Gerald Beathard, MD; Allen R. Nissenson, MD and Terry Litchfield on behalf of the Medical Advisory Board of RMS Lifeline Inc.

Vascular access related problems are the primary reason for hospitalization in end-stage renal disease patients. Scheduling delays within hospital care systems, as well as variations in salvage techniques and outcomes of reparative procedures, lead to high morbidity, mortality and cost.

In 1999, a dedicated system of freestanding outpatient centers was formed to focus on the access needs of the ESRD patient. Most of the centers are established in cooperation with an existing nephrology practice where the physicians already have developed an access surveillance program, which prospectively identifies malfunctioning accesses prior to total failure. The nephrologists are then trained to perform interventional procedures. The intensive training course for nephrologists includes didactic sessions along with hands-on performance, written examination and documentation of a minimum number of training cases. This comprehensive training program provides the physicians with the knowledge and skills required for safe and efficient performance of access salvage procedures.

In addition to performing procedures in the access center, a dialysis-unit based educational program has been developed to increase the knowledge of the dialysis unit staff and patients regarding the care of dialysis access and general access related issues.

The centers have been very successful from the nephrologist's perspective and in the year 2000 almost 5,000 procedures were performed with a 96% success rate (at least one successful dialysis is possible following the procedure) and a complication rate of 2.9% using the stringent definitions of complications recommended by the Society for Cardiovascular and Interventional Radiology. The hospitalization rate following the procedures was only 0.9%, and average procedural time was 31 minutes (total patient encounter time of approximately 2 ½ hours, significantly shorter than a typical hospital based procedural event).

Conclusions: The dedicated nephrology vascular access center has fulfilled the vision of creating a high quality, continuum of care for the dialysis patient. The need for hospitalization for vascular access procedures has declined, and overall patient turnaround times are short, minimizing or eliminating missed outpatient dialysis treatments. A nephrologist-led access care program coupled with a vascular intervention center can improve vascular access outcomes.