"Save the Vein" Initiative in Children With CKD: A Quality Improvement Study

Abstract

Rationale & objective: The preferred vascular access for hemodialysis recipients is an arteriovenous fistula in the nondominant arm. Prior placement of a peripheral intravenous (PIV) catheter can lead to vascular injury and limit options for arteriovenous fistula creation, a particular problem for children, who may need hemodialysis for their entire lifetime. We instituted an initiative to increase the frequency of PIV catheter placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD).

Study design: Quality improvement initiative.

Setting & participants: Children with CKD stage 3-5, receiving dialysis, and/or following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020.

Quality improvement activities: Retrospective data on PIV catheter location for patients from January 1 to June 30, 2017, served as baseline data. Quality improvement 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 catheter placement; 3) use of "restricted extremity" arm bands; and 4) vascular access team participation to minimize attempts for PIV catheter placement.

Outcome: Monthly compliance with placement of PIV catheters in dominant arms.

Analytical approach: Location of PIV catheter placements were determined monthly and used to create run charts describing compliance.

Results: At baseline and before institution of this initiative, 34 of 72 (47%) PIV catheters were placed in patients' dominant arms, with only 2 of 8 (25%) PIV catheters placed in the dominant arm for children aged<5 years. After instituting the initiative, 345 of 371 (93%) PIV catheters were placed in the dominant arm of 93 children; in children aged<5 years, 58 of 62 (94%) PIV catheters were placed in the dominant arm. Only 38 of 371 (10%) PIV catheters were placed in the antecubital vein.

Limitations: Single-center study.

Conclusions: 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 catheter placement and potentially preserve vasculature in pediatric patients with CKD.

Keywords: PIV placement; Vein preservation; arteriovenous fistula (AVF); children; chronic kidney disease (CKD); electronic medical record (EMR); end-stage renal disease (ESRD); pediatric CKD; peripheral intravenous (PIV); quality improvement; vascular access; vascular injury prevention; vessel preservation.