NHS Lanarkshire Vascular Access Creation Pathway Guidance Note

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1 Purpose The purpose of this document is to describe the processes involved in the routine creation of vascular access for haemodialysis patients in NHS Lanarkshire. This document primarily refers to patients who are known to the renal service, whose renal function is declining, and who are likely to require RRT in the future. It also refers to patients already maintained on RRT who require the creation of new vascular access. It does not directly apply to those patients who require temporary haemodialysis for acute kidney injury, and whose renal function is expected to recover to a point that haemodialysis becomes unnecessary. It does not describe the process of organising Tenckhoff catheter insertion to facilitate peritoneal dialysis. It also does not describe the process of patient education, modality selection, or other aspects of pre-referral activity. This document should be read in conjunction with the NHS Lanarkshire Vascular Access Maintenance Pathway (Guidance Note) document. Prerequisites for entry to access creation pathway This document concerns patients who have been referred for the creation of vascular access for haemodialysis. It is not the role of this pathway to routinely make decisions as to patients suitability for one RRT modality over another, although clearly the assessment process may result in changes to the original planned access. RRT education and decisions about personalised RRT solution and personalised access solution should be made in conjunction with the patient, and documented in the SERPR electronic patient record prior to referral into the access creation pathway. It is anticipated that patients personal access solution should only be documented as being a tunnelled line when a fistula or graft have been excluded following review at the vascular access clinic. Referral for access creation The SERPR electronic patient record dialysis access screen should be populated by the referring clinician, and a pre-formatted letter generated in SERPR. The letter will remain in SERPR rather than being printed, to facilitate an electronic referral pathway. The patient should then be added to the VAN access clinic referral list via TrakCare. The patient will then be appointed to the next available clinic, typically within 2 weeks. A log of access referrals will be kept (accessible via a SERPR report). This will be used for clinical purposes: to track active patients; and also for clinical audit purposes to improve the service for patients and clinicians.

2 Vascular access clinic This outpatient clinic takes place on a fortnightly basis, using clinic space in the renal unit. The clinic is staffed by a VAN and vascular surgeon, and has administrative support provided by a clerkess. Patients are seen in 15 minute slots, during which time they have a duplex ultrasound scan and a decision made as to where a fistula could be created, or alternatively where a graft could be inserted. Where there is doubt as to the most appropriate surgical approach, imaging studies may be requested from this clinic, and the patient would then be listed for discussion at the next MDT meeting. If significant uncertainty persists consideration will be given (via the MDT meeting) to referring the patient to a regional complex access service. Referral to such a service will be a joint decision between the responsible nephrologist and surgeon. When a patient has been seen, and a decision made as to the operation to be performed, the patient is allocated a slot in the anaesthetic pre-assessment clinic (from the pool of designated renal vascular access pre-assessment slots). The clinic clerkess informs the patient of their appointment date/time and s the patient demographics to the pre-assessment clinic. Pre-assessment clinic At pre-assessment the patient may be referred for further anaesthetic review, for further investigations, or cleared to proceed. Responsibility for onwards referral for anaesthetic review, and for investigations ordered as part of the pre-assessment process, remains with the pre-assessment service. Pre-assessment will inform VAN when a patient has been cleared to proceed, or if they have not been cleared to proceed. VAN will record a brief entry on SERPR around the outcome of preassessment referral. Theatre scheduling VAN will allocate a specific theatre slot to the patient once cleared by pre-assessment. If no slots are available, the patient will instead be added to a waiting list. When surgery is scheduled for the Monklands day surgery, the patient reports to the same day admissions unit or the renal ward. If a bed is required postoperatively this is arranged via the day surgery unit or via the bed manager. When surgery is scheduled for Monklands main theatres, the daily hospital bed meeting is the forum for identifying a postoperative bed for the patient.

3 If a patient fails to attend, or if the procedure does not proceed for any reason, VAN will reschedule the patient to an alternative theatre slot. Postoperative review (see also maintenance pathway document) The (brief) details of the operation should be recorded in the appropriate screen on SERPR. Patients who have an AVF created in theatre should have a backup plan documented that specifies the action to be taken in the event that the fistula fails to mature. This may include a statement that interventional radiology manipulation should be attempted, that a further surgical procedure should be listed, or that the patient should be relisted for an alternative fistula (at a specified anatomical place). The patient should be appointed routinely to see the VAN between 4-6 weeks after their operation. They should not ordinarily be seen for the purposes of fistula maturation assessment before then, although may be seen for the purposes of detecting immediate postoperative complications (eg significant swelling, infection). At that clinic review the fistula will be assessed and a decision made as follows: Fistula appears to be maturing satisfactorily commence routine surveillance pathway Fistula does not appear to be maturing satisfactorily proceed as per documented surgical plan, booking patient directly into next available slot in radiology or surgery Uncertainty as to fistula maturation patient to be discussed at next MDT meeting (or directly with surgeon before next MDT meeting) Patients requiring tunnelled line insertion Where patients are referred for the insertion of a tunnelled line (for chronic haemodialysis), they should also be added to the vascular access clinic for review unless their personal access solution has previously been documented as a tunnelled line following earlier review in the clinic. When the nephrologist indicates that dialysis timing is such that a fistula or graft will be unachievable before the patient requires dialysis, a tunnelled line will be arranged in parallel with the assessment for native vascular access. Patients who have a tunnelled line in situ, but do not have this documented as their personal access solution, will be added to the next available MDT meeting or next available vascular access clinic for discussion / assessment.

4 Referral for tunnelled line insertion must also be made via the SERPR referral route used for other access creation. It is anticipated that tunnelled lines will only be specifically requested as a bridging measure until alternative access is available, ie a fistula or graft has matured. Clinical Responsibility The nephrologist retains responsibility for the timing of referral for access creation, and for the timing of dialysis commencement. The vascular surgeon (and/or VAN) has responsibility for determining the surgical approach to access creation (ie specific fistula / graft). Ordinarily the vascular surgeon will also retain responsibility for determining when a specific patient cannot have a fistula or graft. Patients should normally be seen in the vascular access clinic (and/or discussed at the vascular access MDT) before documentation that a tunnelled line is their personal access solution, unless there are specific medical reasons for using a tunnelled line (eg very short life expectancy). Abbreviations AVF AVG HD MDT RDU RRT arteriovenous fistula arteriovenous graft haemodialysis multi-disciplinary team renal dialysis unit renal replacement therapy SERPR electronic renal patient record TCVC VAN VA tunnelled central venous catheter vascular access nurse vascular access

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