Chronic kidney disease (CKD) affects more than 850 million people worldwide and its prevalence is projected to rise. Haemodialysis remains the most frequently used renal replacement therapy and is dependent on reliable vascular access. Native arteriovenous fistulas (AVFs) are the preferred access owing to better patency and lower infection risk compared with grafts or catheters. However, failure to mature and complications at first puncture remain major challenges. Between 20 % and 60 % of AVFs fail to mature and up to 43 % of new fistulas are infiltrated during initial cannulation, requiring surgical or endovascular intervention. International initiatives, such as the Standardised Outcomes in Nephrology – Haemodialysis project, recognise vascular access as a top priority in HD research because of its impact on quality of life, survival and healthcare costs. In Portugal alone, more than 12 800 individuals undergo regular haemodialysis, underscoring the national relevance of optimising AVF outcomes.
Nursing physical examination (PE) remains the cornerstone for assessing AVF maturity. Guidelines from KDOQI (2019) and GEMAV (2017) emphasise inspection, palpation and auscultation as first‑line techniques. When performed by experienced professionals, PE can achieve diagnostic accuracy greater than 80 %, yet its specificity is modest and dependent on examiner training and contextual interpretation. Studies demonstrate wide variability in how PE is conducted, interpreted and recorded, leading to inconsistent clinical decisions and suboptimal outcomes. No standardised, validated PE‑based instrument currently exists to support nursing decisions regarding AVF maturation.
The WHO Global Patient Safety Action Plan 2021–2030 calls for integration of decision‑support tools and predictive technologies in high‑risk procedures. The Portuguese National Action Plan for Kidney Health 2023–2026 similarly recommends structured consultations and development of parameterised indicators to monitor vascular access performance. Existing research focuses largely on anatomical assessments using Doppler ultrasound (DUS) or non‑validated clinical scoring systems. Although DUS provides precise anatomical data, it requires specialised equipment and is not feasible in all settings. Descriptive frameworks for PE have been proposed, yet none have been subjected to rigorous psychometric validation. Evidence on inter‑rater reliability, responsiveness and diagnostic accuracy is scarce. Furthermore, most studies treat the first AVF puncture as a single event, without modelling the continuum from pre‑maturation assessment to cannulation. This gap undermines professional training and hinders development of quality improvement strategies.
By contrast, the VASCHECK project conceptualises AVF maturity and puncture safety as part of a continuum and draws on contemporary methodological standards. It responds to calls for standardised clinical tools by designing a PE‑based instrument grounded in inspection, palpation and auscultation; validating its measurement properties against DUS; and integrating its outputs into predictive models. The project also explores emerging machine learning techniques. While machine learning models have been applied to predict AVF maturation using clinical and ultrasound variables, no published study has leveraged structured PE data to forecast puncture‑related adverse events. By generating a nurse‑led dataset and applying algorithms such as random forests and support vector machines, the project aims to develop a decision‑support system that can classify high‑risk punctures in real time.
The VASCHECK study proposes a multi‑phase research programme that addresses the lack of validated, nurse‑led instruments for assessing arteriovenous fistula (AVF) maturation and predicting safe first puncture in haemodialysis. Grounded in the Consensus‑based Standards for the Selection of Health Measurement Instruments (COSMIN) and the Standards for Reporting Diagnostic Accuracy (STARD) guidelines, the project will be conducted in four sequential phases. Phase 1 is a JBI‑guided scoping review mapping physical examination (PE) components used in AVF assessment and identifying variations across studies. Phase 2 is a retrospective cohort study analysing clinical records of adult persons with new AVFs to identify PE predictors of maturation validated against Doppler ultrasound. Phase 3 involves developing and validating the VASCHECK instrument and an adverse events checklist through a prospective longitudinal study, with measurement properties evaluated against a DUS gold standard. Phase 4 applies machine learning algorithms to data collected with the VASCHECK tool to predict adverse events during the first AVF puncture. By generating an evidence‑based PE tool and decision‑support models, the project aims to enhance clinical decision‑making, promote person‑centred safety, and contribute to innovation in vascular access nursing care.
The VASCHECK project seeks to create, validate and implement an evidence‑based physical examination instrument capable of assessing the maturation of arteriovenous fistulas and forecasting the safety of the first puncture in haemodialysis. Its overarching objective is to advance nursing autonomy and person‑centred safety in vascular access care by generating reliable clinical tools and predictive models. To achieve this goal the project pursues several interlinked aims.
Phase 1 (scoping review) aims to systematically map the PE components and assessment criteria used to evaluate AVF maturation in adults, thereby clarifying the scope of existing practice and highlighting gaps in standardisation.
Phase 2 (retrospective cohort study) aims to identify the PE parameters that most accurately predict AVF maturation as defined by Doppler ultrasound. This will be achieved by analysing anonymised clinical records of persons with recently created AVFs, estimating adjusted odds ratios for inspection, palpation and auscultation findings, and determining their diagnostic value.
Phase 3 (instrument development and validation) aims to construct the VASCHECK instrument and an adverse events checklist and to evaluate their measurement properties and diagnostic accuracy. A prospective longitudinal design will be used to assess content validity, structural validity, internal consistency, inter‑rater reliability, criterion validity and responsiveness. The study will also generate a nurse‑friendly scoring matrix and recommendations for clinical use.
Phase 4 (machine learning study) aims to develop and internally validate predictive models that estimate the risk of adverse events during the first AVF puncture based on PE data and relevant clinical covariates. Algorithms such as random forests, support vector machines and Bayesian networks will be tested and their discrimination, calibration and clinical utility will be evaluated following the TRIPOD‑AI guidelines.
The innovation of the VASCHECK project lies in its tripartite approach: methodological, technological, and clinical.
1. Methodological Innovation: It is the first project to develop and validate a physical examination instrument for AVF maturation following the rigorous international COSMIN standards. This approach fills a critical gap in the literature, which lacks tools with psychometric and clinometric properties.
2. Technological Innovation: The project is pioneering in bridging a traditional nursing competency (physical examination) with artificial intelligence. Phase 4, which uses structured physical examination data to train machine learning models, represents a new frontier in predicting adverse events in vascular access.
3. Clinical Innovation: The VASCHECK instrument will empower nurses with an evidence-based tool to standardise assessment, reduce subjectivity, and support safer, more autonomous clinical decisions.
For patients on haemodialysis, the direct impact is greater safety and a less traumatic experience at the start of treatment. The reduction of failed punctures, infiltrations, and haematomas decreases pain, anxiety, and the risk of premature vascular access loss, thereby improving quality of life. For society, the project contributes to a more efficient and higher-quality healthcare system. The standardisation of assessment allows, for the first time, the benchmarking of outcomes between dialysis units, fosters continuous quality improvement, and optimises professional training. It thus aligns with the goals of the WHO's Global Patient Safety Action Plan and the National Plan for Kidney Health, promoting safer, more equitable, and person-centred care.
The nature of citizen involvement is advisory.
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