Like many in the renal community, Michelle Shields, CRNP, and Jan Crowell, RN, CNN, are always pushing for the use of fistulas as the gold standard of vascular access. However, it took a bit of a tragedy to spark an epiphany for a simple, yet effective way to promote vein preservation.
Shields, who works with Fresenius Medical Care's CKD Services in Pittsburgh, had a chronic kidney disease patient at her CKD clinic who had a fistula placed before she needed dialysis. Unfortunately, she was in a car accident, and on the way to the hospital the paramedics put a blood pressure cuff on her fistula arm.
“By the time she got [to the hospital] they realized that she had a fistula, and her fistula had lost blood supply,” Shields said at a poster presentation at the 2011 National Kidney Foundation (NKF) Spring Clinical Meetings in Las Vegas. “We then had a woman just about to start dialysis who no longer has a functioning fistula.”
The realization came that patient's who may find themselves in a position when they can’t speak for themselves needed some sort of symbolic intervention, and the idea of a “Save the Vein” bracelet was born. “We initially thought of it because of that access preservation," Shields said. "Again, if patients who already have an existing access wear a Save the Vein bracelet, it will protect them from interventions, such as blood pressure."
The bracelets also serve as a reminder of everyday occurrences that could compromise a vein. “When you are putting on your purse and it slides across the bracelet, you then ask yourself what am I doing?” said Crowell, Director Of Operations Home Therapies at Fresenius Medical Care. “It is a visual reminder, a physical reminder of anything that could restrict blood flow.”
The blue bracelets have a similar look and feel to the ubiquitous, yellow Livestrong bracelets used to promote cancer awareness. Written on the Save the Vein bracelet is: NO BP, IV, PICC or Labs. In other words, no blood pressure, no IV lines, no PICC lines, lab tests, or anything else that could potentially harm the vein.
"A key point of 'save the veins' awareness is to have healthcare professionals be aware of CKD patients and choose PICC line sites that preserve their arm veins for future hemodialysis access," Shields said.
To understand the bracelets' effectiveness, Shields and Crowell studied the impact the bracelets had on vein preservation and presented the results at the NKF conference. For the study, all clinic patients with a GFR less than 20 were educated on the importance of early fistula placement. In addition, each patient was given a Save the Vein bracelet to wear on the designated arm. They then evaluated the patients at 30, 60 and 180 days to see if they patients were still wearing the bracelets, had an arteriovenous fistula (AVF) or graft (AVG) placed or started dialysis with a functional AVF.
In all, 21 bracelets were given to patients in the CKD program; of those, 34 percent were for vein preservation before placement. In addition, 85 percent of the patients asked agreed to wear the bracelet, and 81 percent of those patients were wearing the bracelet on the next visit. After 180 days, 100 percent of the patients wearing the bracelet had a functioning AVF when starting dialysis, and 100 percent of those wearing one had an AVF/AVG placed that were maturing. In addition, of the four patients who refused to wear the bracelet, 50 percent did not have an AVF placed.
Shields said one patient did not want anyone to know that she had kidney disease and chose not to wear the bracelet. She also didn't have an access placement and she eventually started dialysis with a catheter. The other patients thought dialysis wasn't going to happen to them and chose not to wear the bracelets. On the other hand, Crowell said one patient was a large man, and the bracelet was too tight. “Of course we didn't want to constrict him, so now we have larger sizes,” she said. “Extra large and standard.”
In conclusion, Shields and Crowell found that patients who wore the bracelets were more likely to have an access placed. In addition, they found that the bracelets prevented and damage to new fistulas due to any unexpected ER visits, blood draws, and accidents when patients were unable to communicate.
“Really, the most successful step to that access placement is early education for CKD, progression, modality choices, and access placement,” Shields said. “And when we education them at the earlier stages they know they can make that informed choice. What dialysis modality they want, whether that is transplant, PD, home hemo, in-center hemo, or no dialysis option. But if they choose that hemodialysis as their option, then we can get that process started earlier.”
Word of the bracelets' success spread, and Fresenius has now moved to make the 40-cent Save the Vein bracelets a part of its national catheter reduction collaboration. “Now the nephrologists want them, the surgeons want them, and when patients go to their transplant center and they want them,” Shields said. “The primary care physicians are also asking about them. It's really involving all of this healthcare members.”
"A simple intervention like this can make a difference," Crowell said. "Think of how much you will spend if there is an infection. It's a lot more than 40 cents."