TITLE: "Save the Vein" Initiative in Children With CKD: A Quality Improvement Study
Rationale and objective: An arteriovenous fistula (AVF) in the non-dominant arm is the preferred access for hemodialysis (HD) patients. Prior peripheral intravenous (PIV) line placement can lead to vascular injury and limit options for AVF placement, a particular problem for children with the potential need for HD over a lifetime. We instituted an initiative to increase the frequency of PIV placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD).
Study design: Quality improvement (QI) initiative.
Setting & participants: Children with CKD Stage 3-5, on dialysis, and following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020.
Quality improvement activities: Retrospective data on PIV location for patients from January 1 to June 30, 2017 served as baseline data. QI activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation, 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV placement, 3) use of restricted extremity arm bands, and 4) vascular access team participation to minimize attempts for PIV placement.
Outcome: Monthly compliance with placement of PIV in dominant arms.
Analytical approach: Location of PIV placements were determined monthly and used to create run charts describing compliance.
Results: At baseline and prior to institution of this initiative, 34 of 72 ( 47%) PIVs were placed in patient's dominant arms, with only 2 of 8 (25%) PIVs placed in the dominant arm for children <5 years. After instituting the initiative, 345 of 371 (93%) PIVs were placed in the dominant arm of 93 children; in children <5 years, 58 of 62 (94%) PIVs were placed in the dominant arm. Only 38 of 370 (10%) PIVs were placed in the antecubital vein.
Limitations: Single center study.
Conclusion: Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV placement and potentially preserve vasculature in pediatric patients with CKD.
Source：Am J Kidney Dis. 2021 Jan 7;S0272-6386(20)31196-3. doi: 10.1053/j.ajkd.2020.11.016.
原理和目的：非优势臂的动静脉瘘（AVF）是血液透析（HD）患者的首选治疗途径。先前的外周静脉（PIV）管线放置可能会导致血管损伤并限制AVF放置的选择，这对于一生中可能需要HD的儿童来说是一个特别的问题。我们制定了一项倡议，以增加住院的小儿慢性肾脏病（CKD）患者在优势臂中放置PIV的频率。
研究设计：质量改进（QI）计划。
设置和参与者：2018年9月至2020年8月间在一家儿童医院住院的CKD 3-5期儿童，接受透析和肾移植后。
质量改进活动：2017年1月1日至6月30日患者的PIV位置回顾性数据作为基线数据。 QI活动包括：1）对多学科治疗团队，患者和父母进行有关静脉保留重要性的教育，2）在电子病历中放置个性化注释，以识别用于PIV放置的首选手臂，3）使用肢体受限提示带，4）血管通路小组的参与，以最大程度地减少PIV放置的尝试。
结果：每月遵守将PIV放置在优势手臂中的情况。
分析方法：每月确定一次PIV安置的位置，并用于创建描述合规性的操作图。
结果：在实施该计划的基线和开始之前，对于5岁以下的儿童，72个PIV中的34个（47％）放置在患者的优势臂中，而在小于5岁的儿童，8个（25％）PIV中的仅2个放置的优势臂中。发起该倡议后，将371个（93％）PIV中的345个放在了93名儿童的支配臂中。在5岁以下的儿童中，有62个PIV中有58个（94％）被放置在优势臂上。 370例PIV中只有38例（10％）放置在肘部静脉。
局限性：单中心研究。
结论：有关静脉保留重要性的教育，以及实施标准化程序以识别对静脉保留至关重要的儿童，可以帮助指导PIV放置并潜在地保护小儿CKD患者的脉管系统。
启发：患者教育在血管保护方面是非常重要的，不仅在儿童，成人也是。
