Vascular Access for Hemodialysis Policy

1. Policy Statement

It is the policy of this organization that hemodialysis vascular access shall be selected through collaborative, patient-centered decision-making consistent with the established hierarchy of arteriovenous fistula as first choice, arteriovenous graft as second choice, and long-term tunneled cuffed hemodialysis catheter as third choice, and that vessel health and preservation principles shall be applied to all patients with existing or anticipated renal failure requiring hemodialysis, with infection prevention, appropriate access limitations, and comprehensive patient education as integral components of hemodialysis access care.

2. Purpose

This policy exists to:

• Establish collaborative decision-making requirements for hemodialysis vascular access device selection
• Protect the integrity of existing and planned arteriovenous access through extremity protection requirements
• Define access limitations to protect patients and preserve vascular access function
• Establish vessel health and preservation principles beginning at CKD stage 4
• Define the hierarchy of preference for hemodialysis vascular access
• Establish infection prevention standards specific to hemodialysis vascular access
• Define hub care and disinfection protocols for hemodialysis catheters
• Specify cannulation technique requirements for AVF and AVG
• Establish catheter locking solution standards
• Define quality improvement surveillance requirements
• Ensure comprehensive patient education and engagement

3. Scope

This policy applies to:

• All licensed clinical personnel providing care to patients receiving hemodialysis or anticipated to require hemodialysis in the future
• Nephrology, dialysis, vascular access, and infusion therapy services within this organization
• All care settings where hemodialysis access is managed, including inpatient dialysis units, outpatient dialysis centers, and intensive care settings
• Adult and pediatric patients with existing or anticipated end-stage renal disease or chronic kidney disease stage 4 or higher

4. Policy Requirements

4.1 Vascular Access Device Selection

4.1.1 Selection of the most appropriate vascular access device for hemodialysis shall occur through collaborative decision-making involving the patient, their caregivers, and the multidisciplinary healthcare team — including nephrology specialists.

4.1.2 Device selection shall align with the patient’s projected treatment plan, life expectancy, surgical risk profile, and quality-of-life considerations.

4.2 Extremity Protection

4.2.1 Hemodynamic monitoring, venipuncture, and blood pressure measurement shall not be performed on any extremity containing an arteriovenous fistula (AVF) or arteriovenous graft (AVG). This restriction protects vascular access integrity and prevents complications that could compromise dialysis adequacy.

4.3 Access Limitations

4.3.1 Hemodialysis vascular access device lumens shall only be accessed by nephrology or dialysis-trained clinicians. Exceptions to this standard include life-threatening emergencies and situations where clinician training and competency have been formally validated through institutional credentialing processes.

4.4 Vessel Health and Preservation

4.4.1 Foundational Principles

4.4.1.1 Vessel health and preservation principles shall apply to both peripheral and central vasculature in all patients currently receiving hemodialysis or those likely to require hemodialysis in the future.¹²

4.4.2 Early Planning

4.4.2.1 Vascular access planning shall commence when patients reach chronic kidney disease (CKD) stage 4, defined as a glomerular filtration rate below 30 mL/min/1.73m². This planning process shall actively involve both the patient and family members to ensure informed decision-making and optimal outcomes.

4.4.2.2 Clinicians shall recognize that acute kidney injury occurring within the two-year period prior to hemodialysis initiation is associated with significantly lower odds of transitioning to hemodialysis with a functioning AVF or AVG. Early identification and planning for these patients is required.

4.4.3 Peripheral Vascular Preservation

4.4.3.1 For patients with an existing or planned dialysis fistula or graft, peripheral vascular access shall prioritize the dorsum of the hand whenever possible, regardless of arm dominance.

4.4.3.2 The forearm and upper arm veins — including the antecubital fossa — shall be avoided for both phlebotomy and peripheral intravenous catheter placement in this population.

4.5 Vascular Access Hierarchy

4.5.1 Preferred Access Order

4.5.1.1 The established hierarchy of preference for hemodialysis vascular access shall be:

1. Arteriovenous fistula (AVF) — first choice
2. Arteriovenous graft (AVG) — second choice
3. Long-term tunneled cuffed hemodialysis catheter — third choice

This hierarchy reflects the superior patency rates, lower infection risks, and improved long-term outcomes associated with arteriovenous access.

4.5.2 Temporary Catheter Considerations

4.5.2.1 Non-tunneled, non-cuffed hemodialysis catheters may be placed for short-term immediate hemodialysis needs in hospitalized patients requiring emergent access. Their use shall be limited to a maximum of two weeks due to substantially elevated infection risk.

