QUALITY

IMPROVEMENT STUDY
DELAYED VASCULAR ACCESS PLANNING RESULTING TO
HIGH INCIDENCE OF CATHETER RELATED
COMPLICATIONS AT THE HEMODIALYSIS UNIT OF
UNCIANO COLLEGES AND GENERAL HOSPITAL, INC.
FROM JANUARY 2016 TO MAY 2016

PREPARED AND PRESENTED BY: HEMODIALYSIS UNIT

ROMEO A. LAZARTE JR., RN, CNN
HEAD NURSE

STAFF NURSES:
KYLIE ZARLA A. ESCALONA, RN, CNN
EMMANUEL M. GILLA, RN
NOELLE M. MARZO, RN, CNN

JOHN LOUIE S.T. SOLITARIO, RN

INTRODUCTION
The majority of dialysis patients use hemodialysis (HD) for renal
replacement therapy. At any given time, a patient will have one or more
vascular access in place. Still a large percentage of patients start dialysis
with a dialysis catheter in place and, often times, no other vascular
access. An organized approach to the management of vascular access
has been found to be effective in reducing the amount of time a patient
has a catheter in place. Creating a plan for vascular access management
is the best way to ensure an organized approach that will lead to catheter
freedom for your patients.
When an access plan has been created this will decrease the use of
HD catheters and preserve existing accesses for continued use. While the
primary focus of vascular access planning is for patients who are new to
hemodialysis, it is also important to work with all patients on HD who do
not have an access plan or are dialyzing with a catheter. The dialysis care
team (DCT) must create an access plan and checking, using routine
access monitoring that supports early intervention when access
problems are identified. This will decrease the use of HD catheters and
preserve existing accesses for continued use. An access event requiring
intervention or changes to the access plan may provide an opportunity
for the DCT to explore different treatment options with the patient.
Health status and other factors may limit the options available for an
individual patient, but taking the time to evaluate these choices is
recommended. Choices may include:
Peritoneal dialysis (PD) - a home dialysis method.
Kidney transplant- receipt of a kidney from a living or deceased
donor.
The DCT should provide information and arrange for the necessary
referrals in support of patients who want to explore other options.
A vascular access is a hemodialysis patients lifeline. It makes lifesaving hemodialysis treatments possible; it should be in place weeks or
months before the first hemodialysis treatment. Patients should set up a
vascular access well before starting hemodialysis, as AV fistulas and AV
grafts both need time to mature before they are ready for use.

If kidney disease has progressed quickly, a patient may not have

time for placement of an AV fistula or AV graft before starting
hemodialysis treatments. Venous catheters are not ideal for long-term
use. With a venous catheter, a patient may develop a blood clot, an
infection, or a scarred vein, causing the vein to narrow.
This quality improvement study focuses on the underlying factors
regarding high incidence of catheter complications in the hemodialysis
unit, having the delayed vascular access planning as our main cause. We
also aim to formulate strategies to provide an efficient treatment and
promote patients safety and satisfaction as well, by means of developing
a reliable and effective access plan, for those who are newly diagnosed
with End Stage Renal Disease and regular hemodialysis patients.

ABSTRACT
The course of this study is ranging from January to May 30, 2016
at Unciano Colleges and General Hospital, Inc., Dialysis Unit (2 nd Floor)
at Antipolo City.
The scope of this study focused on determining the underlying
factors regarding the high incidence of catheter related hemodialysis
complications, which leads us to come up with the topic Delayed
Vascular Access Planning Resulting to High Incidence of Catheter-related
Hemodialysis Complications at Hemodialysis Unit of Unciano Colleges
and General Hospital, Inc.
This quality improvement study also focused on improving the
awareness of patients and relatives regarding the importance of having a
permanent vascular access as soon as primary option for maintaining
hemodialysis treatment.

OBJECTIVES
At the end of this quality improvement study by the end of June
30, 2016 onwards, the researchers from DIALYSIS UNIT (2 nd Floor) of
Unciano Colleges and General Hospital, Inc. aims the following:

1. Identify the contributory factors resulting to the high incidence of

catheter related infections.
2. Determine the roles of the entire Dialysis Care Team (DCT),
together with the patient, on eradicating the increasing morbidity
and mortality rates concerning catheter related complications by
means of creating an effective vascular access plan, as well as to
involve the patients in the plan of care.
3. Formulate best strategies to improve the process of vascular access
planning through patient education, strong collaboration of the
entire Dialysis Care Team (DCT), and continuous monitoring and
evaluation of the vascular access of the patients.
I.
PROBLEM IDENTIFICATION AND SELECTION
I.A. Identification of Potential Problems
A. Unavailability and Delayed delivery of stocks resulting to delayed
treatments
B. Defective/Outdated Machines affecting Treatment Efficiency
C. Delayed Vascular Access Planning Resulting to High Incidence of
Catheter Related Complications

