Скачать или смотреть Rutherford's 199: Development and Operation of Outpatient Dialysis Access Centers

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This video deep dive explores Outpatient Dialysis Access Centres (DACs), drawing on material from Rutherford's Vascular and Endovascular Therapy textbook. DACs are becoming central to care for patients with end-stage renal disease requiring hemodialysis. Managing vascular access is critical but often leads to complications and hospital visits. Over the last couple of decades, there has been a significant shift towards performing less invasive endovascular access procedures in outpatient settings. This trend is supported by the concept of complete integrated access care, which involves coordinating all aspects of renal replacement therapy and specialists.

DACs aren't all the same, broadly fitting into three models: single physician offices often linked to referral patterns and the 'fistula first' initiative; centres focused primarily on maintaining, repairing, and replacing existing access; and comprehensive centres offering the full spectrum from new access creation to removal, including peritoneal dialysis access. Comprehensive DACs are often linked with hospitals for backup and handle complex cases, sometimes including training programmes.

Regardless of structure, DACs share common features: they are outside the main hospital inpatient setting, often conveniently located near dialysis units, specifically designed for vascular access management, and have close ties with dialysis clinics. These centres are typically efficient yet comfortable, prioritising patient safety and smooth workflow. Key equipment includes fluoroscopy tables (often with portable C-arms), image management systems, lights, monitors, and ultrasound machines. A solid electronic health record (EHR) system is essential for managing everything from billing to tracking outcomes. DACs maintain a focused inventory of necessary intervention supplies, including crucial bailout equipment.

The core team includes a physician interventionist with deep knowledge of dialysis patients and procedural skills, who might also serve as medical director. Supporting staff include registered nurses and radiology technologists per procedure room, often with an access coordinator at the front desk. Clinical staff require Advanced Cardiac Life Support (ACLS) certification. Teamwork is seamless, understanding patient comorbidities and working efficiently within time limits.

Data suggests DACs offer high success rates (e.g., 96% in one study) and low complication rates (e.g., 3.5%). Sedation-related issues are reported as very low (e.g., 0.14% minor events in one study, with no serious adverse events). Radiation exposure may also be lower in DACs compared to hospital settings (three to eight times lower in one study). A large study comparing over 27,000 DAC cases to similar hospital cases found that DAC patients had fewer hospitalisations related to access problems, fewer infections, fewer septicemia hospitalisations, and a lower overall mortality rate. Average cost per patient per month was also lower for the DAC group. These better outcomes are potentially driven by specialisation, smoother workflows, proactive maintenance, and quicker access to intervention.

Patients generally report higher satisfaction with outpatient care, valuing convenience, shorter waits, a less intimidating environment, timely procedures, and building relationships with staff. Economic viability for DACs depends on sufficient patient volume, estimated to require a minimum local dialysis population of 700-800 patients to support a dedicated centre. Common procedures include angioplasty and thrombectomy of fistulas and grafts, and catheter placements/management. Procedure times can be quick, with a single room handling 8-10 cases daily factoring in turnover and recovery.

However, DACs face economic challenges, particularly downward pressure on reimbursement rates. Advocacy groups are working to educate policymakers on the value DACs provide. Regulatory bodies like KDOQI and CMS guidelines influence care standards, encouraging practices supported by DACs. The Advancing American Kidney Health Initiative could increase demand for DACs offering PD catheter placement if home dialysis grows. Overall, DACs offer a specialised, efficient, and patient-centric model with evidence suggesting better outcomes and patient satisfaction despite economic and regulatory complexities. The future may see further evolution of these models combined with potential breakthroughs in vascular access technology.