The effect of new clinical pathways on the outcome of vascular access surgery.
OBJECTIVE
Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid and super-rapid pathways incorporating an access liaison nurse who organized vessel mapping and referred patients for surgery. This audit was to determine whether the pathways were effective in reducing the waiting times and improving vascular accesses outcomes.


METHODS
All 210 patients with established renal failure undergoing 232 vascular access procedures between January 2008 and March 2011 were studied. Detailed patient information including type of procedure and cause of access failure were stored in an Excel spreadsheet and analyzed using SPSS for Windows.


RESULTS
One hundred and twenty patients had a brachiocephalic fistula, 61 a radiocephalic fistula, 39 an access using the basilic vein ± transposition, and 11 a transposition of the long saphenous vein and one a brachio-axillary graft. Overall median waiting time from referral to access surgery was 23 days. Patients were followed up for a median of 248 days after surgery. The overall primary failure rate was 9.1% and 25 of 27 accesses failed because of thrombosis. The overall cumulative survival probability of accesses at one year was 61.4% with a mean survival of 621.2 days (SEM = 34.8).


CONCLUSIONS
The clinical pathways have improved VA service to patients with a drastic reduction in waiting times, elimination of synthetic access, and maintenance of satisfactory results.
South West Transplant Centre, Gastroenterology, Surgery & Renal Services Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth, UK. Jacob.akoh@nhs.net
Jacob A
JA
Akoh
James
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Powys-Lybbe
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods* / Q000451:nursing; D001367:Axillary Vein / Q000601:surgery; D001916:Brachial Artery / Q000601:surgery; D016009:Chi-Square Distribution; D019091:Critical Pathways; D003952:Diagnostic Imaging / Q000451:nursing; D004739:England; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016014:Linear Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D015999:Multivariate Analysis; D015397:Program Evaluation; D017534:Radial Artery / Q000601:surgery; D012017:Referral and Consultation; D006435:Renal Dialysis; D012501:Saphenous Vein / Q000637:transplantation; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014850:Waiting Lists; D055815:Young Adult