I.B. Prioritization and Selection of Problems

Potential
Problem
A
B
C

MI

SI

Av

Ef

Fe

Id

Total

1
3

2
2

1
2

1
2

2
1

2
2

9
12

16

Scale:
3 High Rating
Legend:

2 Medium Rating

1 Low Rating

MI Medical Importance of the problem

SI Social Importance of the problem
Av Availability of safe and effective method for solving the problem
Ef Effectiveness and efficiency of the currently used method
Fe Feasibility of carrying out remedial actions
Id Identifiable of the problem

I.C. Selection of the Problem

Delayed Vascular Access Planning Resulting to High
Incidence of Catheter Related Complications

I.D. Statement of the Problem

Based from the data collected, there were 55 total number of
patients admitted from January 2016 to May 2016 at the Dialysis Unit of
Unciano Colleges and General Hospital Inc. During these dates, the
researchers collected the total number of patient awaiting for a vascular
access implant, undecided to undergo the procedure, and the incidence
of catheter related complications.
From January 2016 to May 2016, there were 16 total number of
catheter related hemodialysis complications. The highest incidence of
incomplete treatments occurred during January 1-31, 2016, which is 5
(31.25%).
These incidences of catheter related complications are highly
associated with the delay of having a permanent vascular access in
place. More importantly, these data reflect a combination of factors,
including absent or late placement of the permanent vascular access
(AVF, and AVG) due to late referral of patients for nephrological care,
patient anxiety and resistance to accepting and participating in plans for
renal replacement therapy, lack of funding for patients with the
opportunity to have a vascular access placed before the need for dialysis,
and challenges posed by the inability to precisely predict the occurrence
and timing of imminent dialysis therapy. Other contributory factors

concerned are the delay and failure of the permanent vascular access to
mature and maintain long term patency.

MONTH

Total
No. of
Census

January

47

Total No. of
Patients
Awaiting for
Vascular Access
Implant
8

Februar
y

51

March
April

54
55

6
6

6
4

3
2

May
TOTAL

55

4
31

2
25

2
16

Total No. of Patients

Undecided to Undergo
Vascular Access Implant
(AVF,AVG)

Total No.
Incidence of
Catheter
Infections

I.E. FORMULATION OF THE SYSTEM

II-A. Process of the System

Key Task
1. HD NOD
identifies the
candidates for
permanent
vascular
access
implant.
2. HD NOD
educates
patient
regarding
advantages,
options, and
process of
obtaining a
permanent
vascular
access.
3. HD NOD
refers patient
to TCVS for
vascular
mapping and
further
surgical
evaluation.

4. HD NOD
monitors the
vascular
access for
signs of
infection and

Standard
Performances
HD NOD
determines the
total number of
patients that are
candidate for AVF
or AVG implant.
HD NOD educates
the importance of
having a
permanent access
available for
hemodialysis
therapy.

Patient is referred
to TCVS for
vascular mapping
and further
surgical
evaluation
regarding
choosing the
applicable
permanent
vascular access.
HD NOD performs
vascular access
monitoring and
assessment to
check for any
signs of infection

Indicator
No. of times HD NOD
identifies the candidates
for permanent vascular
access implant / No. of
incidence of catheter
related complications x
100
No. of times HD NOD
educates patient
regarding advantages,
options, and process of
obtaining a permanent
vascular access / No. of
incidence of catheter
related complications x
100

No. of times HD NOD

refers patient to TCVS for
vascular mapping and
further surgical
evaluation / No. of
incidence of catheter
related complications x
100

No. of times HD NOD

monitors vascular access
integrity and
maturation / No. of
incidence of catheter
related complications x

Target

100%

100%

100%

100%

maturation
5. HD NOD
educates
patient
regarding
proper care of
vascular
access
6. HD NOD
plans for the
removal of
catheter
together with
the patient
7. HD NOD
follows
cannulation
protocol and
permanent
vascular
access
monitoring
and
surveillance.
8. HD NOD
Re-evaluates
the vascular
access for full
integrity and
maturity.

9. HD NOD
performs
catheter
removal
aseptically.

and maturation of
the access.
HD NOD educates
the patient
regarding the
proper self
monitoring and
care of their
vascular access.
HD NOD plans the
timetable for the
removal of
catheter of the
patient
HD NOD follows
the algorithm for
cannulation
procedures and
permanent
vascular access
monitoring and
surveillance.

