Reducing time for vascular access salvage: initial results from a single institution's clinical practice improvement programme.

Background: One of the most common causes of arteriovenous fistula (AVF) and/or arteriovenous graft (AVG) failure is thrombosis. Guidelines recommend early AVF salvage within 24-48 hours. Our institution reported poor compliance with these recommendations, with a median of 3 days prior to vascular access (VA) salvage. We present our initial results following the implementation of a clinical practice improvement programme (CPIP) to reduce delay to VA salvage.

Methods: The CPIP was conducted in three phases: pre-CPIP (23 January to 30 April 2023), CPIP pre-intervention (22 May to 3 September 2023) and CPIP post-intervention (4 September 2023 to 7 January 2024). Root cause analysis was performed to identify factors resulting in VA salvage delay. Measures implemented included a platform for multidisciplinary communication on cases requiring VA salvage, implementation of a structured workflow and regular reminders to ensure compliance. Early salvage was defined as <48 hours from triage at the emergency department. Time from admission to VA salvage, length of stay, incidence of femoral catheter (FC) insertion and overall cost savings were collected.

Results: There were 82 patients (90.1%) who received VA salvage during the CPIP period. The median age was 67 years with a male predominance (64%). There were 45 patients (54.9%) who received early VA salvage during CPIP. The run chart showed a median early VA salvage rate of 6.1% for pre-intervention and 81.0% for post-intervention. The median length of stay pre-intervention and post-intervention was 5.65 days and 2.92 days, respectively. The incidence of FC insertion was 17.1% (n=6/35) during CPIP for thrombosed VA. Eight patients failed to obtain early VA salvage during the post-intervention period. Overall hospitalisation cost savings per patient were SGD$3144 lower post-intervention.

Conclusion: We report the successful implementation of our CPIP through the involvement of stakeholders and stepwise implementation of measures using a structured protocol.