Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA.
Present address: Foothills Nephrology, 126 Dillon Drive, Spartanburg, SC, 29307, USA.
BMC Nephrol. 2019 Jul 17;20(1):270. doi: 10.1186/s12882-019-1422-y.
Despite well-publicized suggestions to utilize arteriovenous fistulae and grafts to initiate hemodialysis, too many patients in the United States start dialysis via central venous catheters despite their well-known association with increased morbidity, mortality, and cost.
To determine the reasons for this high rate of catheter use, and, ultimately, ways to reduce it, we developed a questionnaire designed to determine where in the process of patient care the process to fistula or graft placement was not completed, thus requiring the use of central venous catheters. The questionnaire was reviewed by several nephrologists not involved with the study. We administered the questionnaire to 52 consecutive hospitalized patients who started maintenance dialysis with catheters at a University-affiliated Hospital and referral center. The questionnaire asked each patient to provide details pertaining to pre-dialysis care, referrals, and follow-through on recommended referrals. If the patient did not see the physician to whom he/she was referred, we asked the reason(s) for such failure.
Patient responses showed that there were two major lapses in the transition from diagnosis of advanced kidney disease to construction of appropriate dialysis access: failure by the patients to see a nephrologist and/or an access surgeon, and failure by physicians to refer patients to an access surgeon. Twenty percent of the patients failed to follow up with either a nephrologist or a surgeon. Only 38% (15/40) of those seen by a nephrologist had been referred to a surgeon.
The quality of care was impaired by lack of referral to surgeons by nephrologists and by lack of follow-through by patients. Areas for improvement include improved communications between physicians and patients and more careful follow-up by both physicians and patients. Several methods of providing better patient care and communication between patients and nephrologists are recommended.
尽管有广为宣传的建议利用动静脉瘘和移植物来启动血液透析，但美国仍有太多患者通过中心静脉导管开始透析，尽管它们与更高的发病率、死亡率和成本有关。
为了确定这种高导管使用率的原因，并最终找到降低这种使用率的方法，我们开发了一种问卷，旨在确定在患者护理过程中的哪个环节未能完成瘘管或移植物的放置过程，从而需要使用中心静脉导管。该问卷由几位未参与研究的肾病学家进行了审查。我们向在一家大学附属医院和转诊中心接受导管维持性透析的 52 名连续住院患者发放了该问卷。问卷要求每位患者详细说明透析前护理、转诊和推荐转诊的后续情况。如果患者未就诊于他/她被转诊的医生，我们会询问未能就诊的原因。
患者的回答表明，从诊断晚期肾病到建立适当的透析通路的过渡过程中存在两个主要失误：患者未能就诊于肾病学家和/或血管通路外科医生，以及医生未能将患者转介给血管通路外科医生。有 20%的患者未能与肾病学家或外科医生进行后续就诊。只有 38%（15/40）看过肾病学家的患者被转介给外科医生。
缺乏肾病学家向外科医生转介以及患者缺乏后续就诊导致护理质量受损。需要改进的领域包括改善医生与患者之间的沟通以及医生和患者更仔细的随访。建议采用几种方法来改善患者护理和患者与肾病学家之间的沟通。