HD NOD reassess
the readiness of
the vascular
access for
permanent usage
by inspecting full
maturity after 3
consecutive
successful
cannulations.
HD NOD performs
the removal of
catheter
aseptically.

100
No. of times HD NOD
educates patient
regarding vascular access
care / No. of incidence of
catheter related
complications x 100
No. of times HD NOD
plans for the removal of
catheter / No. of
incidence of catheter
related complications x
100
No. of times HD NOD
follows cannulation
protocol and permanent
vascular access
monitoring and
surveillance / No. of
incidence of catheter
related complications x
100
No. of times HD NOD Reevaluates the vascular
access for full integrity
and maturity / No. of
incidence of catheter
related complications x
100

No. of times HD NOD

performs catheter
removal aseptically / No.
of incidence of catheter
related complications x

100%

100%

100%

100%

100%

100

III. PROBLEM ANALYSIS

III-A. Verification of the Problem

KEY TASK

1. HD NOD
identifies the
candidates for
permanent
vascular access
implant.
2. HD NOD
educates patient
regarding
advantages,
options, and
process of
obtaining a
permanent
vascular access.
3. HD NOD refers
patient to TCVS
for vascular

TOTAL NO. OF
INCIDENCE OF
NO. OF
CATHETER
MEASUREMENT TARGET
INCIDENCE
RELATED
COMPLICATIONS

16

(7/16) x 100
= 43.75 %

100%

16

(8/16) x 100
= 50 %

100%

16

(6/16) x 100
= 37.5 %

100%

mapping and
further surgical
evaluation.
4. HD NOD
monitors the
vascular access
for signs of
infection and
maturation
5. HD NOD
educates patient
regarding proper
care of vascular
access
6. HD NOD plans
for the removal of
catheter together
with the patient
7. HD NOD
follows
cannulation
protocol and
permanent
vascular access
monitoring and
surveillance.
8. HD NOD Reevaluates the
vascular access
for full integrity
and maturity.
9. HD NOD
performs
catheter removal
aseptically.

16

(0/16) x 100
= 100 %

100%

16

13

(13/16) x 100
= 81.25 %

100%

16

(0/16) x 100
= 100 %

100%

16

(8/16) x 100
= 50 %

100%

16

(6/16) x 100
= 37.5 %

100%

16

(4/16) x 100
= 25%

100%

III-B. Verification of Factors Causing the Problem

III-B.1. Balloon Chart

III-B.2. Ishikawa Diagram

III-C. Validation of Probable Cause

III-C.1. Data Collection
Frequency Distribution of Root Causes of Delayed Vascular Access
Planning Resulting to High Incidence of Catheter Related Complications At
The Hemodialysis Unit of Unciano Colleges And General Hospital, Inc.
ROOT CAUSES

FREQUE
NCY

PERCENTA
GE

Cumulativ
e%

A. Patient undecided to
have Permanent Vascular
Access

1. Financial Constraints
2. Low Socio-economic
status
3. Unemployment

6%

6%

B. Contamination of
Central Venous Catheters

1. Exposure of CVC to
external environment
2. Dressing dressing comes
off/manually removed
3. Dressing gets wet due to
sweat/when taking a bath;
Activity or during sleep

13%

19%

C. Patient anxiety &

resistance to
accept/participate in HD
Treatment

1. Patient is unprepared to
have HD
2. Patient still in denial of
their present condition

6%

25%

D. Failure of PVAs
(AVF/AVG) to mature

1. Encountered Vascular
access complication (e.g.
thrombosis
2. Due to comorbid
conditions (e.g. DM)
3. Improper PVA care &
monitoring

13%

38%

E. Delayed referral to
Nephrologist

1. Patient unaware of their

present condition
2. Lack of Knowledge about
HD Treatment

6%

44%

F. NOD breaks aseptic

technique
during catheter dressing

1. Improper handwashing
and not wearing/changing
PPEs
2. Time cramming and
inavailability of stocks

19%

63%

G. Defective
Extracorporeal Circuit

1. Cracked/ improperly
fitted caps
2. Manufacturer defect

6%

69%

H. Clotted catheters

1. Catheter is not properly

heparinized
2. Patients are known
clotters

6%

75%

I. Contaminated Supplies

1. Exposure to air
2. Not properly sterilized or
covered well
3. Lack of time
management

6%

81%

J. Accumulation of dirt &

hair
around the drressing

1. Improper hygiene/
Presence of pets at home
2. Lack of patient
education

6%

88%

K. Presence of Airborne
Pathogens within the
facility

1. Contaminated
circulating air around the
premises
2. Irregular terminal
cleaning or sanitation of
the entire unit

6%

94%

L. Presence of Airborne
Pathogens
inside the Pts house

1. Contamination of
Patients
belongings
2. Unclean home

6%

100%

16

100%

TOTAL

IV.

