Insights into the real-world practice of vascular access care pathways in Italy: data from a national survey.

Abstract

Background: International guidelines issued recommendations for vascular access (VA) care for hemodialysis, but there are no registry data regarding this topic in Italy.

Methods: A survey consisting of 17 items was sent to all Italian dialysis wards, via the Italian Society of Nephrology (SIN) website, from April to June 2021. The items were defined, discussed and approved by experts in vascular access management within the Italian Society of Nephrology. A total of 124 dialysis units answered, accounting for 14% of all dialysis units. The survey thus encompasses all regions within the country, with some regional variations in terms of adherence.

Results: One hundred twenty-four facilities provided data, regarding 12,276 patients: 61% had an arteriovenous fistula (AVF), 34% had a central venous catheter (CVC), and 5% had an arteriovenous graft (AVG). Among them, two-thirds of the facilities reported having a vascular access care pathway, formally standardized in 79% of cases. Forty-six % of centers had a fully equipped vascular access care pathway, encompassing preoperative mapping (80%), vascular access setup (71%), arteriovenous fistula maturation monitoring (76%), first-level (80%) and second-level (78%) monitoring, and surgical and/or endovascular treatment of complications (66%). Vascular access monitoring was computerized in 39% of facilities. First-level monitoring (physical examination) was primarily done by nurses in two-thirds of facilities. Of note, 45% of centers had nurses who were skilled in ultrasound-guided cannulation. Quite surprisingly, facilities with less than 100 patients had a greater prevalence of arteriovenous fistulas than those with more than 100 patients (p = 0.0023). A protocolled vascular access care pathway was associated with a higher likelihood of having an arteriovenous fistula (70% AVF vs 42,1% CVC; p = 0.04). The presence in the facility of interventional nephrologists or nurses with ultrasound-guided cannulation skills significantly reduced the prevalence of central venous catheters.

Conclusion: These survey data further strengthen the need for formal and shared vascular access monitoring protocols.