We’re kicking off this first issueof In Control by focusing on oneof the most challenging topicsyou face today: Fistulas. Howcan we increase the numbers ofhemodialysis patients who usefistulas for vascular access?

Good access is key to patientconfidence and well-being, andfistulas are the best accesschoice. Compared to catheters,fistulas have fewer complica-tions and provide better bloodflow for better dialysis. They lastlonger, cause fewer hospitaliza-tions, permit greater longevity…and they even cost less.

The advantages of fistulas areso extensive that the ESRDNetworks and CMS have madea new Fistula First initiative theirtop priority: working toward a goal of 50% of new patientsand 40% of all current patientsusing fistulas for access. “Ifdialysis professionals andproviders can work together toincrease fistula placement, itwill have a significant impacton quality of care,” says JennyKitsen, Executive Director ofthe ESRD Network of NewEngland and a member of theFistula First leadership group.

Fistula FirstThe Fistula First initiative hasidentified 11 key clinical andorganizational changes to helpincrease fistula use. (Seeresource list on page S8.) All arecritical, but “we’re discoveringthat the most important factor inimprovement is having someone(in the center) take the initiativeand pay attention to access,”says Kitsen. “Get a handle onwho’s got what type of accessand how long they’ve had it;then put a plan in place for thefuture,” she advises. “Thatway the issue of access won’tjust fall through the cracks.”

Improving access “is going to be a challenge,” Kitsenadmits. “We will have to becreative in reaching outbeyond our comfort zone inthe center—to surgeons, tohospitals, etc.—in dealing with the problem.”

Patients, too, can play a role to increase the likelihood thatthey will get and keep a fistula,by learning more aboutaccess, participating in activeself-care, and speaking up: in fact, by being “in control.”

www.lifeoptions.org www.kidneyschool.org

In Control is supported by Amgen Inc.

Focus on Fistulas

VOL. 1 | NO. 1

MARCH 2004

and published in cooperation with

A Medical Education Institute/Life Options Publication

New Name, New LookThe Renal RehabilitationReport has gotten a makeover!After more than 10 years, we’vere-designed our newsletter tomake it easier for dialysis pro-fessionals and patients to use.

New name. Our new namereflects the Life Options philos-ophy that being In Control iskey to a long life with chronickidney disease. What you learnhere will help put you and yourpatients In Control—with prac-tical, how-to guides and tips.

2-in-1 design. Our new lookmakes it easy to find contentthat meets your needs. For you,there are 4 pages of importantissues and information on how toput key concepts into practice.For your patients, there 4 pagesof easy-to-use patient education,complete with a quiz to testtheir knowledge.

We encourage you to makecopies of the patient pages anduse them as supplements toyour own educational materials.

The nursing staff at UVAAugusta Dialysis Center, led byClinical Director Kim Deaver,RN, BSN, CNN, were able toincrease fistula use from 51% to76% of all hemodialysis patientsin their unit—and reduce cathe-ters and graft use by half—injust 18 months! Here’s how.

Targeted AnalysisIn July 2002, Deaver and herstaff undertook an analysis ofexactly what happened whennew dialysis patients came tothe center. What they foundsurprised them. Most patientswere in the center for morethan a month before the issueof access was addressed. Inaddition, surgeons, radiolo-gists, and patients were notwell-informed about reasonsfor choosing a fistula.

New Protocols Working together, the staffdeveloped new protocols toensure that access got moreattention. In acute centers, newpatients now receive accessinformation right away.Nephrology and surgical con-sults are set up automatically,vein mapping is always ordered,and patients are discharged withan appointment for accessplacement. “That eliminatesa month of delay right there!”said Deaver.

In the chronic center, acharge nurse evaluates eachnew patient’s vascular accesswithin the first 5 days.Anyone with a catheter auto-matically gets informationabout fistula placement andvein mapping, and surgicalappointments are scheduled.

Preventive MeasuresTreatment protocols routinelyinclude preventive access care,too. Venous pressure monitor-ing is done at every dialysistreatment, and primary nursesare responsible for trackingaverage pressure ranges on amonthly basis. Any signs ofstenosis are promptly investi-gated with radiographic testing.

Too much work? Not at all,said Deaver. “We actuallyhave less. Monitoring takesless than 1 minute per treat-ment, but now we rarely haveto deal with the problems ofclotted accesses, like difficultneedle sticks, longer treat-ments, or missed and re-scheduled treatments.” In aunit of 87 patients, Deaverreports only one clottedaccess every 6 months!

Lots of Education“We had many meetings,”said Deaver, “with surgeons,nephrologists, and radiolo-gists in multiple hospitals.”

