SERVICE SPECIFICATION 2 Vascular Access

SERVICE SPECIFICATION 2 Vascular Access Table of Contents Page 1 Key Messages 1 2 Introduction & Background 2 3 Relevant Guidelines & Standards 2 4 Scope of Service 3 5 Interdependencies with other specialties & support services 4 6 Markers of Good Practice 5 7 Quality Measures & Audit Criteria 5 Appendices 1 Impact Statement 2 Consultation Record, Document History & Version Control This document should be read in conjunction with the Common Themes document which is relevant to all Renal Service Specifications. Vascular Access Page 1 of 8 Version:2.3

1 Key Messages Patients who may require renal replacement therapy should receive information on options for vascular access at an early stage and be referred into the vascular access service at time that allows this to be created prior to commencement of dialysis The vascular access service should have a named lead in each centre who is supported by a full multidisciplinary team (which includes as a minimum a nurse(s), nephrologists, surgeon(s), a vascular technician and a radiologist(s)) Access should be monitored and maintained to allow timely planning for replacement and to avoid the necessity of emergency access 65% of patients should commence haemodialysis using an arteriovenous fistula (AVF) 85% of all prevalent haemodialysis patients should receive dialysis via a functioning AVF The annual Staphylococcus aureus bacteraemia rate in the prevalent haemodialysis population should be less than 2.5 episodes per 100 HD patients and less than 1.0 for MRSA over 2 years 2 Introduction and Background In Wales, the majority of dialysis access surgery is performed in the five major Welsh centres (Cardiff, Swansea, Wrexham, Glan Clwyd and Bangor) which serve their own central renal units and the surrounding satellite units. A small number of patients cross the border from Flintshire to Arrowe Park Hospital in the Wirral, from Welshpool to Shrewsbury, and from Llandrindod Wells. Some patients from mid Wales are treated in Shrewsbury but the Welshpool dialysis unit, managed by the Wrexham Maelor Hospital based team manage the majority of patients from North Powys, and new patients will be expected to have access procedures in Wrexham. Historically, the three provider LHBs via the five Welsh centres have provided all diagnostic and surgical services required to establish and maintain access. With the centralisation of major vascular surgery this may change. Vascular Access Page 2 of 8 Version:2.3

3 Relevant Guidelines and Standards 4 Scope of Service The service starts at the point on the Renal Replacement Therapy pathway from the decision to opt for haemodialysis and when egfr has declined to Stage 4, or in urgent cases when a similar egfr is reached in acute patients, and ends at cessation of use of access (e.g. due to change of modality). Service description The vascular access service is a multidisciplinary service involving as a minimum a Vascular Access Nurse (VAN), nephrologists, a vascular access surgeon(s), a vascular technician(s) and an interventional radiologist(s) who work together with the patient to achieve optimum dialysis access. The service will have a named lead in each unit who may be any of the members of the multidisciplinary team (MDT) and will be supported by the wider MDT. Planning for vascular access should normally begin at an early enough stage to allow the creation and maturation of optimal vascular access before dialysis is required. The precise timing of referral into the vascular access service depends on the rate of decline of renal function, patient co-morbidities and the local patient pathway. All patients will require information provision and support to make an individual decision on their optimal vascular access. The majority of patients will choose the vascular access which is most reliable and carries the lowest risk of morbidity. This is nearly always an autologous arteriovenous fistula (AVF), but alternative options include an arteriovenous graft (AVG) or a tunnelled Central Venous Catheter (CVC). The creation of an AVF is possible for the majority of patients, although it not infrequently requires more than one surgical procedure. The location of the fistula will vary but each service will be expected to state its policy, report performance, participate in audit of outcomes and be prepared to alter practice in the light of accepted best practice. AVGs may be an alternative for some of the patients where AVF formation has not been successful and as the first choice vascular access for a small number of patients. CVCs are essential for most patients requiring haemodialysis as an emergency but are associated with significantly higher rates of morbidity and mortality and therefore their use should usually be restricted to as short a duration as possible. When a CVC is required for longer than two weeks it should be tunnelled under the skin to reduce the risk of infection. There will be regular surveillance of access. Acceptance and Entry to Pathway As describe above planning for access should commence when patients enter CKD stage 4. Referral into the service will be made by either specialist Chronic Vascular Access Page 3 of 8 Version:2.3

