[AVBC 2025] Reducing Time to Permanent Hemodialysis Access Creation for End-Stage Kidney Disease Patients
Care Process & Redesign
Appropriate & Value-based Care Conference
National Healthcare Group
3 November 2025
To decrease the median time from referral to permanent vascular access creation in ESKD patients initiated on dialysis via a. The interventions show promise for improving the time to access creation for ESKD patients, reducing the median time significantly...
Year Submitted: 2025
Published Date: 03 November 2025
Tags: Care Process ＆ Redesign, Quality Improvement, Workflow Redesign, Access To Care, Waiting Time, Time Saving
About this Content
Aims
To decrease the median time from referral to permanent vascular access creation in ESKD patients initiated on dialysis via a tunnelled dialysis catheter (TDC) from 142 days to 40 days over a sustained period.
Background
Singapore is currently number 3 worldwide for diabetes-induced kidney failure, with 6 new patients starting dialysis daily. Up to 80% of new ESKD patients in Singapore are initiated via a TDC. International data assessing time from referral to access creation surgery ranged from 5-6 days (Italy/Japan/Germany) to 40-43 days (Canada/United Kingdom). A sample of 80 patients in the institution from May to October 2023 showed a median time from referral to access creation of 142 days, with only 3% successfully undergoing surgery in less than 40 days from referral. The risk of catheter-related complications is highest during the first 90 days of catheter placement.
Methods
The methodology involved implementing two interventions: Intervention 1: Vascular Surgeon to Review & List Patient for Surgery on the Same Day of Clinic TCU (implemented on 18 Dec 2023). Intervention 2: Established Criteria and Workflow for Inpatient Referral for AVF Creation (implemented on 15 Jan 2024).
Results
The pre-intervention median time was 142 days, and the post-intervention median time was reduced to 96 days. There was an initial increased stress on the outpatient load due to rearrangement of outpatient appointments for same-day VDL map and clinic appointment, but this did not affect future appointments. The use of bedside US allowed listing of patients for surgery without formal vein map but increased clinic consultation time; this was balanced by shorter time to surgery and reduced extra clinic appointments.
Conclusion
The interventions show promise for improving the time to access creation for ESKD patients, reducing the median time significantly and addressing a critical healthcare issue in Singapore.
Lessons Learnt
Implementing Intervention 1 led to increased outpatient load initially, but it was balanced by reduced time to surgery. Intervention 2 increased the inpatient team's workload but reduced SOC clinic load and decreased SOC waiting time. Regular reminders and feedback from stakeholders and patients were important for process improvement.
Keywords
Hemodialysis, ESKD, Vascular Access, Dialysis, Catheter
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Medical |
Applicable Specialty or Discipline | Nephrology, Surgery |
Project Lead(s) | Adj Asst Prof Timothy Koh Jee Kam |
Project Member(s) | Malcolm Mak Han Wen |
Connect with this contributor!
Adj Asst Prof Timothy Koh Jee Kam - timothy_koh@ttsh.com.sg