HD-CL-007 · Vascular Access Monitoring & Referral Tracking (UPDATED)

Vascular Access Monitoring, Intervention, and Referral Tracking

Policy HD-CL-007 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To ensure timely identification of vascular access dysfunction, track all interventions, and document referrals for permanent access placement to reduce CVC days and CRBSI per KDOQI 2020, CMS F-tags V405-V408, and MOH-Jordan 2023.

2 Scope

Applies to all HD patients with AVF, AVG, or CVC. Includes physicians, RNs, vascular surgeons, and access coordinators.

3 Definitions

Primary Failure AVF/AVG never usable for HD Intervention Angioplasty, thrombectomy, revision, banding KDOQI Goal >65% AVF, <10% CVC >90 days Access Lifeline Target <90 days CVC

4 Policy Statement UPDATED

Update 1.1 CVC temporary · 48-hour referral rule

CVC temporary. Monthly surveillance. Dysfunction → referral. Log required. Medical Director review of CVC >90 days.

Enhanced: • CVC is Temporary: All CVC patients must have documented permanent access plan within 7 days of start. • Monthly Surveillance: Every access examined q treatment + formal assessment monthly. • 48-Hour Rule: Dysfunction identified → MD notified 24h → referral sent 48h. • Log Required: HD-CL-007-F1 tracks every patient, every intervention, every referral. • Medical Director Review: All CVC >90 days reviewed monthly in QAPI.

Rationale: MOH requires CVC day tracking. CMS V-tags require documented referral for all CVC patients. >20% CVC = action plan required.

5 Procedure UPDATED

A. Access Monitoring – Every Treatment – RN Responsibility

Access Type	What to Check	Dysfunction Triggers = Refer	Document
AVF	Thrill, bruit, no pulsatility, arm swelling, steal signs, aneurysm, Qb >300	No thrill/bruit, high venous pressure >250, recirc >10%, URR <65%, difficult cannulation ×3	HD-CL-007-F1
AVG	Same + check for pseudoaneurysm, infection	Same as AVF + pulsatile mass, skin thinning	HD-CL-007-F1
CVC	Exit site, tunnel, function, flushes easy, locks held	Redness, drainage, fever, poor flows <300, locks don't hold, suture loose	HD-CL-007-F1 + HD-IC-001-F2

B. Monthly Access Assessment – 1st Week Each Month – RN + MD

Use HD-CL-007-F2 Monthly Access Assessment Form

Physical Exam: Thrill/bruit grade 0-3. Arm elevation test. Allen test if steal suspected.
Functional: Qb achieved, VP/AP, recirculation if URR <65%.
CVC Days: Count days since insertion. If >60 days, escalate.
Plan: Continue, Monitor, Refer for intervention, Refer for new access.
Signatures: RN + MD sign monthly.

C. Referral Triggers – Automatic Within 48 Hours UPDATED

New ESRD + CVC startVascular surgery for AVF/AVG evaluation
Timeline: Day 1-7 · Form: HD-CL-007-F3

CVC >60 daysVascular surgery if no plan yet
Timeline: Day 60 · Form: HD-CL-007-F3

CVC >90 daysMedical Director review + MOH may cite
Timeline: Day 90 · Form: HD-CL-007-F4

AVF not usable 6 weeks post-opSurgeon for revision
Timeline: Week 6 · Form: HD-CL-007-F3

Venous pressure >250 ×3 txIntervention radiology for angioplasty
Timeline: 48h · Form: HD-CL-007-F3

URR <65% ×2 monthsAccess flow study + intervention
Timeline: 48h · Form: HD-CL-007-F3

Access infectionSurgeon for excision if graft + ID
Timeline: STAT · Form: HD-CL-007-F3 + HD-IC-001-F2

Steal syndromeSurgeon for banding/revision
Timeline: 48h · Form: HD-CL-007-F3

CRBSI 1st episodePlan for AVF/AVG if none. Remove CVC.
Timeline: 7 days · Form: HD-CL-007-F3 + HD-IC-001-F2

D. Intervention & Referral Tracking – HD-CL-007-F1 Access Intervention Log UPDATED

This is the log MOH/JCI asks for. Must be current within 7 days.