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Nursing Protocol Increases Fistula Placements

Pre- and Post-intervention Access Choice at UVA Augusta

(continued on page S4)

www.lifeoptions.org www.kidneyschool.org S3

Nephrologists, surgeons,radiologists, primary carephysicians, and dialysis care professionals must work together as a team toincrease the use of fistulas.But patients also play a criti-cal role in making decisionsabout vascular access.

Q:Why is it important tofocus on the patientside of this issue?A: From signing on the dottedline for fistula surgery totaking good care of an existingaccess, patients can influencethe success of a team effort touse fistulas. Improved out-comes and good quality of lifeare tied to patients’ active par-ticipation in decision-makingand adherence to treatmentplans. Patients who “buy into”a decision to choose a fistulawill be likely to get betterresults than those who just “dowhat the doctor tells them.”

Q.What is the best wayto convince new patientsto choose a fistula?A: Start early! Ideally,every new patient would

establish an access 6months before dialysis. The long lead time allowsfor education (and repetition),access maturation, and problem solving. Even forurgent start patients, timingis important. Start talkingabout a fistula as soon aspossible, and clearly statethat catheters are temporary.It often gets harder to convert catheter patients to fistulas as time goes by.Resistance to change andcomplacency can be realobstacles.

Q. What advantagesof fistulas have youfound are mostappealing to patients?A: Although individualpatients may vary, manypatients find these argu-ments compelling:

Medical benefits – fistulasreduce the risk of seriousinfection, provide betterblood flows for better dialysis, and are associatedwith feeling better and living longer.

Fewer surgeries –establishing a fistula usuallytakes just one surgery, andmay help patients avoid mul-tiple de-clotting proceduresand additional surgeries forreplacement.

It’s my own body – there’snothing “artificial” about a fistula; it’s completely natural and uses the amaz-ing biological powers of thehuman body. Also, there is nothing that “sticks out,”like a catheter.

Q. How do you helppatients overcomefear of needle sticks?A: Cannulation is not pleas-ant, but it is a means to abetter end. De-sensitizationwith local anesthetics tohelp patients get used to theprocess often works. Peercounseling can help, too.Sharing with another patientwho has had good resultscan reduce fears. Also,there is always the option of self-cannulation. Being in control of the situationcan help reduce anxiety.

Q & A:Ask the ExpertsWe interviewed Carolyn Barclay, RN, CNN, Vascular Access Program Manager, Kaiser-Permanente; Anne Campbell, MSPH, Pre-dialysis Patient Educator, DCI Mid-Missouri;Lesley Dinwiddie, MSN, RN, FNP, CNN, Nephrology Nurse Consultant, Cary, North Carolina; and MaryLou Pederson, RN, MA, Patient Services Coordinator, Northwest Renal Network

(continued from page S2)

Nursing Protocol Increases Fistula PlacementsAnd, the dialysis nurses hadto provide their professionalcolleagues with rafts of clini-cal information, includingthe K/DOQI guidelines for vascular access. (Seeresource list, above.)

“Patient education plays a big part,” said Deaver. “We explain to all ourpatients that catheters aretemporary, and really a lastresort.” The UVA Augustastaff also talk to patientsabout why it’s important to

get a fistula, and how to askfor a fistula when they go to the surgeon.

Impressive Results“It took about 6 monthsfor us to begin to seeresults,” noted Deaver,“but then everythingstarted to fall intoplace.” UVA Augustanow reports 76%AVFs, 6% grafts, and18% catheters (withonly 14% of cathetersolder than 90 days.)

For more information aboutthe UVA Augusta protocols,contact Kim Deaver atkcd6v@virginia.edu.

Internet Resources• Kidney School™ Module 8:

Vascular Access – A Lifeline forDialysis at www.kidneyschool.org

• K/DOQI guidelines on vascularaccess at www.kidney.org/profes-sionals/kdoqi/guidelines_updates

• Forum of ESRD Networks websitewith links to websites of all 18Networks at www.esrdnetworks.org

• Patient’s perspective on theimportance of a fistula at www.nwrenalnetwork.org/cade.htm

• Clinical performance measureinformation at www.cms.hhs.gov/esrd/1.asp

• Change concepts summary at www.networkofnewengland.org/ffirst.htm

• Description of how and why a vascu-lar access coordinator can improvethe rate of fistula placement at www.ikidney.com/iKidney/community/pro2pro/nurses/TheRoleoftheVascularAccessCoordinator.htm

• Presentation by RN LesleyDinwiddie at www.nwrenal network.org/vsmeet99.ppt

Journal Articles• Dhingra RK, Young EW, Hulbert-

Shearon TE, Leavey SF, Port FK.Type of vascular access and mor-tality in US hemodialysis patients.Kidney Int 60(4):1443–1451, 2001

• Pastan S, Soucia M, McClellan WM.Vascular access and increased riskof death among hemodialysis patients.Kidney Int 62:620–626, 2002

www.lifeoptions.org www.kidneyschool.orgS4

For More Fistula Information...

