EPA: Dialysis Access (ie Renal Replacement Therapy)

Evaluatee Name (Last, First)*

Enter resident starting with last name. Once a form has been submitted, the resident will receive a copy of the evaluation.

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Phase of Care

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preop: Evaluation*

Performs BASIC ARTERIAL EXAM in an access patient. Receives consultation for placement of permanent hemodialysis access and OBTAINS A FOCUSED HISTORY BUT REQUIRES GUIDANCE TO ARTICULATE A PLAN.

Identifies utility of & INTERPRETS PREOP IMAGING (duplex/venography/arteriography) to recognize anatomic variants/dx arterial inflow dz. PERFORMS COMPLETE EXTREMITY VASCULAR EXAM (arterial/venous exam, qualitative skin/ST assessment) for 1ST-TIME ACCESS

Performs COMPLETE EXTREMITY VASCULAR EXAM IN REDO ACCESS PT. Completes full consultation for STRAIGHTFORWARD PLACEMENT OF PERMANENT HEMODIALYSIS ACCESS; COMMUNICATES URGENCY to supervisors & surgical recommendation to the consulting service

SYNTHESIZES ALL RELEVANT DATA and generates an INFORMED RENAL REPLACEMENT THERAPY LIFE PLAN (short-, medium-, and long-term strategy for dialysis/transplant) for standard hemodialysis scenarios.

Not applicable/not observed

Preop: Medical Knowledge*

ARTICULATES ETIOLOGIES OF RENAL DISEASE and the 3 general types of renal replacement therapies.

ARTICULATES A PLAN FOR HEMODIALYSIS ACCESS CREATION but may OMIT CONSIDERATION OF COMORBIDITIES that confound surgical timing and outcomes. Articulates the 3 general types of hemodialysis access.

RECOG COMORBIDITIES that impact surg timing/outcomes. Develops PLAN FOR STRAIGHTFORWARD PT (uses preop imaging findings). Identifies medical hx (failed perm access attempts, central ven occlusion), req SPECIALIZED PROVIDERS INVOLVEMENT (vascular surg).

MANAGES COMORBIDITIES that impact surg timing/outcomes. INTEGRATES PREOP IMAGING W/ ABNL ANATOMY (duplex/venography/arteriography) & initial choice of access (eg, autogenous fistula, graft, catheter) to RECOG VENOUS OUTFLOW ISSUES that req change in plan

Not applicable/not observed

Preop: Communication with Patient*

Respectfully communicates BASIC FACTS about the condition to a patient/caregiver(s) but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES and audio/visual aids.

Respectfully communicates BASIC FACTS about the diagnosis to a patient/caregiver(s), CUSTOMIZING COMMUNICATION TO OVERCOME BARRIERS AND CULTURAL DIFFERENCES and using applicable language services and audio/visual aids

Communicates a STRAIGHTFORWARD PATIENT’S medical condition across barriers and cultural differences to ELICIT A PERSONALIZED CARE PLAN IN A SHARED DECISION-MAKING PROCESS

Customizes communication based on individual patient characteristics and preferences across barriers and cultural differences in a DIFFICULT KIDNEY DISEASE DISCUSSION; NEGOTIATES AND MANAGES CONFLICT between a patient, caregivers, and the health care team

Not applicable or not observed

Preop: Consent*

Respectfully COMMUNICATES BASIC FACTS about the condition to a patient/caregiver(s) but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES and audio/visual aids.

Respectfully COMMUNICATES BASIC FACTS about the diagnosis to a patient/caregiver(s), CUSTOMIZING COMMUNICATION TO OVERCOME BARRIERS AND CULTURAL DIFFERENCES and using applicable language services and audio/visual aids

Communicates a straightforward patient’s medical condition across barriers and cultural differences to ELICIT A PERSONALIZED CARE PLAN IN A SHARED DECISION-MAKING PROCESS

Customizes communication based on individual patient characteristics and preferences across barriers and cultural differences in a DIFFICULT KIDNEY DISEASE DISCUSSION; negotiates and MANAGES CONFLICT between a patient, caregivers, and the health care team

Not applicable or not observed

Preop: Care Coordination*

Identifies some indications for consultation and requests a consult from other services (nephrology, cardiology, anesthesiology)

Identifies general indications for consultation and respectfully requests a consult from other services

Completes consultation for complicated placement of permanent hemodialysis access, including assessment of urgency, and communicates the surgical recommendation clearly to others

Completes a full consultation for all permanent hemodialysis access placements or their resultant complications and communicates the recommendations clearly to others

Not applicable/not observed

Preop: Health Care System*

Enumerates basic health payment systems in the U.S.

Demonstrates basic understanding of financing structures for renal health in the U.S. health care system

Discusses how different types of renal replacement therapies impact patients, their caregivers, and the health care system

Uses shared decision-making in treatment planning, taking into consideration costs to the patient

Not applicable/not observed

Intraop: Anatomy*

Names but REQUIRES PROMPTING TO INTRAOPERATIVELY IDENTIFY nervous/musculoskeletal/subfascial vascular structures.

Identifies arm nerves/musculoskeletal/subfascial vascular structures under NORMAL CONDITIONS.

IDENTIFIES BUT CANNOT ADAPT TO ABNORMAL ANATOMY discovered intraoperatively (eg, high brachial artery bifurcation, poor quality arterial inflow, smaller than expected vein).

