Putting it Into Practice
Access Patency Initiative
Integrating Vasc-Alert into your Center’s Clinical Operations
Over the years, we have worked with many centers and have developed a wealth of best practices for vascular access surveillance programs. Based on our experience, we have prepared a roadmap that should help you obtain the maximum benefits for you and your patients. This roadmap presents some concepts that support a QIP program called the Access Patency Initiative or API.
When you choose to use Vasc-Alert to improve quality of care, it is important to make sure the basics are being accomplished, since it is impossible to ‘run before you can walk’. At minimum, your center needs to have the following in place:
Report review – A clinical staff person, usually termed the vascular access coordinator (VAC), who has received training must review the reports and act at investigate those patients who a) have been on alert for a good period of time, b) have high pressures for 2 or more weeks, or c) show steep increases in the pressures indicating possible rapid growth.
Frequency of report review – We recommend that the Vasc-Alert reports be reviewed each week for the first 6 – 9 months of use. This frequency can be extended to every 2 weeks once the backlog of initial patients has been decreased so that only developing access issues are present.
Referrals being made – Those patients who show evidence of issues and are deemed to be ‘at-risk’, need to be referred for a fistulagram. The use of the Referral Module that is available on-line at Vasc-Alert.com should be considered as a tracking tool.
Integration of Vasc-Alert into Routine Clinical Operations
In addition to having the designated VAC review the weekly reports for changes, we strongly suggest that the report of any patient who is ‘on alert’ be placed in a patient’s chart so that the patient’s nephrologist can review it when doing weekly rounds. We also suggest printing a full set of alert reports along with the monthly management reports to review during the monthly patient care conferences. These two adjustments to your regular routine will assure that the reports are being reviewed. It will also provide the doctors with a better sense of the status of their patients’ accesses.
Another feature of Vasc-Alert is the ability to review reports on-line. This enables authorized clinical and medical staff to pull up any patient’s record from any computer with secure Internet access to view the latest results. Nephrologists, interventionalists, surgeons or any authorized staff member can use this feature to review the latest results, see how successful a procedure was or how well a new fistula is maturing. We suggest that you show the on-line function to each physician with patients in your center when you have the opportunity to see if they might be interested in having their own login information.
Quality Improvement Initiatives
The fundamental goals that we all want to see with the use of Vasc-Alert are early identification of problems, proactive/non-emergent referrals for intervention, reduction in thrombectomies and improved quality of vascular access management and care in your patient population. To this end, we have created a set of management reports that are released monthly that provide you with some feedback on progress each month and over a six-month time period. For example, you should see a decrease in the percentage of patients on alert as detailed in the ‘On-Alert Percentage Report’. Some of our long-term users have an ‘on-alert’ percentage as low as 5% to 10%, which means that they are catching stenosis early and proactively referring for intervention.
Over time, you want to see:
- A decreased thrombosis rate.
- An increase in average blood flow rate by patient and by center.
- A decreased catheter rate.
- An increase in access life due to a decreased number of thrombectomies.
- Improved clearances.
But in order for these benefits to become reality, the data needs to be transmitted weekly for Vasc-Alert reports to be produced, but more importantly, the reports need to be picked up and acted upon. Our reports provide an early warning of pending access site issues and patients need to be referred in a timely fashion, to achieve optimal success with the Vasc-Alert service. We will try to let you know if reports are not being picked up in a timely fashion.
Closing the Loop
Retrieving and acting on Vasc-Alert reports is one aspect of implementing a good vascular access program within your center. Another key element is tracking what has happened to those patients who you have referred for intervention. While intervention centers should send you copies of the intervention reports, in our experience, this often is not the practice. It is important that you contact the organizations that perform access interventions on your patients and make sure that they send you a copy of the intreventionalist’s report on the procedures performed.
Once you start receiving these reports, it is good practice to start some form of access tracking system so you start to accumulate pertinent data on your patients’ accesses. We can provide you with a spreadsheet that can be used as a basic template (you can modify for your needs). This form includes fields for tracking the reason for referral, procedures performed, findings (location of problem, percent occlusion) and any ancillary issues noted by the interventionalist that should be considered the next time the patient is ‘on-alert’.
Done correctly, it can provide many benefits over time and greatly improve your ability to understand what is going on with each of your patients’ accesses.