1. Patient Chronicles Learning from the Journey

2. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Course Objectives Use the education tips to guide and encourage patients Discuss the health risks associated with CVCs Explain the procedure and rationale for vessel mapping State the goals of a pre-operative appointment Describe the fistula creation and maturation process List the common reasons fistulas fail to mature Relate the general guidelines for initial fistula use Identify the process and timing for CVC removal

3. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Welcome to the Journey Join us as we bring to life the challenges, barriers and successes of the journey from CVC to fistula A compilation of stories written by Lifeline Vascular Access Nurse Educators based on their experiences with patients

4. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Things We Will Explore Personal barriers patients face - Physical, emotional, psychological Value of support and encouragement - Family and IDT Information and education related to each leg of the journey

5. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Topics we will visit Patient Education Vessel Mapping Surgical Evaluation Fistula Surgery Fistula Maturation Evaluation First Cannulation Catheter Removal

6. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Patient Education: Jose’s New Fistula

7. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know Patients who dialyze via catheters have a higher risk of: Morbidity and mortality Infection, thrombosis and central vein stenosis Low blood flows necessitating longer treatment time Patients dialyzing via fistula typically enjoy better health

8. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Think about the patients in your clinic Do we have patients like Jose who are fearful? What forms of encouragement have helped patients agree to access placement and use? How is each member of the healthcare team involved in educating, encouraging and supporting patients?

9. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Arnold’s Vessel Mapping

10. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know Vessel mapping process: Ultrasound is a noninvasive test used to measure artery and vein diameter and evaluate blood flow Venography uses fluoroscopy with contrast to visualize vessel size, patency and continuity Patients may have one or both tests

11. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Think about the patients in your clinic Do we have patients like Arnold who are ready for vessel mapping? Has anyone seen vessel mapping performed? How do you explain the procedure, its importance and how to prepare for it?

12. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Don’t Miss the Boat on Surgical Evaluations

13. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know At this appointment the surgeon will: Review the vessel mapping results Decide the access type and location Determine medical clearance for surgery Identify the date for access creation Provide pre-operative instruction Be sure to have all of your surgical questions ready

14. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Think about the patients in your clinic Do we have patients like Arnold who’ve had the vessel mapping but have not yet met with their surgeon? Who has patients that repeatedly fail to keep these appointments? What actions have you taken that have helped patients accept access creation that previously declined it?

15. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Cathy’s Fistula Surgery

16. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know Fistula creation and maturation process: Anastomosis of an artery and vein for long term access Vein enlarges, walls thicken and blood flow increases Typically 6-8 week maturation time to become useable Some fistulas fail to mature and require an intervention Ongoing evaluation of a new fistula’s maturity is critical

17. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions What do we teach patients to expect post-operatively about the signs of infection, pain management and the maturation process? When do we teach a patient about assessing their own access?

18. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Arnold’s Immature Fistula Artery AA JA stenosis Draining veins

19. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know A fistula must be mature prior to cannulation Determine cannulation readiness - Assessment – look, listen and feel and “Rule of 6’s” - Obtain an evaluation if an AVF fails to mature at 4 weeks Common reasons a fistula fails to mature - JA stenosis or draining veins “If in doubt, check it out” philosophy

20. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Do we have patients like Arnold who have recently had a fistula created? How do we assess maturation at each treatment? What do we teach patients about evaluating their AVF? Do we have fistulas that are not maturing? What are our next steps?

21. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Nellie’s First Cannulation

22. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know First use recommendations: Confirm cannulation readiness Expert cannulator Tourniquet “Wet stick” Smallest needle gauge and progress as tolerated The expert may not be the person with most seniority

23. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Do we have patients like Nellie with a new fistula that is ready for the first cannulation? How do we communicate maturation progress and when cannulation will begin? How do we handle needle phobia? What do team members do to help conquer this fear? Do we have fistulas that are difficult to cannulate? What are our next steps?

24. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Arnold’s Catheter Removal

25. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. What Your Patients Need to Know Confirm that our patient now dialyzes at the prescribed blood pump speed and needle gauge with acceptable pressures and without cannulation difficulties Catheter removal process: - Skin prep to sterilize the exit site - Local anesthesia is provided then instruments free the cuff from the tissue so that the CVC is easily pulled out - Antibiotic ointment and a sterile bandage are applied The removal procedure is much easier than placement

26. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Discussion Questions Do we have patients like Arnold who are ready to have their catheters removed? What can we do about patients who are reluctant to have the catheter out?

27. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. The Destination Is the Beginning Celebrate the successful culmination of the journey Remember that successful cannulation and catheter removal are the beginning of the access preservation story Providing consistent monitoring can make this a long term success story

28. © 2013 Lifeline Vascular Access. All rights reserved. Proprietary and confidential. Do not copy; do not distribute. Guiding Your Patients Through the Journey Be patient and kind Every journey is different There is always something to be learned and opportunity to grow YOU can make a difference!