staff member (preferably RN) who would stay on-a-top of vascular access needs of ESRD patients.

32. Conclusion
“I believe the intrinsic value of a vascular access coordinator is not just in the individual talents and commitment, but in the collaborative commitment and support from the team. The question is not, “can we afford to implement the role of the vascular access coordinator?” but “ are we willing to form the team?” and if so, “ How can we afford Not to have a vascular access coordinator?”
LESLEY C, DINWIDDIE, MSN,RN,FNP,CNN
The Value of a Vascular Access Coordinator
Nephrology & Issues. May 2003
University of North Carolina

33. References
Vascular Access Coordinator Role
Example: Job Description Vascular Access Nurse Coordinator
Barelay.C Role of a dialysis Access Coordinator(Vascula Access Manager) Kaiser Permante.USA
The Value Vascular Access Coordinator

34. Thank You