Case study: A workflow model for optimizing the use of surveillance in a dialysis clinic
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East Side Vascular Access (East Side) is a member of St. Clair Nephrology, a specialty medical practice with offices across the greater Metro-Detroit area. At East Side, the access center has an average of five patient encounters per day and about 1,100 encounters each year. St Clair Nephrology physicians are medical directors at multiple dialysis centers. Our role within the network is to provide access-related services to the patients who are referred by all the dialysis centers in our area.
Workflow
Typically, the vascular access manager at the dialysis units is responsible for identifying patients who were at high risk for vascular access stenosis, including using surveillance data. When staffing was sufficient, the vascular access manager at the dialysis unit was meticulous in tracking patients and sent the appropriate referrals. After the manager moved to another facility, no one stepped in to take over management of access surveillance. As a result, patients were still being monitored but there was no trained staff available to analyze patients’ data.
Soon, we began receiving multiple referrals for the same patient and the dialysis staff were not consistently documenting reasons for the referrals. Eventually, the lack of coordination caused delays in referrals and many patients lost functioning accesses.
It became clear that the staffing issues within the dialysis units were not going to be resolved soon, so the author began documenting all patient encounters in a spreadsheet. Shortly after, reports were developed so physicians at the access center and liaisons at the dialysis centers were aware of each patient’s medical status.
Eventually, we incorporated the information from the reports. This gradually evolved into our current workflow process.
Surveillance model
Typically, staff are designated to be in charge of access care at a dialysis center and would take the lead on monitoring and analyzing the reports. They would also be responsible for identifying patients who needed clinical evaluation and possibly intervention for access dysfunction.
There are two major flaws with this workflow model: 1) our dialysis units have a large patient base and 2) rapid staff turnover is an ongoing challenge for most dialysis centers, including the ones in our health care system.
Without trained staff to monitor the reports, the technology was being underutilized and at-risk patients were being referred too late.
In contrast, East Side did not experience the same level of turnover seen in the dialysis centers. Furthermore, we had fewer patient encounters, and our staff were trained to analyze the reports.
Access surveillance technology
The obvious solution was to assign the responsibility for identifying patients with the highest risk for access stenosis to me. As the vascular nurse lead, I would send shortlists to the dialysis units, which would allow the dialysis staff to prioritize evaluation of those patients who were at risk for losing a functional access. These reports would include patient name, date of birth and last known intervention to help with their decision making. The reports were sent out weekly to the physicians and dialysis units to aid in tracking referrals as well as assist clinicians on making clinical decisions surrounding access care. This was a simple, yet effective way to work around ongoing staffing issues experienced by busy dialysis centers.
It is important to note that the dialysis centers do not simply make referrals for the patients we have identified as high risk. Before a referral is made, the dialysis center must confirm stenosis based on clinical indicators. That way, East Side avoids self-referral. In my experience, approximately 75% to 80% of patients identified as high risk using the algorithm are referred for intervention by their dialysis center.
Flow-based devices require trained staff to conduct a test directly on the patient’s access, a process that can take 15 to 30 minutes to complete. Because of this, flow-based surveillance is usually performed monthly. Use of other options like direct Doppler ultrasound is limited due to accessibility and cost. Another limitation is that blood flow can vary due to several factors (eg, age, diabetes, obesity) and may not provide an accurate picture of access health.
Vasc-Alert, the surveillance system used at East Side, is an FDA-approved system that uses treatment data already being collected during each dialysis session (blood pump flow to the dialyzer, venous and negative arterial pressure, and the mean arterial pressure) and recorded every 30 minutes in the patient’s run record to derive the intra-access pressure at the tip of the venous needle.
An algorithm is used to assign a risk score (ranging from 1 to 10) based on various measurements, including the rate of change in derived venous pressure, the number of recently derived venous pressure readings above threshold (alerts), inability to reach prescribed blood flow and arterial pressure alerts. High scores correlate with a higher probability of stenosis. Kumbar and colleagues reported that patients with a high score (8-10) have a sevenfold higher risk for stenosis.
Risk score
There are several advantages to using this surveillance system. First, it is suitable for busy, understaffed dialysis centers because the algorithm builds on patient data that are collected automatically for every treatment, eliminating the need for staff to spend valuable time doing manual surveillance testing to evaluate each patient’s access. Like other technologies in the specialty that require staff review and assessment, trained staff are needed to review the weekly reports.
The risk score makes it easier for staff to interpret the results and prioritize clinical monitoring for patients with the highest risk for access stenosis.
The model we outlined above was created to address unmet needs that are common to many centers. It provides a basic framework for simplifying workflow, particularly when working with busy dialysis centers. It is not intended to be a “one-size fits-all” approach. Here are some additional things to consider:
The time commitment is relatively low, but frequent touchpoints with dialysis center staff and patients are recommended to make timely referrals.
The reports are generated weekly. On average, alerts for five to six patients are generated per dialysis center. Vascular access stenosis can occur at any time, even in patients with a low-risk score.
Interpreting the results is easy, but training is required. There are several factors that need to be considered when trying to determine whether a patient is at high risk for access stenosis. In addition to the risk score, historical pressure trends, the number of alerts and the type of access need to be considered.
The East Side model may not be suitable for smaller dialysis centers. Centers with fewer patient encounters have more time to devote to time-intensive monitoring for each patient.
Getting buy-in from the physicians is an important part of the success of the model. Having direct access to physicians within the nephrology practice is helpful, including the medical director. Including them in weekly communication makes the impact of the surveillance more evident. They trust the model and are more likely to promote its use throughout the network.
Patient education is a priority. Many times, high-risk patients do not understand why they are being referred to us, so they refuse our services. Each week, a follow-up is done with these patients to explain the importance of maintaining their access. Sometimes patients do not have enough knowledge to be an advocate for themselves. Clinical staff should use all tools available so that we can better advocate for them.