Change Concept 12

Modify hospital systems to detect CKD and promote AV fistula planning and placement

  • Hospitals develop a comprehensive plan for early identification of patients with kidney disease to allow for interdepartmental coordination for protective measures programs to prevent nephrotoxicity or other causes of further kidney damage, to allow for vessel preservation, patient and family support, and vascular access planning and/or placement.

Early identification1 , early education, timely referral to nephrology, and coordination with discharge planning will provide patient and family support in making decisions related to renal replacement therapy and vascular access. Hospital stays provide an additional opportunity for early diagnosis of CKD. Early identification1 of patients with kidney disease can slow the progression of the disease.

Changes for Improvement:

Hospitals develop a comprehensive plan of care for patients at risk for or with kidney disease to include:

  • Early identification1 of patients with kidney disease to allow for interdepartmental protective measures programs (pharmacy, radiology) to prevent nephrotoxicity and/or further kidney damage.
  •  Early identification1 of patients with kidney disease to allow for interdepartmental coordination (dietary, education, social services, case management) for patient and family support.
  •  Early identification1 of patients with kidney disease to allow for vessel preservation measures.
  •  Hospital care coordination infrastructure (attending physicians, case management, quality improvement, risk management, infection control, discharge planning, social services) to assist patients in arranging necessary care during and after a hospital stay to assure that CKD Stage 3B (eGFR 30 – 44) and CKD Stage 4 (eGRF 15 – 29) patients receive appropriate primary care follow-up and nephrology and/or surgical consults as needed.
  •  Hospital care coordination infrastructure (attending physicians, case management, quality improvement, risk management, infection control, discharge planning, social services) assists patients during and after a hospital stay in arranging necessary care that ensures CKD Stages 4 (eGFR 15 – 29) and 5 (eGFR <15) patients obtain appropriate vascular access assessment, coordination and placement as well as nephrology follow-up and education regarding renal replacement therapy options.
  •  Hospital care coordination infrastructure collaborates with local dialysis centers to develop and implement discharge documentation tools that communicate detailed vascular access placement plans for patients who choose hemodialysis as their renal replacement therapy option.

1Patients with eGFR <30 – 44 (CKD Stage 3B)

Related Tools

Epicardial First

An FFBI position statement supporting cardiac rhythm devices to be placed by the epicardial approach as a first option for patients with both kidney failure and cardiovascular disease.  Linked here are the reference list utilized for this paper as well as five supporting publications of interest: Am J Kidney Dis. 2011 Kidney International (2011) 79Seminars in Dialysis (2010)Clinical Nephrology (2010), and Am J Kidney Dis. (2010) .

Hospital Care Plan

From: The FFBI Coalition, Hospital Systems Change Concept Workgroup
Midlothian, Virginia, USA
Revised 04/10

What Hospital Professionals Can Do

From: The FFBI Coalition, Hospital Systems Change Concept Workgroup
Midlothian, Virginia, USA
Developed 02/10

The formation, maintenance and care of a vascular access involves the coordination and skills of multiple healthcare professionals. Each professional has a specific role and set of responsibilities in assuring that CKD patients are provided with quality vascular access care. A healthcare team working in collaboration and following recommended guidelines CAN MAKE a difference in maximizing the use of native AV fistulas.

Discharge Planning Tools

From: The Heartland Kidney Network, ESRD Network 12 with revisions by the FFBI Coalition, Hospital Systems Change Concept  Workgroup
Kansas City, Missouri, USA
Revised 03/10

CKD Assessment Algorithm – Emergency Room Visit 

From: The Renal Network of the Upper Midwest, Inc., ESRD Network 11
St. Paul, Minnesota, USA
Revised 07/10

CKD Treatment Algorithm

From: The Renal Network of the Upper Midwest, Inc., ESRD Network 11
St. Paul, Minnesota, USA
Revised 07/10

Midwest CKD Coalition Position Paper on GFR Reporting

PICC Line Recommendations

FFBI white paper recommending that PICC lines not be placed in anyone identified as having mid-Stage 3 chronic kidney disease (CKD), Stage 4 and 5 CKD or ESRD with instructions to obtain GFR estimates for all patients with high serum creatinine levels, and to defer a PICC line decision until it is clear that the patient does not have CKD.

Recommendation for the Avoidance of Radial Artery Access for Procedures

This document discusses avoidance of the radial artery as an acess vessel for cannulation in patients with CKD stage 4, 5 or ESRD due to possible loss of upper extremity vasculature.

Vein Preservation and Hemodialysis Fistula Protection

A one page paper with instructions for health care providers on vein preservation and hemodialysis fistula protection including directions for protection of forearm veins, for patients with working hemodialysis access and for patients with CKD or at risk CKD.

Reducing the Use of PICC Lines in CKD Algorithm

From: The Renal Network, ESRD Network 9/10
Indianapolis, Indiana, USA

Reducing Central Venous Catheter Infections Diagram

Vein Preservation Tools