Check the Access report to see if the patient is listed there with the correct access information. If the information is incorrect, please make changes in your electronic medical record (EMR) so the patient will have calculations in the next week's reports.
If the patient is completely missing from our reports it means that we did not receive data on that patient. Check with your EMR vendor to find out why the patient's data was not transmitted.
Q. What should I do if my patient is on alert?
If it is an isolated alert, continue monitoring your reports per your normal protocol. If the patient has an upward trend of VAPR (venous access pressure ratio) or AAPR (arterial access pressure ratio) and starts alerting, the patient may need to be referred for intervention. This is particularly true if other indicators are present, such as a decrease in BFR.
You should also confirm the patient's access information and see if there are any other clinical findings that may be relevant. Vasc-Alert is often an early or first indicator for identifying a dysfunctional access and although your patient may be on alert, many of these clinical findings are considered late indicators and may not be present. Some examples include: prolonged bleeding, difficult cannulation, infiltration, etc.
Q. My patient recently had angioplasty. The VAPR (or AAPR) result did drop initially, but it is rising again rapidly. What does that mean?
Most likely the patient is re-stenosing. You should refer the patient back to the interventionalist. The interventionalist may decide to angioplasty again. If the results rise rapidly again after another intervention, the patient probably has a chronic or recurrent stenosis. The interventionalist may opt to place a stent in the access in an attempt to prolong its use.
For patients with chronic or recurrent stenosis issues it may be best to try to get another access placed (if possible). That way when the first access fails, the patient can be moved onto the next access without having to have a central line placed.
Q. Why my arterial pressure readings are low or missing?
If the arterial pressure readings are very low, it may mean that you have a wet transducer (either internal or external), although this would generally only effect single treatments. Persistent low readings could mean that the arterial pressure monitoring line is being clamped during the treatment. If there are no arterial pressure readings and you are monitoring arterial pressure, it may mean that the monitoring line was clamped and removed from the sensor.
Persistent missing or low arterial pressures can identify a need for additional staff training and education to improve you clinical quality, outcomes and safety. In particular it would be a good time to point out to care givers that clamping or disconnecting the monitoring line puts the patient is at risk of losing his/her access, because the patient may have an arterial inflow issue. For arterial problems not related to an individual treatment cannulation problem, the best practice is for the care giver to inform the charge nurse so that the patient can be referred for fistulogram and intervention.
Q. What does it mean when I see a *** result in the data table in the Patient Detail report?
It means that a calculation was not made for that result. This could be for several reasons.
The run data was entered incorrectly or missing.
The patient's MAP was less than 65 throughout the session, so we did not calculate.
The result was less than zero.
VAPR results can be less than zero under two conditions:
If the patient's BFR has remained steady, the result of the VAPR calculation may be less than zero because the venous segment of the access has a larger diameter than the arterial segment. In other words if the outflow of the access has a larger diameter than the inflow, the pressure readings would be lower on the venous end of the access and that could result in a VAPR result that is less than zero or ***. Continue monitoring this patient's reports per normal protocol.
If the patient's BFR has been decreasing and there is an increasing trend in AAPR, the VAPR result may be less than zero due to decreased flow and pressure across the access. In other words the magnitude of pressure is greater on the arterial end of the access and that limits the amount of blood flow and pressure in the venous end of the access. This patient is at high risk for losing his/her access due to decreased flow/pressure. Refer this patient for intervention promptly.