Hemodialysis vascular access coordinator: Three‐level model for access management

Management of vascular access is a challenge for the dialysis team, particularly to keep the arteriovenous access working. The vascular access coordinator can positively contribute to increase the number of arteriovenous fistulas and reduce central venous catheters. In this article, we introduce a new approach to vascular access management centered on (the results of setting up) the role of vascular access coordinator. We described the three‐level model (3Level_M) for vascular access management organized in three levels: vascular access nurse manager, vascular access coordinator, and vascular access consultant. We defined the instrumental skills and training required to be developed by each element and clarify the articulation between the model and all members of the dialysis team related to vascular access.


| INTRODUCTION
The implementation and effectiveness of renal replacement therapy (RRT) depend directly on appropriate vascular access, such as arteriovenous fistula (AVF) (best choice), or alternatively a graft or a central venous catheter (CVC). 1 Nowadays, chronic kidney disease (CKD) patients are older, suffer from a larger number of comorbidities, and have more complex vascular accesses.Therefore, the dialysis team and patients face new challenges.The complications of the arteriovenous accesses are already documented and require supervision (monitoring and surveillance) in order to decide the appropriate time to intervene. 1,24][5][6][7][8] The vascular access coordinator's role can be crucial to improve the planning of timely interventions free of thrombosis, 7,6 improve vascular access outcomes, 3,7 decrease the number of grafts and CVCs, 5 and apply a quality policy with the vascular access. 6The purpose of this article is to analyze the vascular access coordinator's contribution (to) in the vascular access outcomes and introduce a new approach on vascular access management, the three-level model (3Level_M).

| Vascular access coordinator
Literature shows the importance of the vascular access coordinator to increase the number of AVFs 7 and reduce the number of CVCs 3,5 and patient hospitalizations related with vascular access problems.
A few articles describe the role and the responsibilities of a vascular access coordinator 3,5,7 who is usually a nurse with experience in hemodialysis, who understands the importance of the vascular access and has good communication skills.
Each organization has a vascular access-coordinator model focused on the nurse working in collaboration with a nephrologist or vascular surgeon (Table 1).The study by Loon et al 7 involved 2300 patients who participated on a program to improve the quality of the vascular access in 47 dialysis centers in the Netherlands during 3 years.A working group was created including nephrologists, vascular surgeons, radiologists, and three nurses trained as vascular access coordinators.This taskforce developed multidisciplinary procedures and protocols for the construction, surveillance, and intervention in vascular accesses.Their model increased the AVF success rate from 69% to 77% ( p < 0.01) and increased the percentage of interventional access by percutaneous transluminal angioplasty (from 0.39 to 0.50 patient/year, p < 0.001). 7e of the most important tasks of the vascular access coordinator is monitoring and surveillance of the arteriovenous access through physical examination, pressure monitoring, and access flow. 7Kalman et al 4 showed a reduction in CVC permanence (2.5 ± 0.06 vs. 1.1 ± 0.03 days, p = 0.001), and Dwyer et al 3 found an increase of the AVF success rate from 45% to 64.3% (p < 0.001), explained by the tasks associated the vascular access coordinator.
In a study with 184 patients with end-stage renal failure starting hemodialysis therapy, the role of the vascular access-coordinator nurse was used to reduce the incidence of CVC in patients on hemodialysis. 5The vascular access coordinator decreased the number of catheter-days (2833 vs. 4685 days) and increased the AVF success rate from 56% to 75% ( p = 0.007). 5ery study shows the vascular access coordinator must train the patient about vascular access care and maintenance, [3][4][5][6][7] which are considered an important coordinator's task.However, no study has defined the skills or the training required for nurses to be a vascular access coordinator.Experience in hemodialysis was the only factor mentioned in two studies. 3,5terature does not clearly show how the vascular access coordinator should be trained nor what instrumental skills and educational background are required to take on this job.These issues should be made clear, and the articulation among the dialysis team members should be set.

| 3LEVEL_MOF THE VASCULAR ACCESS MANAGEMENT
Vascular access management is complex and a challenge for the entire dialysis team (nephrologist, nephrologist nurse, nurse, and patient). 9intaining the vascular access in a good condition for an effective hemodialysis treatment requires a monitoring and surveillance program designed to detect complications and to define the "best" time to intervene. 1,8,10terature shows the hemodialysis vascular access coordinator can optimize the vascular access management and increase the number of AVFs, providing better cost-effectiveness. 7However, literature is not very clear about the academic education and training required by a vascular access coordinator.From this point of view, setting up a vascular access coordinator must be organized and well planned in order to extract the full potential from this position.
The vascular access management model focused on the vascular access coordinator requires thinking about the role of the dialysis nurse in regard to access monitoring and surveillance.We describe a vascular access management model, called the three-level model, which consists of three levels, the most relevant being the vascular access coordinator (Figure 1).The first level is called the vascular access management nurse, the second level is the coordinator and the third level is the consultant.The 3Level_M defines the academic background, education/training, and skills competencies required for each level.

| Vascular access manager nurse
4][15] The number of patients to be carefully assessed by any nurse should be no greater than five.The nurse must document all the vascular access information and notify the vascular access coordinator new changes or findings in the vascular access.
The nurse at this level needs specific training on vascular access such as a basic vascular access course focused on physical examination (normal and with complications) and surveillance methods. 12mplete physical examination (inspection, palpation, and auscultation) 10 should be done every fortnight.This training should be developed in a clinical context using simulation for 50 h.When a situation may lead to a process of vascular access dysfunction is detected or when doubts about some aspects of monitoring and/or surveillance arise, the manager nurse must let the coordinator know.

| Vascular access coordinator
The second level of the vascular access management model is the vascular access coordinator.He is required to be experienced in vascular access, and particularly, in access physiology, pathophysiology of complications, ultrasonography, physical exercises to improve the vascular network, and intervention approaches.Patient assessment should be carried out in a vascular access consultation, dedicated to access mapping, detection of complications and their impact on the vascular The coordinator plays an important role in the education and training of the entire dialysis team. 12He should promote and provide the vascular access nurse manager with continuing education, especially on cannulation techniques, physical examination, surveillance, and ability to refer patients to the coordinator.
The vascular access coordinator needs specific training on ultrasonography and decision-making related to the vascular access.

| Vascular access consultant
The third level is the vascular access consultant whose main role is advising and supporting the coordinator.He can raise questions and may need to discuss decisions occasionally.This counseling and discussion/reflection process enables the coordinator to develop his decision-making ability.
The vascular access consultant is supposed to promote scientific publication, organize and update scientific evidence, and promote the development of research projects with the coordinator.Furthermore, he must have experience in scientific publishing, and it is suggested a Master or PhD degree related to the vascular access.

| Articulation of the 3Level_M
The articulation between the vascular access coordinator and the F I G U R E 2 Flowchart of the 3Level_M for vascular access management.
manager nurse is very important for the success of 3Level_M.Definition of the information flow and the process of monitoring and referring patients is a key factor.Communication between the coordinator and the vascular access center or the vascular surgeon is essential to understand what was been previously done, providing directions to the vascular access manager nurse.A representative flowchart of the 3Level_M dynamic shown in Figure 2. F I G U R E 1 The 3Level_M for vascular access management.
Description of the activities of vascular access coordinator.
(nephrologist, nephrologist nurse, nurse, and vascular surgeon) with the purpose of making the best decision for the patient vascular access.Such decisions can lead to maintain monitoring and surveillance or enable the identification of the appropriate moment for intervention.Another important issue is passing the information and