Reducing time to arteriovenous access creation in incident end stage kidney disease: A single-centre quality improvement study

Abstract

Background:

Timely arteriovenous (AV) access creation to reduce catheter burden in patients with End-Stage Kidney Disease (ESKD) is essential, but delays remain common. We implemented a Clinical Practice Improvement Programme (CPIP) to reduce delays to AV access creation in patients with incident ESKD, who initiated haemodialysis via tunnelled dialysis catheters and underwent first-time AV access creation.

Methods:

We conducted a quality improvement study in a single-centre, tertiary institution in Singapore. Interventions implemented used root cause analysis and Plan–Do–Study–Act cycles to streamline workflows, desynchronised the need for vessel mapping prior to surgical consultation, and introduced a prioritised inpatient referral pathway. Primary outcome was time from nephrology referral to surgical AV access creation. Secondary outcomes included time intervals between referral, vessel mapping, surgical listing and surgery.

Results:

A total of 227 patients were included (75 pre-CPIP, 152 post-CPIP). Following CPIP implementation, the median time from referral to AV access creation decreased from 142 days pre-intervention to 105 days at 6 months and 86 days at 12 months post-intervention (p < 0.001), representing a reduction of 40.9%. The median time from vessel mapping to surgical listing was significantly reduced from 41 days pre-CPIP to 11 and 9 days at 6 and 12 months post-CPIP, respectively (p = 0.002). Time from surgical evaluation and listing to surgery remained unchanged.

Conclusions:

The CPIP significantly reduced delays from nephrology referral to surgical AV access creation. Earlier surgical evaluation and streamlined workflows may improve time to fistula use and reduce catheter-related complications.