A NATIONAL INITIATIVE TO IMPLEMENT POINT-OF-CARE ULTRASOUND-GUIDED (POCUS-G) ARTERIOVENOUS FISTULA/GRAFT (AVF/AVG) CANNULATION TRAINING FOR PARAMEDICS IN A LIMITED-RESOURCE SETTING

In Malaysia, an estimated 20,000 haemodialysis (HD) patients are managed across 400 public-sector HD units. AVF/AVG are the preferred access modality, yet complications during cannulation remain a major contributor to patient morbidity, vascular access loss, and increased healthcare burden. To address this, we initiated a nationwide program to train dialysis paramedics in POCUS-G AVF/AVG cannulation.

We developed a standardized training module that includes didactic lectures on AVF/AVG anatomy, ultrasound principles, and cannulation techniques, followed by simulation using home-made phantoms using tofu and party balloon as innovation (Figure-1 and 4). A simplified PA3D checklist (Patency, Anomalies, Distance, Depth, Diameter) guided AVF assessment, followed by real-time cannulation using handheld ultrasound(US)(Figure-2). A 3-month competency model based on Observe–Assist–Perform–Certify (OAPC) was implemented with logbook tracking for credentialing(Figure-3). Regional nephrologists led “train-the-trainer” workshops across four zones between October 2023 and August 2024 and carried out echo-training locally.

A total of 250 paramedics from over 20 public HD centres were trained. Post-workshop evaluations showed significant increases in confidence and competence in using POCUS-G AVF/AVG cannulation. Participants strongly advocate for early incorporation of the module into national dialysis paramedic curriculum.

This national initiative demonstrates the feasibility and scalability of POCUS-G cannulation training in a low-resource setting using handheld US and home-made phantoms. Through structured teaching, supervised practice, and national-level credentialing, we aim to elevate vascular access care standards and improve patient safety across the public dialysis network.