ADAPTS TO ABNORMAL ANATOMY discovered intraoperatively (eg, high brachial artery bifurcation, poor quality arterial inflow, smaller than expected vein)

Intraop: Steps of Operation*

Requires PROMPTING TO ARTICULATE STEPS of direct autogenous fistula creation. Demonstrates uncertainty about the necessary equip for operation.

ARTICULATES BASIC STEPS & identifies optimal skin incision. REQ ACTIVE DIRECTION TO MOVE THE CASE FORWARD (obtaining vascular control/constructing anastomosis). Anticipates some next steps/necessary instruments (req assist to coordinate with periop staff)

PERFORMS STEPS of direct autogenous fistula creation in STRAIGHTFORWARD case, including obtaining vascular control & constructing technically sound vascular anastomoses. Identifies optimal skin incision location for arm prosthetic straight or loop grafts

PERFORMS STEPS OF COMPLEX autogenous fistula & AV graft access creations, including obtaining vascular control and constructing technically sound vascular anastomoses. Devises/implements plan when deviation from the initial operative plan is required.

Intraop: Technical Skills*

Maintains a sterile field and performs superficial wound closure. HANDLES INSTRUMENTS SAFELY BUT TENTATIVELY; follows intraoperative directions; displays COORDINATED HAND MOVEMENTS for simple maneuvers under DIRECT INSTRUCTION, though INEFFICIENTLY

Performs BASIC VASCULAR SURGERY SKILLS (eg, dissects/ligates subcutaneous veins, performs suture ligation, closes incisions) w/o oversight. Maintains dissection plane but freq deviates from correct plane. Requires assist to control bleeding

Performs MORE ADVANCED VASCULAR SURG SKILLS (dissects/exposes subfascial arteries & veins). Identifies arm tissue planes & musculoskeletal/subfascial vascular structures (inflammation/scarring) & ADAPTS TISSUE HANDLING BASED ON TISSUE QUALITY

Identifies OPTIMAL INCISION LOCATION FOR COMPLEX ACCESS CONSTRUCTIONS (basilic vein transposition). Identifies intraop challenges (dissections, access inflow & outflow lesions, hand ischemia) that req involvement of specialized providers (vascular surg)

Intraop: Communication with Others*

ASSISTS w/ positioning/pt prep/retraction for exposure. Demonstrates respect for & engages in culturally sensitive COMMUNICATION WITH ENTIRE OR TEAM. REQ ASSIST TO DESCRIBE ANESTHETIC CONSIDERATIONS & APPROACHES for permanent HD access creation in arm

Identifies common positioning options but cannot name factors to select one over another; recognizes the importance of protecting against nerve & pressure injuries but cannot describe resulting morbidity. CLEARLY COMMUNICATES w/ all members of the OR team

POSITIONS THE PATIENT TO PREVENT IATROGENIC INJURY. FORMULATES AN ANESTHETIC APPROACH in partnership with the operative team

Identifies additional instruments/equipment necessary for performing COMPLEX ACCESS CREATION & coordinates with OR team for their availability. FORMULATES ANESTHETIC APPROACH ACCOUNTING FOR COMPLEX COMORBIDITIES in partnership with anesthesia team

Not applicable/not observed

Postoperative: Management*

Manages a routine postop course with guidance after direct AV fistula construction.

Manages a routine postop course without guidance after direct AV fistula construction

Manages the routine postop course of a patient with a complex construction or a complicated course after a routine construction

Manages a complicated postop course.

Postop: Complications*

Evaluates vascular construction patency & BASIC POSTOP PROBLEMS (eg, bleeding, hypotension, HTN), requiring assistance to recognize some signs or symptoms of complications

Performs basic perm HD access PEx, MISSES ABL SIGNS: thin skin, distal pulse augment w/ access occlusion, outflow thrill. MANAGES EARLY SURG COMPLICATIONS: cellulitis, MANAGE W/ ASSIST EARLY ACCESS-SPECIFIC complications: bleed/thrombosis/steal syndrome

RECOGNIZES AND MANAGES EARLY ACCESS-RELATED complications (eg, bleeding, thrombosis, steal syndrome)

Recognizes and coordinates MANAGEMENT OF COMPLEX SHORT- TERM COMPLICATIONS (eg, ischemic mononeuropathy) AND LONG-TERM COMPLICATIONS (eg, pseudoaneurysm, infection, arm edema, failure to mature)

Not applicable/Not observed

Postop: Access Plan of Care*

Requires prompting to generate criteria for access maturation. Clearly and respectfully communicates basic aspects of the operative procedure along with routine discharge instructions and wound care details to a patient/caregiver(s)

Generates most criteria for access maturation without prompting

Identifies standard criteria for access maturation

Confirms that a permanent hemodialysis access is ready for attempted use. Communicates an access use timetable/plan to a patient/caregiver(s) and dialysis center/nephrologist in an understandable and respectful way

Not applicable/Not observed

Postop: Documentation*

Describes basic elements of documentation for billing/coding

Completes documentation with few omissions of needed elements for billing/coding

Completes documentation, including all needed elements for billing/coding

Customizes and streamlines documentation, including all needed elements for billing/coding

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

Please add comment on why you selected the answer above. Specifically note what steps the resident can take to achieve the next level of autonomy.