Table 1.

Multidisciplinary vascular access team structure and functions

Composition/ActivityMultidisciplinary Vascular Access Team
StructureDirector (nephrologist); three registered nurse coordinators; three surgeons; three radiologists
Patient identificationAccess team nurses review all new hemodialysis education referrals in CKD clinic and in all patients starting hemodialysis weekly. The nurses see all patients within 4 wk of dialysis modality education before hemodialysis start, or within 4 wk of hemodialysis start
ReferralPatients identified in predialysis clinics or hemodialysis facilities are referred to the team coordinators who meet with them directly and arrange vascular access clinic visit or surgery
Vascular access clinic structureTwo simultaneous weekly vascular access clinics: surgeon clinic (vascular access creation/complications) and the nephrologist clinic (6-wk routine postoperative assessments/complications); common waiting list for the first available vascular access surgery or diagnostic imaging procedure
Vascular access team activitiesPhysical exam (clinical monitoring) and vascular access planning for all referrals; ultrasound vein mapping when veins are not visible or arteries not palpable; physical exam and ultrasound of an existing access; guidance about needling for hemodialysis staff; catheter removal if a catheter is in place and the fistula can be used reliably; diagnostic imaging and intervention orders/booking
Maturation assessmentAll fistulas are assessed for patency (auscultation) at 1 and 3 wk after creation, and for maturation at 6 and 8 wk (full physical examination and ultrasound). The team nurses use the rule of 6’s to assess maturation: 0.6 cm in diameter, 600 ml/min flow (assumed on the basis of thrill and bruit), and within 0.6 cm of skin surface (ultrasound exam). In case a fistula is considered not mature at 8 wk or a stenosis is suspected (arm elevation or augmentation test) an x-ray/angioplasty is arranged; a surgical procedure is considered if needed
Vascular access surveillance (blood flow in the access)Performed every 8 wk by the access team using ultrasound dilution technique
Policy review and protocol updatesReferral for x-ray/angioplasty (i.e., venous pressure >150 mmHg with 15G needles on three consecutive runs at blood pump speed of 200 ml/min; signs of access dysfunction [difficulty needling, poor clearance, prolonged bleeding post dialysis, arm swelling, etc.] and access flow <500 ml/min; or access flow reduction ≥20%); referral for surgery if stenosis >3 cm or multiple lesions
RoundsDifficult cases are discussed monthly
EducationStaff education and quality assessment/improvement reports