4.5.2.2 When a temporary dialysis catheter incorporates a center third lumen appropriate for infusions, clinical teams shall collaborate to determine optimal infusion timing, any necessary filter changes on dialysis equipment, and which clinicians bear responsibility for care of the infusion lumen, including flushing protocols, tubing management, and needleless connector changes. This shall be documented in institutional policy.

4.5.3 Central Venous Access Site Selection for Hemodialysis Patients

4.5.3.1 When central venous access is required for patients in the hemodialysis population, the subclavian vein shall be avoided whenever possible due to elevated risk for thrombosis, central vein stenosis, and occlusion. PICCs and midline catheters shall similarly be avoided in this population.

4.5.3.2 The preferred order for central venous access device placement in hemodialysis patients is:

1. Internal jugular vein (first choice)
2. External jugular vein (second choice)
3. Femoral vein (third choice)
4. Subclavian vein (fourth choice — use only when all other options are exhausted)
5. Lumbar vein (fifth choice)

4.5.3.3 PICC placement — whether before or after hemodialysis initiation — is associated with failure to transition to a working fistula. Nephrology consultation shall be obtained before PICC placement in any patient with existing or anticipated renal disease.

4.6 Special Population Considerations

4.6.1 Patients with Heart Failure

4.6.1.1 In patients with heart failure, AVF and AVG creation shall occur as distally as possible on the extremity. Fistula and graft formation affects cardiac function and can exacerbate heart failure symptoms; distal placement mitigates this effect.

4.6.2 Elderly Patients

4.6.2.1 For older patients requiring hemodialysis, the decision between AVF/AVG creation versus hemodialysis catheter placement shall involve careful evaluation of life expectancy, surgical risk, patient preferences, and quality-of-life considerations.³⁴⁵⁶ A hemodialysis catheter may represent the most appropriate choice for patients with limited life expectancy or those for whom surgical intervention poses unacceptable risk. Shared decision-making shall be documented.

4.7 Infection Prevention and Aseptic Technique

4.7.1 Aseptic Non Touch Technique

4.7.1.1 All access procedures, dressing changes, and site care for hemodialysis access devices — including AVFs and AVGs when dressings are present — shall adhere to Aseptic Non Touch Technique (ANTT) principles.

4.7.2 Antiseptic Solutions

4.7.2.1 An alcohol-based chlorhexidine solution shall be used as the first-line antiseptic for vascular access device exit site care.

4.7.2.2 For patients with chlorhexidine sensitivity, povidone-iodine — preferably formulated with alcohol — shall be used as an appropriate alternative.

4.7.2.3 Chlorhexidine-containing dressings shall be considered as an adjunct strategy to reduce infection risk.

4.7.2.4 When chlorhexidine dressings are not utilized, topical antiseptic or antimicrobial barrier application at the central venous access device exit site shall be used during site care and dressing changes. Triple antibiotic ointment containing bacitracin, neomycin, and polymyxin B is an appropriate alternative.

4.7.3 Ointment Compatibility

4.7.3.1 Clinicians shall verify compatibility between selected ointments and catheter materials, as ingredients in antibiotic and povidone-iodine formulations may interact with certain catheter compositions. Manufacturer consultation is recommended to prevent material degradation.

4.7.3.2 Mupirocin ointment shall not be applied at the catheter insertion site due to the dual risks of facilitating mupirocin resistance and causing potential damage to polyurethane catheters.

4.7.4 Personal Protective Equipment

4.7.4.1 Appropriate personal protective equipment shall be used for all vascular access procedures. Both clinician and patient shall wear masks during catheter access procedures to reduce the risk of droplet transmission of oropharyngeal flora.

4.8 Hub Care and Disinfection

4.8.1 Disinfection Protocols

4.8.1.1 Hemodialysis catheter lumens shall be disinfected before and after every access.

4.8.1.2 When dead-end caps are utilized, the connection between the cap and lumen shall be disinfected prior to cap removal. The lumen threads and sides shall be cleaned using friction to remove any residue.

4.8.1.3 For closed-system high-flow needleless-style connectors, manufacturer directions for cleaning and cap changing intervals shall be followed.

4.8.2 Antimicrobial Barrier Caps

4.8.2.1 Antimicrobial barrier caps shall be considered for patients receiving hemodialysis through a central venous access device as a strategy to reduce bloodstream infection rates.

4.9 AVF and AVG Cannulation

4.9.1 Cannulation Techniques

4.9.1.1 Two primary techniques are acceptable for needle insertion into AVF/AVG: the rope ladder technique and the buttonhole technique.

4.9.1.2 The buttonhole technique typically produces less pain for patients; however, evidence suggests it may carry higher infection risk compared to the rope ladder approach. Technique selection shall incorporate patient preference and individual risk assessment.