Patient	Access Type	Date Placed	CVC Days	Last Assessment	Dysfunction?	Referral Date	Referral To	Appt Date	Intervention Done	Outcome	Next Plan
Ahmed M	R IJ CVC	15/04/26	72	01/06/26	Poor flows	20/04/26	Dr. Surgeon	10/06/26	AVF created 12/06/26	Maturing	F/u 4 weeks
Fatima S	L BCF AVF	10/01/26	0	01/06/26	VP 280 ×3	02/06/26	IR	08/06/26	Angioplasty 08/06/26	VP now 150	Monitor
Omar K	R Fem CVC	20/05/26	37	01/06/26	None	22/05/26	Dr. Surgeon	Pending	—	—	Chase appt

Rules for Log:

Update weekly by Access Coordinator or In-Charge RN.
Red Flag: CVC days >90 = highlight red. MD must document why.
Pending >14 days: Call surgeon office. Document attempts.
Closed Loop: Outcome must say "AVF usable" or "CVC removed" or "Patient refused – signed HD-CL-007-F5."

E. Medical Director Monthly Review – CVC >90 Days

HD-CL-007-F4: CVC >90 Day Justification Form – MD Signs Monthly

For EACH patient with CVC >90 days, document:

Why no AVF/AVG: Failed ×2, no vessels, patient refused, life expectancy <6mo, other
Plan: Re-attempt, graft, HeRO, PD, transplant, palliative
Infection history: # CRBSI, last date
Date of next vascular appointment

No form = citation. "Patient refused" without signed refusal = citation.

F. Patient Refusal of Permanent Access

Educate: RN + MD document education on CRBSI risk, mortality. Use HD-CL-007-F5 Patient Education Checklist.

Signed Refusal: Patient signs HD-CL-007-F6 Refusal of Permanent Access q6 months.

Continue to Offer: Document offer q3 months even if refused. Never stop asking.

6 Roles & Responsibilities UPDATED

Primary RNAssess access q tx. Update HD-CL-007-F1 weekly
Every shift

In-Charge RNAudit log weekly. Send referrals 48h. Chase appointments
Weekly

NephrologistReview monthly assessment. Sign referrals
Monthly + PRN

Medical DirectorSign HD-CL-007-F4 for all CVC >90d. QAPI report
Monthly

Access CoordinatorIf you have one: Maintain log, schedule, track outcomes
Daily

Vascular SurgeonSee referrals <14 days. Report back to unit
Per appointment

7 Quality Monitoring – QAPI – MOH Required UPDATED

Update 4.1 CVC reduction metrics

% CVC, % CVC >90 days, % AVF, days from CVC to referral, days to surgery, intervention rate, CRBSI rate.

Enhanced: • % CVC: Target <10%. Your unit >20% = action plan required. • % CVC >90 Days: Target <10%. • % AVF: Target >65%. • Days from CVC to AVF Referral: Target <7 days. • Days from Referral to Surgery: Target <30 days. • Intervention Rate: Target <1.5 angioplasties/patient/year. • CRBSI Rate: Target <1.0 per 1000 CVC days.

Rationale: If >20% CVC, must submit written improvement plan to MOH with this data monthly.

9 References UPDATED

Update 5.1 Updated reference list

KDOQI Clinical Practice Guideline for Vascular Access 2020 Update.
CMS Conditions for Coverage V-Tag 405-408: Vascular Access.
MOH-Jordan. Dialysis Access Quality Indicators, 2023.
JCI IPSG.1: Reduce risk of HAIs.
MOH-Jordan Access Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	CVC temporary – permanent access plan within 7 days; 48-hour referral rule; Medical Director review of CVC >90 days	MOH requires CVC day tracking. CMS V-tags require documented referral for all CVC patients.
5. Procedure (C)	Referral triggers table: 9 triggers with timelines (STAT, 48h, 7 days, 60 days, 90 days)	Clear triggers prevent delays. MOH audits referral timeliness.
5. Procedure (D)	Access Intervention Log with red flag for CVC >90 days; pending >14 days requires documented follow-up	Log is the primary document MOH/JCI asks for. Red flags highlight problem patients.
5. Procedure (E)	CVC >90 day justification form – MD signs monthly; no form = citation; refusal without signed form = citation	MOH requires documented justification for all CVC >90 days.
5. Procedure (F)	Patient refusal: education documented, signed refusal q6 months, continue to offer q3 months	"Patient refused" without signed form is a citation. Never stop offering.
7. QAPI	% CVC target <10%; >20% = action plan required; days from referral to surgery <30 days	If >20% CVC, must submit written improvement plan to MOH monthly.

Policy HD‑CL‑007 · Proposed updates June 26, 2026 All changes reviewed against KDOQI 2020, CMS V‑Tags 405-408, MOH‑Jordan 2023, JCI IPSG.1.
⚠️ This policy is audit-proof for MOH 2023 + CMS V‑Tags. >20% CVC = red flag – monthly MOH reporting required.

Access Intervention And Referral Log · Version 2026-06-27 · Hemodialysis Unit

📋 Back to All Policies · 🖨️ Print This Page

Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.