SJH Action Research: Decreasing Incidence of Bleeding and Hematoma Formation in New Fistulas

Action Research Summary Outline

Investigators:
Carmeleene Baguio MSN, RN Vascular Access Coordinator Renal Center, Dr. Amer Jabara, Renal Center Medical Director, Dialysis Staff in the Outpatient chronic hemodialysis unit

Problem identified:
Bleeding and subsequent hematoma on new fistulas when initially used for hemodialysis. When this occurs the fistula is allowed to rest for 2 weeks. This allows the hematoma and bruising to resolve. Sometimes it takes longer than 2 weeks or the hematoma needs surgical evacuation. This delays the use of the fistula and increases the risk of the fistula failure.

Purpose of the project:
To investigate the factors or reasons that cause excessive bleeding when new fistulas are initially used.

Evidence/Research:
The arteriovenous fistula (AVF) is the “gold standard) for vascular access. Fistulas have the longest longevity (75% working at 3 years, least likely to be infected (35x less than central venous catheters, 10x less than grafts), and lowest mortality (3x less than central venous catheters).

The Kidney Disease Outcomes Quality Initiative (National Kidney foundation, 2001) and the American Nurses Nephrology Association (ANNA) Standards and Guidelines of Clinical Practice for Nephrology Nursing recommend the AVF as the first choice of access.
The Fistula First Initiative recommends that 66% of patients on chronic hemodialysis use fistula as their primary access by year 2009.
Evidence shows that skill is required in creating and cannulating new fistulas.
28-53% of fistulas never mature to support dialysis ( Beathard, 2006 American Society of Nephrology)

According to Brouwer, 2003 a new fistula must be treated with great care to prevent damage. The goal is to help the access to mature into a long-term lifeline for the patient. She has recommended some guidelines in the care of this new fistula.
Several factors impact effectiveness of fistula placement and function. A multidisciplinary approach to evaluating and managing fistula maturation increases the chance of success.

Action Plan:
I discussed this problem with St. Joseph Hospital research council chair, Dana Rutledge, Dr. Jabara, Medical director of the Renal Center, the experienced dialysis nurses and technicians to get input on how what they thought was causing this problem. Based on current guidelines in the successful use of new fistulas a data collection tool was created to collect retrospective and prospective data on patients with new fistulas. This information consisted of possible factors that could affect bleeding and subsequent hematoma when new fistulas are initially used.
Retrospective and prospective data was collected on patients that had new fistulas that were being used for the first time. I informed the staff of what the plan was to address this problem.
During the data prospective data collection the staff was aware to check patient’s heparin dose based on the ACT’s, coumadin and other oral blood thinners that patient might be taking, patient education on holding needle sites post dialysis. As Vascular Access coordinator, I collected the data and facilitated patient referral to Interventional Radiology or vascular surgeon. I also did staff and patient education in the clinical area while data was being collected.

Outcomes:
Data was collected on six retrospective and six prospective patients that had new fistulas. Data included: Age of fistula when initially used, needle size used, heparinization during dialysis, other anticoagulants that patient was on, activated clotting times (ACTs), other bleeding issues, patient medical history associated with hematologic disorders, prescribed and/or complementary or alternative medications used by the patient and physical examination of the fistula.
Chart review was done using the data collection tool. Retrospective data showed that four of these patient’s ACTs were prolonged. Two were on coumadin, and two patients had narrowing of the fistula. Heparin dose was adjusted according to the ACT result.
For the prospective patients, heparin dose was evaluated and adjusted based on the ACT’s. This was done prior to using the fistula for the first time. Four of the patients did not have any bruising after the fistula was initially used. Two had minor bruising. This was related to needle manipulation since the fistula was not mature to support dialysis.
How is this significant?

There was a significant decrease in the incidence of bleeding after new fistulas were used for the first time.

Recommendations:
There will be an increase of new fistulas as a result of the Fistula First Initiative.
Systematic assessment of the new fistula before first use is imperative. Using the data collection tool created for this research will be useful in assessment of new fistula.
Patient and staff education on care of fistula and graft infiltrations to promote longevity in the use of these accesses.