In Control

Contact:Life Options Rehabilitation Programc/o Medical Education Institute, Inc.414 D’Onofrio Drive, Ste. 200Madison, WI 53719Tel: (800) 468-7777Fax: ( 608) 833-8366E-mail: lifeoptions@meiresearch.org

www.lifeoptions.orgwww.kidneyschool.org

Quiz Answers1. False. A fistula is the

type of access mostlikely to let you live a long life.

2. False. A fistula ismade by linkingtogether an artery and a vein.

3. False. Fistulas areless prone to clottingand infection becauseveins and arteries area part of your body.

4. True

5. True

Choosing your vascular access is a life anddeath issue. A recent study of more than5,000 hemodialysis (HD) patients showedthat people with fistulas lived longest, withgrafts placing second, and catheters last of all.1

What’s a fistula? It’s the best type of vascular access—a pathway to your blood-stream that makes it possible to do HD.

A fistula is made by linking two bloodvessels: a fast-flowing artery and an easy-to-reach vein. (A graft links anartery and a vein with a piece of man-made vein, and a catheter is a plastic tube placed into a vein in the neck, chest,

or groin).

Fistulas arethe “Cadillac”accesses,mainlybecause:

• They are less prone to infections,because veins and arteries are part of your body.

• They are less prone to blood clots,because blood vessels have a smooth,inner lining that clots can’t stick to.

• They can last a long time, becauseveins and arteries self-heal after eachneedle stick.

Choose a FistulaIf you don’t have a fistula now, but wouldlike one, speak up—this is your lifeline:

• Ask your doctor for a letter tellingother healthcare workers not to takeyour blood pressure or draw bloodfrom your access arm. Keep the letterwith you all the time.

• Ask for an internal jugular (IJ) if you musthave a catheter for a while. An IJ is lesslikely to cause blood vessels in yourarm to become too narrow for a fistula.

• Ask your doctor about making a newfistula if a graft or fistula fails.

• Ask to see a vascular (blood vessel) sur-geon who creates a lot of fistulas. Somesurgeons are better at this than others.

www.lifeoptions.org www.kidneyschool.org

Your Access: A Choice for a Better Life

A Medical Education Institute/Life Options Publication

VOL. 1 | NO. 1

MARCH 2004

Patients

P1

Patients

In Control is supported by Amgen Inc.

and published in cooperation with

(continued on page P4)

Fistula

Vein

Artery

A fistula is the best access. And thebest way to ensure that your fistula willserve you well for a long time is to putin your own needles. Scary? Yes! Butas Ann tells you in this story, you’ll feelmore in control, have less pain, andknow that you are helping yourself asmuch as you can.

Setting the Stage for DialysisAnn’s kidneys first failed in 1988, as a result of lupus. She did peritoneal dialysis (PD), for a year, then received a transplant that failed rightaway. When the surgeonsremoved the failing kidney,they created a fistula in herarm, in case she would needit in the future. “I went onPD again for a short time, buthad to stop due to infection,”recalls Ann. “I then beganin-center hemo using a temporarycatheter, since my fistula was not ready to use.”

After about 7 months, Ann’s doctor toldher the fistula was ready to use. But itwasn’t. “I would bruise and swell andthey couldn’t run me on the machine,”says Ann. “So they used my cathetersince I still had it in.” Ann felt limitedby the catheter and was determined tostop using it. “I started exercising myfistula arm with a squeeze ball, even though I had read articles by doctorsthat said exercise doesn’t help. I think

it was starting to use it plus exercisethat built my fistula up for me.”

A Fistula for LifeSince Ann began using her fistula in 1989,her quality of life has improved. “I was notinformed in the early days of my treatmentand didn’t even know what a fistula was,”says Ann. “It has been so liberating—I don’thave to be as careful taking a shower oreven swimming. I love my lifeline!”

Ann feels that many patients don’t asktheir doctors about theiraccess options. “Checkwith your health care team members about getting a fistula over agraft—take charge,” advises Ann. “A fistulaprovides more efficientand faster dialysis, with

better blood flow rates.”

Though Ann loves her fistula, she hashad to make some changes to safeguardher lifeline. “As a woman, I have to becareful with my purse because I carry it on my access arm,” she says. “I try to buy purses with wide, double clothstraps, which seems to help.” Ann alsowears a loose-fitting watch and tries not to sleep on her access arm.

