“Save the Vein” Initiative in Children With CKD: A Quality Improvement Study

Rationale and objective An arteriovenous fistula (AVF) in the non-dominant arm is the preferred access for hemodialysis (HD) patients. Prior peripheral intravenous (PIV) line placement can lead to vascular injury and limit options for AVF placement, a particular problem for children with the potential need for HD over a lifetime. We instituted an initiative to increase the frequency of PIV placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD). Study design Quality improvement (QI) initiative. Setting & participants Children with CKD Stage 3-5, on dialysis, and following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020. Quality improvement activities Retrospective data on PIV location for patients from January 1 to June 30, 2017 served as baseline data. QI activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation, 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV placement, 3) use of restricted extremity arm bands, and 4) vascular access team participation to minimize attempts for PIV placement. Outcome Monthly compliance with placement of PIV in dominant arms. Analytical approach Location of PIV placements were determined monthly and used to create run charts describing compliance. Results At baseline and prior to institution of this initiative, 34 of 72 ( 47%) PIVs were placed in patient's dominant arms, with only 2 of 8 (25%) PIVs placed in the dominant arm for children Limitations Single center study. Conclusion Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV placement and potentially preserve vasculature in pediatric patients with CKD.