A multidisciplinary team approach to increasing AV fistula creation.

Despite high patient comorbid factors, our Renal Care [table: see text] Group program was able to totally eliminate placement of AV grafts and to use only fistulae with an acceptable rate of catheter use--all within four years' time. This demonstrated the importance and value of a multidisciplinary vascular access team. Organization was the key element. All the team members were already in place prior to 1996, but they were not focused on vascular access and lacked education in this area. With the nephrologist not trained in fistula creation and not involved in that process, the absence of leadership led to a high number of dialysis grafts and catheters and frequent thrombotic and infectious complications. The nephrologist must assume the team leadership since he or she is the only provider who can interact with all other team members (see Table 3, p. 60). It is recommended that each nephrology group select a lead nephrologist to begin the team-building process (see Table 4, p. 60). A checklist (see Table 5) should be maintained for each pre-dialysis or dialysis patient as documentation for vein mapping and a surgical plan. This will make preoperative vein mapping mandatory for every patient. Education is important at all levels of the multidisciplinary team. This training effort should be started during nephrology fellowship, surgery and radiology residency, dialysis staff education programs, and renal networks. In 2002, the NW Renal Network led the way with fistula creation seminars, focusing on practicing nephrologists, surgeons, radiologists, and dialysis caregivers. The result of this Vascular Access Quality Improvement Program is pending.