HD-CL-001 · Vascular Access Cannulation & Assessment (UPDATED)

Vascular Access Cannulation and Assessment

Policy HD-CL-001 · Hemodialysis Unit

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

1 Purpose

To establish standardized, evidence-based procedures for the assessment and cannulation of arteriovenous fistula (AVF) and arteriovenous graft (AVG) to minimize complications, preserve access longevity, and reduce infection risk in accordance with KDOQI 2020, CDC 2016, and MOH-Jordan guidelines.

2 Scope

This policy applies to all registered nurses and dialysis technicians authorized to perform cannulation within the Hemodialysis Unit. Medical staff are responsible for access orders and complication management.

3 Definitions

AVF native vessel anastomosis AVG synthetic bridge Rope Ladder rotating sites Buttonhole same-site tract Infiltration vessel wall puncture Thrill palpable vibration Bruit auscultated whoosh

4 Policy Statement UPDATED

Update 1.1 Technique selection & shared decision

Rope ladder is default. Buttonhole requires MD order + trained staff.

Rope ladder default; buttonhole restricted to specific indications, requires nephrologist order AND separate certification. Shared decision-making with patient (anatomy, preferences, priorities).

Rationale: Modern guidance (KDOQI 2025, UKKA) emphasizes patient-centered care; moving beyond “fistula first” to respect individual choice and vascular anatomy.

Update 1.2 Ultrasound guidance

(no mention of ultrasound)

For patients with difficult intravenous access (DIVA) or after 2 unsuccessful attempts, real-time ultrasound guidance is recommended per unit protocol and staff competency.

Rationale: Strong evidence supports ultrasound to improve success rates and reduce complications (ASE 2025, AAGBI 2025).

5 Procedure UPDATED

Update 2.1 Pre‑cannulation – vessel preservation

Inspect entire limb, palpate for thrill, etc.

Also consider long‑term vessel health: avoid flexion points, previous difficult sites, and document preservation strategy.

Rationale: Vein preservation is a core principle of modern vascular access care to support future needs.

Update 2.2 Skin antisepsis & dry time

Cleanse: 2% chlorhexidine + 70% alcohol, concentric circles for 30 sec, air dry.

Back‑and‑forth friction scrub for full 30 seconds each site. Must air dry completely; do not re‑palpate or fan. Critical IP measure.

Rationale: Reinforces infection prevention; scrub time/technique deficiencies are commonly cited in audits (CDC 2016, AAMI 2024).

Update 2.3 Attempt limits – reinforcement

Max 2 attempts per staff, 4 total per treatment.

Max 2 attempts per staff. After 2 unsuccessful, escalate to experienced colleague. 4 total attempts across all staff is absolute maximum; physician notified thereafter.

Rationale: Prevents unnecessary vessel trauma and patient harm by setting clear limits and escalation pathway.

7 Competency & Training UPDATED

Update 3.1 Ultrasound competency

Initial: 3 observed cannulations (AVF/AVG). Annual: written + observed.

Ultrasound competency requires separate formal certification: didactic + supervised practice (minimum 10–30 successful procedures).

Rationale: Ultrasound is a distinct skill requiring dedicated training beyond basic cannulation.

8 Quality Monitoring UPDATED

Update 4.1 Key performance indicators

Infiltration <5%, attempts >2, infections, maturation assessment.

Now also track: ultrasound utilization rate for difficult access; chlorhexidine 30‑sec scrub compliance (via audit); patient‑reported outcomes (pain, satisfaction).

Rationale: Expands QAPI to include process measures (scrub time, US use) and patient-centered metrics.

9 References UPDATED

Update 5.1 New evidence‑based guidelines

UK Kidney Association. Clinical Practice Guideline on Vascular Access for Haemodialysis. BMC Nephrology. 2025.
American Society of Echocardiography. Guidelines for Ultrasound‑Guided Vascular Cannulation. J Am Soc Echocardiogr. 2025.
Allon M, Young CJ, Lee T. Optimizing Dialysis Vascular Access: Moving beyond Fistula First. Clin J Am Soc Nephrol. 2026.
Association of Anaesthetists. Safe Vascular Access Guidelines. Anaesthesia. 2025.

Also retained: KDOQI 2020, CDC 2016, AAMI/ISO 23500‑5:2024, MOH‑Jordan 2023.

⏺ Summary of key updates

Section	Update	Clinical rationale
4. Policy	Patient‑centered access choice; ultrasound for DIVA	Modern guidance shifts from rigid 'fistula first' to individual preferences & anatomy; US evidence strong
5. Procedure	Vessel preservation; 30‑sec friction scrub + dry time; reinforced attempt limits	Preserve long‑term veins; infection prevention (audit gaps); prevent trauma
7. Competency	Formal ultrasound certification (10‑30 supervised procedures)	Ultrasound is a separate skill requiring dedicated training
8. Quality	New KPIs: US utilization, scrub compliance, patient‑reported outcomes	Expands QAPI with process & patient‑centered metrics
9. References	Added UKKA 2025, ASE 2025, Allon 2026, AAGBI 2025	Maintains evidence base with most current authoritative guidelines

Policy HD-CL-001 · Proposed updates June 26, 2026 All changes reviewed for alignment with KDOQI 2020/2025, CDC, MOH‑Jordan, and AAMI standards.

Vascular Access Cannulation And Assessment · Version 2026-06-27 · Hemodialysis Unit

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