A fistula is the gold standard for hemodialysis vascular access in older patients if judged appropriately.

Background and Aims Belluno is a mountainous province of 3610 Km2, with a low population density (56 people/Km2), and an high ISTAT old age index of 228. Four HemoDialysis (HD) Centers assist 112 patients, who spend up to 8 hours/week by ambulance to arrive at the HD Center, with a CO2 estimated emission (EE) up to 6.6 ton/year patient. The cost of in-Center HD may reach up to 61.000 €/year patient. Giving these premisis, we consider as first choice either Peritoneal Dialysis or Home HD (HDD), otherwise than in-Center HD. HHD can be Not assited HHD (NHHD), performed by the patient himself, or Assisted HHD (AHHD), the new HHD service which involves a nurse assistance at home. Both HHDs enables patients to stay at home, may improve patient’s quality of life, reduce the HD costs (32.000-34000 €/year patient), and may reduce the environmental burden of the healthcare procedures (CO2 EE of 0-2.3 ton/year patient). Method One patient have undertaken NHHD and other two the AHHD. Patient 1, on NHHD, is a 50 year old (y.o.) male, on HD since 9/2013. His Past Medical History (PMH) encompasses End Stage Renal Disease (ESRD) due to IgA Nephropathy, a previous kidney transplant, and hypertensive cardiopathy. Patient 2, on AHHD, is a 88y.o. woman, on HD since 01/2020. Her PMH includes ESRD due to multiple myeloma, and hypertension. Patient 3, on AHHD, is a 95y.o. male on HD since 09/2009. His PMH includes ESRD due to hypertensive nephropathy, atrioventricular block with pacemaker, hepatopathy. HHD is performed utilising: the NxStage System (Fresenius®) for NHHD, and the Dialog iQ® System (B.BRAUN®) for AHHD. The HD prescription plans 2 hours treatment for 6 times/week for NHHD, and 4 hours treatment for 3 times/week for AHHD. The total amount of the economical resoureces employed for HD comprise: HD equipment, healthcare-worker, and ambulance transportation (Figure). The EE of CO2 have been determined using a calculator (www.myclimate.org). The EE of CO2 for in-Centre HD comprise both those caused by patients and nurses (Figure). We assumed the same fuel consumption of a diesel Van for the ambulances one. We assumed that nurses use a diesel compact car to commute. Results All patients reported a significantly improved quality of life because they were able to avoid many hours of travel to reach the HD Center. Moreover, the patient on NHHD, appreciated an increased subjective wellness, a greater independence in setting the daily work and personal appointments, and a wider freedom in the eating and drinking habits. The economical resources that may be riallocated by the Healthcare System are up to 30.000 €/year patient. Finally, the environmental burden of the HD procedures may be significantly reduced, with a CO2 EE saved up to 6.6 ton/year patient (equal to 3 round-trip flights Venice-NY). Conclusion Home HD enable patients and their families to substantially improve their quality of life, provide a safe and effective dialysis treatment for the patients, contribute to operational efficiency of the healthcare system, and reduce both the economical impact and the environmental burden of hemodialysis. In conclusion, we believe both HHDs are exellent solution, in particular NHHD for active young patients, and AHHD for fragile patients without a caregiver, resulting in a better management and outcome.

Vascular access (VA) is the key point to obtain an efficient dialysis, since VA dysfunction can hinder efficacy by increasing costs and hospitalization time, and by worsening quality of life. Costs of VA are increasing, due to the development of new grafts, catheters, and stents, and the increasing number of old patients. A global strategy to contain costs in this field requires a solid and consistent strategy of process management. The Toyota Production System could offer a method to analyze VA from a patient-oriented point of view, by means of identifying wastes and value stream during the process. Vascular burden of at-risk patients (chronic disease, frequent hospital stay) must be protected by skilled nurses. Late referral must be constrained to low figures by controlling the territory and allowing the planning of internal native VA. Residual CVC must be evaluated for AVF conversion, and a hierarchy among AVF, AVG and CVC must be established and respected. Finally, angioplasty and stents must be used in selected cases. CVC appear to be the main waste, while AV fistula is the access with maximum added value. Such a complex activity, involving many professionals, fits very well with a low volume/high quality industry model, and is based on the empowerment of each professional along the production chain. The multi-professional model requires a coordinator able to guide the patient along a pathway composed by the classical steps of planning, monitoring, clinical discussion, and corrective measures. It is our opinion that a senior nurse could be the right professional to do this job, as suggested by the model implemented in organ transplantation.

L'accesso vascolare per dialisi continua a sfuggire a una precisa organizzazione, capace di dare risposte al complesso problema demografico e clinico di pazienti comorbidi e sempre più anziani. Descriviamo l'intero processo gestionale alla luce dei principi del Lean Management (LM), filosofia gestionale divenuta un metodo di produzione industriale. I concetti cardine sono quelli di valore aggiunto per il paziente, di scarto (inteso come esposizione a un rischio) e di partecipazione del paziente e dell’ operatore alla revisione continua del prodotto (servizio) fornito. Si parte dalla materia prima (patrimonio vascolare), passando per la progettazione (riferimento tempestivo e controllo del territorio), la realizzazione chirurgica e il controllo del prodotto funzionante (monitoraggio). Per esempio, in termini consoni al LM, i CVC sono un magazzino troppo grande di parti di ricambio con un'elevata percentuale di difetti di produzione. La loro manutenzione (antibiotici, ricoveri, sostituzioni, trombolisi e stenting dei vasi centrali) costa molto e causa un elevato tasso di incidenti sul lavoro (per pazienti e operatori). Si tratta di un contratto non conveniente, perché serve a finanziare un'attività di scarso valore aggiunto e con un interesse passivo troppo elevato. Questo approccio richiede una crescita culturale che parte dalla creazione di un gruppo coordinato: gli attori sono stati più volte individuati (nefrologo, chirurgo vascolare, radiologo e infermiere di dialisi), ma spesso non esiste il coordinatore, che proponiamo di individuare secondo il modello organizzativo dei trapianti. Anche le Direzioni Sanitarie dovrebbero essere coinvolte in un cambiamento organizzativo cruciale per il contenimento prospettico dei costi.