Patient preferences, vascular access

Improving Patient Safety in Vascular Access A Role for Individualization and Patient Preferences... 

Dialysis vascular access is currently the lifeline for hemodialysis patients. Unfortunately, due to the many complications associated with dialysis vascular access, it is also the Achilles heel of hemodialysis. A relatively ignored aspect of dialysis vascular access pertains to patient safety. The first part of this chapter will describe patient safety issues in the traditional context of arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs) and tunneled central venous catheter (tCVC). In the second half of this chapter, however, we will make the case that a nontraditional approach which emphasizes (a) individualization of care, and (b) patient preferences and patient involvement maybe our best opportunity to improve patient safety in hemodialysis patients. 

Finally, we strongly believe that the best way to reduce patient safety issues related to dialysis vascular access is to actively involve patients in the whole process of vascular access care. This could be at the level of patient involvement or patient preferences. 

Linked to the concept of patient involvement is the adoption of patient preferences. W e believe that an individual patient s perception of the risks and benefits of the different forms of dialysis vascular access may be quite different from those of the health care professionals. An older patient with multiple comorbidities and limited survival may feel that the use of a tCVC which avoids needle sticks may be preferable to an AVF which may need multiple procedures to be able to support dialysis. Although the concept of bringing patient preferences into the decision making mix for dialysis vascular access is new, we believe that it could allow us to develop a much more holistic and patient-centric approach to dialysis vascular access safety. 

We have therefore described a nontraditional, albeit more holistic approach to patient safety for dialysis vascular access (fig. 1), which emphasizes process of care pathways, individualization of therapy through risk stratification and the use of novel technologies, active patient involvement and identification of individual patient preferences. 

This is the time after the patient is discharged. Exercises with a rubber ball are started after suture removal (preferably by the vascular access surgeon who operated on the patient), which is the first surveillance point, and additional exercises with a venous tourniquet are prescribed. 

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