Needle ControlEarly in her treatment, Ann asked forlidocaine to numb her needle sticks

www.lifeoptions.org www.kidneyschool.orgP2

Take Charge of Your Dialysis Needles

www.lifeoptions.org www.kidneyschool.org

sites—for a total of four sticks at eachtreatment. But a concerned technicianurged her to change her ways. “He saidI should really try to preserve my accessby sticking it just twice with the largerneedles,” Ann remembers. “I thank him for that advice, because I’vefound that getting two stickswith larger needles hurts nomore—and it helps preservemy fistula!”

Through the on-line dialysis_supportgroup, Ann also learned that it was better to put in her own needles, aprocess called self-cannulation. “I hadneedle phobia and never watched whenmy needles were put in,” declares Ann.

“But once I learned about self-cannulation,I decided to watch. It took my fear awayand I said, ‘I can do that!’”

Ann has been self-cannulating withoutnumbing cream since 1996. “It’s aboutmore than being in control—you get to

know your fistula intimately andcan feel and sense everythinginside it,” she explains. “If youare too close to the wall of your

fistula, for example, you can feel that and adjust your stick before you punc-ture it.” Ann also rotates her needlesticks between three different sites so no one place is overused. “Doing myown needle sticks has been just a wonderful change.”

P3

Do needles make you cringe—or evenpass out? If so, you may be among theestimated one in 10 people with needlephobia. Some people’s fear is so greatthat they insist on a catheter instead ofa fistula. Luckily, there is help!

Lidocaine creams or gels can numbneedle sites without extra injections soyou don’t feel the sticks. These may be covered by your insurance. Askyour center what pain control it offers,check local or on-line pharmacies forover-the-counter products (e.g, ELA-Max® or Topicaine®), or ask your doctorabout prescribing EMLA® cream.*

Other steps you can take to feel betterabout needles include:

• Desensitize yourself: Ask yoursocial worker to refer you to a therapist or hypnotist.

• Share your feelings: Talk to other patients about how theyhandle needles.

• Take control: Learn how to put in your own needles.

• Avoid them: Ask your doctor if PDor a transplant is an option for you.

*Note: Life Options does not endorse any products.

“I love mylifeline!”

Are You Worried About Needle Sticks?

You may have to look outside your areafor a good fistula surgeon. (Check withyour insurer).

• Ask the surgeon to do venous mappingor a venogram, to see if your bloodvessels will work for a fistula.

• Get a second opinion if one surgeontells you a fistula cannot be done.

Planning AheadEven with the best care, a fistula can fail.Since you have only a few sites where anaccess can be created, you and your doctorneed to think ahead and have a plan. Ifyour fistula fails, where will your nextsite be? And the one after that? A writtenplan that is updated any time a fistulaproblem occurs will help you feel morein control of your access and future.

Learn All You CanGetting answers to your questions aboutkidney disease is important to living longand well. You’ve taken the first step by read-ing this issue of In Control. To learn more,talk to your doctor or visit these resources:• Kidney School™ Module 8: Vascular Access –

A Lifeline for Dialysis at www.kidneyschool.org.• Keys to a Long Life Vascular Access Fact

Sheet at www.lifeoptions.org/combined/materials/indexpr.shtml

• Getting the Most from Your Treatment: WhatYou Need to Know About HemodialysisAccess at www.kidney.org/general/atoz/

• Understanding Your Hemodialysis Access Optionsat www.aakp.org/Programs_And_Services.htm

Reference1 Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF,

Port FK. Type of vascular access and mortality in UShemodialysis patients. Kidney Int 60(4):1443-51, 2001

www.lifeoptions.org www.kidneyschool.orgP4

Your Access: A Choice for a Better Life(continued from page P1)

In Control

Contact:Life Options Rehabilitation Programc/o Medical Education Institute, Inc.414 D’Onofrio Drive, Ste. 200Madison, WI 53719Tel: (800) 468-7777Fax: ( 608) 833-8366E-mail: lifeoptions@meiresearch.org

www.lifeoptions.orgwww.kidneyschool.org

Now that you’ve read about fistulas, let’s see how much you’ve learned! See if you can answer the questions below (the answers are on page S8):1. A graft is the type of access most likely to let

you live a long life. ❒ True ❒ False

2. A catheter is made by linking an artery anda vein together. ❒ True ❒ False

3. Fistulas are more prone to infection because veins and arteries are part of your body. ❒ True ❒ False

4. Lidocaine creams and gels can numb needle sitesso you don’t feel the sticks. ❒ True ❒ False

5. In case your fistula fails, you and your doctor should have a written plan. ❒ True ❒ False

Fistula Quiz