Dialysis Vascular Access and Lean Management

Abstract

Vascular access (VA) is the key point to obtain an efficient dialysis, since VA dysfunction can hinder efficacy by increasing costs and hospitalization time, and by worsening quality of life. Costs of VA are increasing, due to the development of new grafts, catheters, and stents, and the increasing number of old patients. A global strategy to contain costs in this field requires a solid and consistent strategy of process management. The Toyota Production System could offer a method to analyze VA from a patient-oriented point of view, by means of identifying wastes and value stream during the process. Vascular burden of at-risk patients (chronic disease, frequent hospital stay) must be protected by skilled nurses. Late referral must be constrained to low figures by controlling the territory and allowing the planning of internal native VA. Residual CVC must be evaluated for AVF conversion, and a hierarchy among AVF, AVG and CVC must be established and respected. Finally, angioplasty and stents must be used in selected cases. CVC appear to be the main waste, while AV fistula is the access with maximum added value. Such a complex activity, involving many professionals, fits very well with a low volume/high quality industry model, and is based on the empowerment of each professional along the production chain. The multi-professional model requires a coordinator able to guide the patient along a pathway composed by the classical steps of planning, monitoring, clinical discussion, and corrective measures. It is our opinion that a senior nurse could be the right professional to do this job, as suggested by the model implemented in organ transplantation.