OBJECTIVE SETTINGS

Target Setting:
To decrease the incidents of catheter related complications, researchers
targets to aim the following by the end of June 2016, in the Dialysis Unit (2 nd
Floor) of Unciano Colleges and General Hospital, Inc.:
IV-A. Formulation of Solutions
A. BRAIN STORMING
B. ALTERNATIVE SOLUTIONS
C. SELECTION OF SOLUTIONS
Scale:
3 High Rating

2 Medium Rating

Legend:
MI Medical Importance of the problem

1 Low Rating

SI Social Importance of the problem

Av Availability of safe and effective method for solving the problem
Ef Effectiveness and efficiency of the currently used method
Fe Feasibility of carrying out remedial actions
Id Identifiable of the problem

IV-B. Most Probable Solutions

ROOT CAUSES
A. Patient
undecided to have
Permanent
Vascular Access

1. Financial
Constraints
2. Low Socio-economic
status
3. Unemployment

B. Contamination of
Central Venous
Catheters

1. Exposure of CVC to
external environment
2. Dressing dressing
comes off/manually
removed
3. Dressing gets wet
due to sweat/when
taking a bath; Activity
or during sleep

1. Patient is +
C. Patient anxiety &
resistance to
accept/participate
in HD Treatment

unprepared to have HD
2. Patient still in denial
of their present
condition

Potential Solutions
1. Provide referrals to
social serv
ice assistance and
politicians.
2. Encourage to find
alternative means of
gaining income.
1. Educate patient and
relatives to keep catheter
dressing intact and dry.
2. Advice patient to refrain
from sleeping on the side
where catheter is inserted
3. Educate patients
regarding maintaining the
catheter site dry and intact
at all times and
encouraged to have sponge
bath near the affected
area.
1. Patient education
regarding importance of
HD.
2. Assist patient to
accepting present
condition by reality
presentation.

M
I

S
I

A
v

E
f

F
e

I
d

TOT
AL

18

10

D. Failure of PVAs
(AVF/AVG) to
mature

1. Encountered
Vascular access
complication (e.g.
thrombosis
2. Due to comorbid
conditions (e.g. DM)
3. Improper PVA care &
monitoring

E. Delayed referral
to Nephrologist

1. Patient unaware of
their present condition
2. Lack of Knowledge
about HD Treatment

F. NOD breaks
aseptic technique
during catheter
dressing

1. Improper
handwashing and not
wearing/changing
PPEs
2. Time cramming and
inavailability of stocks

G. Defective
Extracorporeal
Circuit

1. Cracked/ improperly
fitted caps
2. Manufacturer defect

H. Clotted catheters

1. Catheter is not
properly heparinized
2. Patients are known
clotters

I. Contaminated
Supplies

1. Exposure to air
2. Not properly
sterilized or covered
well
3. Lack of time
management

1. Referral to nephrologist
or TCVS for appropriate
medical/surgical
intervention
2. Referral to attending
physician for management
of other conditions
3. Educate patient
regarding proper care and
regular monitoring of their
vascular access
1. Early consultation and
referral to nephrologist to
determine their current
health condition.
2. Patient education
regarding the benefits of
complying with
hemodialysis treatment.
1.NOD must observe and
comply on proper hand
washing and wearing /
changing PPEs at all
times
2. Practice time
management at all times
and notify manufacturers
ahead of time.
1. NOD to double check
caps to be used
2.abruptly inform
suppliers about defective
supplies
1. NOD must always check
proper heparinization of
catheters.
2. Referral to nephrologist
for medical intervention.
1. Ensure that all supplies
were covered or sealed
properly.
2. Proper sterilization or
disinfection of supplies.
3. Practice time
management at all times.

18

16

18

16

17

14

J. Accumulation of
dirt & hair
around the
drressing

1. Improper hygiene/
Presence of pets at
home
2. Lack of patient
education

K. Presence of
Airborne Pathogens
within the facility

1. Contaminated
circulating air around
the premises
2. Irregular terminal
cleaning or sanitation
of the entire unit

L. Presence of
Airborne Pathogens
inside the Pts
house

1. Contamination of
Patients
belongings
2. Unclean home

1. Encourage maintenance
of proper hygiene and
minimize exposure to pets.
2. Educate patients
regarding proper care of
their central venous
catheters.
1. Maintain regular air
sanitation by using air
sanitizers or UV lamps.
2. Maintain regular
cleaning and sanitation of
the entire unit.
1. Encourage patients to
regularly clean or disinfect
their belongings.
2. Advice patient and
relatives to maintain
cleanliness at home.

