Using root cause analysis as a tool to reduce central venous catheters in haemodialysis patients.

BACKGROUND: Haemodialysis remains the most common modality of renal replacement therapy. National and international guidelines continue to promote arteriovenous fistulas or grafts as the preferred vascular access for haemodialysis, given the increased risks associated with use of central venous catheters (CVCs). Our renal centre pursues a 'fistula first' culture and uses root cause analysis and a patient safety incident based approach to meet the recommended standards of minimal CVC use in dialysis patients. METHODS: We undertook a retrospective observational review looking at patterns of CVC use amongst our patients to identify themes and changes over time. Using data collected over a 5 year period, we examined 100 patient safety incidents involving CVC use in planned haemodialysis patients. We used a contributory factors framework to identify systemic contributors to each incident. RESULTS: During the study period our centre achieved the national standard of at least 60% of incident dialysis patients commencing planned haemodialysis via arteriovenous access. About 26% of cases of CVC use in incident dialysis patients were deemed potentially avoidable. The most common contributory factor identified in these cases was poor communication. CONCLUSIONS: Using a root cause analysis based methodology to examine CVC use in haemodialysis is a novel approach to quality improvement in this area. Our methodology can be used as a framework by other centres to optimise the provision of safe, effective, and timely vascular access for dialysis, with multiple benefits for both renal services and individual patients.

Effect of first cannulation time and dialysis machine blood flows on survival of arteriovenous fistulas.

Background: To study the effect of cannulation time on arteriovenous fistula (AVF) survival. Methods. Analysis of two prospective databases of access operations and dialysis sessions from 12 January 2002 through 4 January 2015 with follow-up until 4 January 2016. First cannulation time (FCT), defined from operation to first cannulation, was categorized as <2 weeks, 2-4 weeks, 4-8 weeks, 8-16 weeks and ≥16 weeks. Early cannulation was defined as FCT within 4 weeks. AVF survival was defined as the date until the AVF was abandoned. Maximum machine blood flow rate (BFR) for the first 29 dialysis sessions on AVF was analysed. Results: Altogether, 1167 AVF with functional dialysis use were analysed: 667 (57%) radial cephalic AVF, 383 (33%) brachiocephalic AVF and 117 (10%) brachiobasilic AVF. The 631 (54%) AVF created in on-dialysis patients were analysed separately from 536 (46%) AVF created in pre-dialysis patients. AVF survival was similar between cannulation categories for both pre-dialysis patients (P = 0.19) and on-dialysis patients (P = 0.83). Early cannulation was associated with similar AVF survival in both pre-dialysis patients (P = 0.82) and on-dialysis patients (P = 0.17). Six consecutive successful cannulations from the start were associated with improved AVF survival (P = 0.0002). A below-median BFR at the start of dialysis was associated with better AVF survival (P < 0.0001). A below-median increase in BFR in the first 2 months was associated with worse AVF survival (P = 0.007). The type of AVF, diabetes, pre-dialysis state at operation and six successful cannulations from the start were independent predictors for AVF survival. Conclusions: FCT is not associated with AVF survival. Failures to achieve six successful cannulations from the start of dialysis and higher machine BFR in the first week of dialysis are associated with decreased AVF survival.

Is early cannulation of an arteriovenous fistula associated with early failure of the fistula?

OBJECTIVE: To study the effect of early cannulation of arteriovenous fistulas (AVF) on early AVF failure. METHODS: Analysis of two databases of access operations and dialysis sessions from 1/12/2002 till 1/4/2015. Follow-up until 1/4/2016. Functional dialysis use defined as six consecutive cannulations of the AVF with two needles. Early cannulation defined as needling of the AVF within 30 days of creation. Early failure was defined as abandonment for new form of access within 90 days of first cannulation. Machine blood-flow rates (BFR) of each dialysis session for the first 2 months collected from the dialysis database. RESULTS: We analysed 1167 AVFs with functional dialysis use. Some 148 AVFs (11%) were needled within 30 days. Early needling was not associated with increased early failure rates (p = 0.43). Early failure rates were lower in AVFs with six consecutive successful cannulations from the start (p = 0.002). There was a trend of reduced early failure rates (test for trend: p = 0.018) in the latter years of the study period, but no trend in early cannulation rates (p = 0.19). Failure to achieve six successful cannulations from the start was an independent predictor of early AVF failure but early needling was not an independent predictor in multivariate analysis. Average starting BFRs were higher in AVF that were needled early. CONCLUSIONS: Early cannulation was not associated with early failure. Failure to achieve six successful cannulations from the start was an independent predictor of early failure. The trend in yearly variation of early failure rates suggests that evolving practices influenced early failure rates.