Kidney Disease (CKD) nurses or nephrologists, who will have already started the provision of information to the patient. Each centre will have an individual patient pathway (according to local service circumstances) which will be both formally documented and regularly audited. The pathway will allow patients to have the greatest opportunity to commence dialysis by means of the optimal vascular access, and be sufficiently robust to not rely on the presence of individual members of the MDT. Exclusions All patients who opt for haemodialysis should be referred into the vascular access service. Every attempt should be made to inform patients who decline to engage with the service about the options for vascular access including the risks and benefits of each type of access. MDT Working The overall skillset of the MDT will be similar between centres but likely unique within that centre. Wherever MDT meetings are held these should not be a substitute to a more reactive or virtual MDT whereby there is a continuous dialogue between clinicians, often co-ordinated by the Vascular Nurse, to enable services to be provided in response to changing clinical presentations. Some of the required roles may be performed by different specialists in each centre (for example CVC insertion). Each centre will be responsible for ensuring that all MDT members have been appropriately trained and are supported in conducting their required roles. The service will also have a role in training future vascular access specialists and allied professionals. 5 Interdependencies with other specialties & support services The provision of a high quality vascular access service requires a truly multidisciplinary approach with input from a diverse group of allied specialists. The service in all centres will require input from the nephrology, surgery and radiology departments. There is also the need for close liaison with all of the dialysis units to monitor and maintain vascular access and it is imperative that the providers of the dialysis services are fully engaged with the service. The provision of vascular access has a significant impact on morbidity, mortality and emergency admission rates for patients with CKD. To provide a robust service there is requirement for dedicated access to surgical sessions, the exact number of which will vary according to the population served by individual centres. As the majority of vascular access surgical procedures can be performed under local anaesthetic there is no need for these theatre sessions to be located within a major vascular centre. However a proportion of patients will require more extensive surgical procedures and therefore each centre providing vascular access will also need access to appropriate theatre lists to perform these. Vascular Access Page 4 of 8 Version:2.3

The service will require access to a vascular laboratory for vein mapping and follow-up scanning. There is also a requirement for access to interventional radiology (IR) vascular support for a proportion of patients which, when required, needs to be performed promptly to maximise successful outcomes. IR support may be required in theatre. 6 Markers of Good Practice Evidence of written pathways and protocols for the vascular access programme Unnecessary venepunctures and peripheral venous access in the upper limb intended for creation of access is avoided Evidence of the provision of good information to patients and help provided to reach a consensus on the optimal individual vascular access The agreed pathway is audited regularly and shown to allow the majority of patients to commence dialysis by means of the optimum vascular access Systematic observation and, when appropriate, advanced surveillance is employed to predict and prevent access failure Regular audit of CVC use, including root cause analysis for incident haemodialysis patients Infections are minimised by avoiding CVCs whenever possible, using strict aseptic technique, cleaning of catheter exit sites, hubs and antibiotic locks for CVCs, and early catheter removal The proportion of all patients with urgent access related complications treated according to locally agreed protocols by the multidisciplinary team is monitored The MDT has the appropriate skill mix to provide all of the necessary vascular access procedures, and reacts promptly to changed clinical circumstances. When the patient numbers are too small to allow the development of expertise in certain rarer procedures (e.g. insertion of hybrid CVC-AVG), referral pathways exist to allow patients to attend a centre with the appropriate skills Access related ischaemia prompts urgent surgical referral Vascular Access Page 5 of 8 Version:2.3

7 Quality Measures and Audit Criteria Each vascular access centre will collect and submit regular audit data for review and discussion by the All Wales Vascular Access Network. This network will include representatives from each centre and will meet twice per year to discuss issues relating to vascular access in Wales. Proportion of incident haemodialysis patients commencing dialysis by means of an AVF (target 65%) Proportion of prevalent haemodialysis patients receiving dialysis by means of an AVF (target 85%) The annual Staphylococcus Aureus bacteraemia rate in the prevalent haemodialysis population (target less than 2.5 episodes per 100 HD patients and less than 1.0 for MRSA over 2 years) As WRCN commissions this service adherence to the specification will be monitored and significant shortcomings reported to the LHB. Vascular Access Page 6 of 8 Version:2.3

Appendix 1: Impact Statement This would be a general statement of possible impact and/or a record of what the impact on each provider is agreed to be. The value of such a statement in this appendix will be reviewed during 2016 before a statement is included Vascular Access Page 7 of 8 Version:2.3

Appendix 2: Consultation Record, Document History & Version Control Document Author: Executive Lead: Approved by: Issue Date: Review Date: Document No: Document History Insert Role Title Insert Role Title Insert Committee To be obtained from Corporate Services Manager or Corporate Governance Manager Revision History Version No. Revision date Summary of Changes Updated to version no.: Date of next revision Consultation Name Date of Issue Version Number Approvals Name Date of Issue Version No. Distribution this document has been distributed to Name By Date of Issue Version No. Vascular Access Page 8 of 8 Version:2.3