1. Should we make perfect fistulas or train our nurses to do better cannulation? Deborah Brouwer-Maier RN, CNN Director Dialysis Access Initiatives Fresenius Medical Care North America

2. European Vascular Course 2014 Disclosure of speaker’s interests (Potential) conflict of interest See below Potentially relevant company relationships in connection with event 1 Fresenius Medical Care North America Sponsorship or research funding 2 Fee or other (financial) payment 3 Shareholder 4 Other relationship, i.e. … 5 Employee

3. Short Answer-BOTH Need more consistent AVF maturation and more consistent cannulation skills

4. US Study Showed High AVF Fail to Mature Rates Objectives and Design of the Hemodialysis Fistula Maturation Study American Journal of Kidney Diseases Volume 63, Issue 1, Pages 104-112, January 2014 Objectives and Design of the Hemodialysis Fistula Maturation Study: Background A large proportion of newly created arteriovenous fistulas cannot be used for dialysis because they fail to mature adequately to support the hemodialysis blood circuit. The Hemodialysis Fistula Maturation (HFM) Study was designed to elucidate clinical and biological factors associated with fistula maturation outcomes. Setting & Participants : Approximately 600 patients undergoing creation of a new hemodialysis fistula will be enrolled at 7 centers in the United States and followed up for as long as 4 years.

5. Fistula Maturation Study Outcomes: The primary outcome is unassisted clinical maturation, defined as successful use of the fistula for dialysis for 4 weeks without maturation-enhancing procedures. Secondary outcomes include assisted clinical maturation, ultrasound- based anatomical maturation, fistula procedures, fistula abandonment, and central venous catheter use. Measurements: Preoperative ultrasound arterial and venous mapping, flow-mediated and nitroglycerin-mediated brachial artery dilation, arterial pulse wave velocity, and venous distensibility; intraoperative vein tissue collection for histopathologic and molecular analyses; postoperative ultrasounds at 1 day, 2 weeks, 6 weeks, and prior to fistula intervention and initial cannulation. Goal 50% unassisted maturation

6. Fistula Maturation Study DAC Study- Fistula surgeries were performed at 27 hospitals by 71 surgeons, and dialysis was performed at 125 facilities affiliated with the 9 clinical centers. Equals 12.3 cases per surgeons

7. Would You Have Surgery With a 50% Success Rate? I would not if I was informed of the odds Patients are not given the surgeon’s success rates to even make an informed decision Why should our patients be uniformed?

8. Leads to Questions

9. Leads to Questions (continued) There does not appear to be any agreed surgical protocol in the article. Are these surgeons dedicated to vascular access? Vascular surgeons in my institution say that one cannot perform carotid artery endarterectomies if one deals with less than 30 cases a year. Should we not consider a minimum number of fistulae created per year per surgeon before reporting series like this one?

10. We Need to Determine the best Anastomosis No standardization of the key element of AVF creation – the anastomosis! No standardization of the flow dynamics of the AVF No standardization = No Best Practices = Varied Outcomes

11. Or train our nurses to do better cannulation? YES No standardization of the key element of AVF use– the cannulation! No standardization for cannulation training No standardization = No Best Practices = Varied Outcomes

12. What are we missing? Tools to teach cannulation in a safe non-harmful environment (not using patients as training models) Need as standardized cannulation training program that includes theory of cannulation Need more evidence to support best cannulation techniques – not myths

13. Potential Solutions Improved Hemodialysis Fake Arms

14. Potential Solutions? Virtual Simulator Virtual I.V.® Simulator or Virtual Phlebotomy® by Leardal

15. Simulation What is Simulation? “Simulation is the imitation or representation of one act or system by another. Healthcare simulations can be said to have four main purposes – education, assessment, research, and health system integration in facilitating patient safety.”

16. Simulation “Simulation education is a bridge between classroom learning and real-life clinical experience.”

17. Advantages of Simulation Learning A range of easily accessible learning opportunities The freedom to make mistakes and to learn from them The learning experience can be customized Detailed feedback and evaluation

18. Should we make perfect fistulas or train our nurses to do better cannulation? Both Deborah.Brouwer-Maier@fmc-na.com