10

16

16

IV-C. Action Plan

ACTIVITY
Identifying patients that are
possible candidates for an
alternative access.

Routine CKD education:

Standard CKD and vascular
access education with
coordinated referral from the
physicians office for all
patients.

IMPLEMENTOR
Attending
Physician,
Hemodialysis
Head Nurse and
Staff Nurses
Attending
Physician,
Hemodialysis
Head Nurse and
Staff Nurses

TARGET
GROUP

TIME
FRAME

Patients

May 31,
2016
onwards

Decreased incidence of
catheter infections and
further complications on
HD access.

May 31,
2016
onwards

Patients will become more

aware of their present
condition and understand
the importance of access
care and monitoring, as
well as they express their
willingness to be involved
in the treatment plan.

Patients

EXPECTED RESULT

Automatic education and

referral for vascular mapping
and surgical evaluation upon
admission of catheter patient
to the dialysis facility.

Construct and Implement

Catheter Reduction Program,
involving the patients in the
plan of care.

Continuous monitoring and

surveillance of vascular
access use.

Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse and
Staff Nurses
Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse,
Staff Nurses,
and Patients
Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse and
Staff Nurses

May 31,
2016
onwards

Patients will become more

aware of the importance of
vascular mapping and
surgical evaluation before
obtaining a permanent
vascular access.

May 31,
2016
onwards

All the members of the

Dialysis Care Team (DCT),
as well as the patient, will
be able to achieve
reduction of catheters by
implementing permanent
vascular access implant.

Patients

May 31,
2016
onwards

Dialysis Care Team will be

able to assess the
progress of the maturation
and readiness of the
particular vascular access
to be used for long-term
therapy.

Patients

Patients

Monthly meeting of the

dialysis team.

Hemodialysis
Head Nurse

Hemodialysis
Staff Nurses

Every 4th
Week of the
Month
(MayDecember,
2016)

Continuous monitoring and

evaluation of the
effectiveness of proposed
activities and
recommendations

Hemodialysis
Head Nurse &
Staff Nurses

Hemodialysis
Head Nurse
and Staff
Nurses

May 31,
2016
onwards

All members of the

dialysis team will be able
to assess the strengths
and weaknesses of the
recently implemented
program.
All Staff Nurses will
adhere to the proposed
activities and
recommendations.

IV-D. Gantt Chart

V.

BENEFITS OF THE STUDY

After solutions were made to solve problems regarding complications on

hemodialysis access, this quality improvement study have come up with
solutions in decreasing incidence among patients undergoing hemodialysis
treatment which is listed as follows:
1. Constant observance of proper PPE use among dialysis staff decreases
contribution to hemodialysis complications.
2. Continuous health education aids in enforcing proper access care in
order to prevent infections and further complications.
3. The emphasis of proper care of their hemodialysis access leads to better
access patency thus promoting better health status.
4. Regularly updating HD staffs on ways and means to decrease further
catheter complications.
5. Providing patients options on alternative access placement in case the
current access fails thus continuing HD treatment to prevent further
6.

complications regarding their health.

Emphasizing compliance on HD medications such as blood thinners,
antibiotics

and

complications.

hypertensive

meds

that

prevents

HD

access

VI.

INSTITUTIONALIZATION

Upon achieving the study, the entire Dialysis Care team recognized the
importance to be presented for the benefit of the patients of the entire
institution, as well as the staffs of Unciano Colleges and General Hospital, Inc.
The researchers recommended that the prompt implementation of catheter
reduction program by emphasizing the importance of obtaining a permanent
vascular access is the main key to decrease the high incidence of catheter
related complications. And these goals will be achieved by means of educating
patients regarding the importance of having a permanent access for use, as
well as to involve them to the implementation of catheter reduction program.
Patient education greatly provides awareness to patients on how can
their health status be improved. Regularly updating patients about their health
condition makes them more cooperative and active about their health
management. When patients are well informed they are more likely to
participate in their health care needs and are actively compliant to health
regimens. When patients are aware of the dos and donts in health
management this tends them to have a positive outlook on their health status.
Moreover, it is important as well to recognize patients readiness and
acceptance of their health condition so as health management will be effective.
Acceptance from patients plays a vital role in order to proceed to effective
management. It provides them positive views in life and hope to gain an
optimum level of self-worth thus making them actively participate.