4.9.2 Ultrasound Guidance

4.9.2.1 Point-of-care ultrasound shall be considered for assessing AVF vessel maturation, identifying vessel abnormalities, and facilitating difficult AVF access.

4.10 Catheter Locking Solutions

4.10.1 Recommended Solutions

4.10.1.1 Hemodialysis central venous access devices shall be locked with heparin solution or low-concentration citrate (less than 5%). Evidence does not demonstrate significant differences in outcomes between these solutions; selection shall be based on nephrology team preferences and institutional protocols.

4.10.2 Heparin Dosing

4.10.2.1 When heparin is selected as the locking solution, dosing shall correspond to the fill volume stamped on the catheter lumen. The typical concentration for adult patients is 1000 units/mL.

4.10.2.2 Lower-concentration heparin formulations shall be considered to decrease systemic exposure and reduce the risk of heparin-induced thrombocytopenia.

4.10.3 Prophylactic Thrombolytic Therapy

4.10.3.1 Weekly prophylactic locking with tissue plasminogen activator (tPA) shall be considered to reduce the risk of catheter occlusion.

4.10.3.2 Other antimicrobial locking solutions may be utilized in accordance with organizational policies and nephrology practice guidelines.

4.11 Quality Improvement and Surveillance

4.11.1 Ongoing surveillance for bloodstream infections and other dialysis-related adverse events shall be maintained.⁷ Surveillance outcomes shall be systematically shared with the healthcare team to drive continuous quality improvement and benchmark institutional performance against established standards.

4.12 Patient Education and Engagement

4.12.1 Shared Decision-Making

4.12.1.1 Patient engagement through shared decision-making and empowerment shall be a cornerstone of quality hemodialysis care. Patients shall be encouraged to participate in monitoring clinician infection prevention practices, including observation of hand hygiene compliance before each hemodialysis access procedure.

4.12.2 Required Education Topics

4.12.2.1 Comprehensive patient education shall address the following domains:

• Vascular Access Planning. Education regarding hemodialysis vascular access options shall begin when patients reach CKD stage 4, allowing sufficient time for informed decision-making and access maturation.
• Vein Preservation. Patients shall understand the importance of protecting peripheral vessels for future access creation and the specific sites to avoid for blood draws and intravenous access.
• Infection Prevention. Education shall address both the patient’s role in infection prevention and recognition of institutional practices that protect patient safety.
• Access Protection and Care. Whether the patient has an AVF, AVG, or central venous catheter, specific guidance for daily protection and care of the access site is required.
• Self-Assessment Away from the Dialysis Unit. Patients shall receive education on monitoring their access between dialysis sessions, including appropriate responses to concerning findings.
• Recognition of Complications. Patients shall be able to identify signs and symptoms of access dysfunction, infection, and other complications, with clear instructions for reporting these findings to the healthcare team.

5. Compliance

5.1 Key Performance Indicators

• Rate of AVF/AVG use versus tunneled catheter use for prevalent hemodialysis patients (Fistula First Catheter Last benchmark)
• Rate of PICC avoidance in patients with CKD stage 4 or higher, or receiving hemodialysis (target: ≥95% rate of nephrology consultation prior to PICC placement)
• Rate of extremity protection compliance (no venipuncture/BP on AVF/AVG extremity) (target: 100%)
• Dialysis catheter-related bloodstream infection rate per 1,000 catheter-days
• Rate of non-tunneled catheter dwell time exceeding two weeks (target: 0%)
• Rate of patient education documentation for vascular access planning at CKD stage 4 (target: ≥90%)
• Rate of ANTT compliance for hemodialysis catheter access procedures (target: ≥95%)

5.2 Enforcement

Non-compliance with this policy shall be addressed through the organization’s standard performance improvement and professional accountability processes, including surveillance data review, documentation audits, targeted education, peer feedback, and escalation to nephrology leadership, the Vascular Access Governance Committee, and credentialing bodies as appropriate.

6. Exceptions

Exceptions to this policy, including temporary use of non-tunneled catheters beyond two weeks or PICC placement in renal patients, require documented clinical justification, nephrology specialist consultation, and a plan for transitioning to preferred access at the earliest opportunity. Life-threatening emergencies shall be documented with a retrospective review of the circumstances and a care plan for appropriate access establishment. Exceptions shall not become routine practice without formal policy revision.

7. Related Documents

• Vascular Access Device Selection and Insertion Policy
• Vascular Access Site Preparation and Skin Antisepsis Policy
• Aseptic Non Touch Technique (ANTT) Policy
• Hand Hygiene Policy
• Standard Precautions Policy
• Central Vascular Access Device Tip Location Policy
• Quality Improvement — Vascular Access Policy
• Adverse Event Management and Reporting Policy
• Patient Education — Going Home with a Dialysis Access Device

8. Revision History

References