Title: Fistula First: Implementation
1Catheter Wipeout Initiative Updates
Lisle Mukai, QI Coordinator August 2008
2DaVita Catheter Wipeout Initiative
- The project addresses high catheter rates within
the Riverside/San Bernardino area. The involved
facilities are Surf-N-Sun Division facilities who
are divided into 3 teams lead by their Regional
Managers. The teams will be competing against
each other for attaining the lowest catheter
rates. - The facilities will utilize DaVita tracking
tools and implement Fistula First Change Concepts
to attain their goal.
3Project Goal
- To reduce the total catheter rate by 20 in each
of the intervention facilities over an 8 month
period (May December 2008). - Attained by implementing Change Concepts
- 5 Full Range of Appropriate Surgical Approaches
to AVF Evaluation Placement - 7 AVF Placement in Patients with Catheters
Where Indicated - 9 Monitoring Maintenance to Ensure Adequate
Access Function.
4Facility-Specific Goals for Team Sue
5Facility-Specific Goals for Team Franco
6Facility-Specific Goals for Team Rosemarie
7- The circled facilities are those that have
achieved a 10 or greater reduction in at least
one post-baseline month (baseline April 2008)
8- The circled facilities are those that have
achieved a 10 or greater reduction in at least
one post-baseline month (baseline April 2008) - ? Banning Dialysis (552520) has consistently
maintained a 10 reduction within the 3 months.
9- The circled facilities are those that have
achieved a 10 or greater reduction in at least
one post-baseline month (baseline April 2008)
10Team Goals
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13Change Concept 5 Full Range of Appropriate
Surgical Approaches to AVF Evaluation Placement
- Fistula First Website
- Surgical video series Creating AV Fistulae in
All Eligible Hemodialysis Patients - Article Surgical salvage of the autogenous
arteriovenous fistula (AVF). - Autologous AVF Algorithm (Developed by Dr.
Spergel, MD, Clinical Chair for the FFBI) - Commonly Used Permanent Vascular Access Codes
(CPT codes)
14Change Concept 5 Full Range of Appropriate
Surgical Approaches to AVF Evaluation Placement
(continued)
- Make sure surgeons understand the logistics of
cannulation so that they position the veins
suitably and safely for cannulation - Cannulation of the Arteriovenous Fistula (AVF)
DVD Each facility should have received one DVD
from your corporate office. - Encourage acute nursing staff to become more
assertive in asking the Nephrologist to order
vein mapping before discharging the patients from
the hospital.
15Change Concept 5 Full Range of Appropriate
Surgical Approaches to AVF Evaluation Placement
(continued)
- Dialysis Access Clubs
- Presentations and discussions regarding creation,
maintenance, and addressing complications of all
types of vascular accesses are discussed. - This is a great forum for surgeons and
interventional radiologists to share or ask
questions with their peers about vascular access
situations they encounter.
16Change Concept 5 Full Range of Appropriate
Surgical Approaches to AVF Evaluation Placement
(continued)
- Currently there are two active Dialysis Access
Clubs San Diego and Orange County. These clubs
were started by Vascular Access Surgeons who are
truly engaged in the Fistula First program. - These meeting are usually held on a quarterly
basis. - Invitations are directly e-mailed to surgeons
(the sponsoring organization has a vascular
surgeon database they use to e-mail these
invitations), because there is no Access Club in
the Inland Empire as of yet, encourage your
surgeons to contact their colleagues within the
Orange County San Diego County area and find
out when these meetings occur. - Hopefully this communication between colleagues
will open opportunities for vascular access
discussions and interest that will engage all
surgeons.
17Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated
- Evaluation and mapping of catheter patients is
crucial to facilitate the placement of AV
fistulae. While catheters are necessary in some
circumstances (e.g., while an AV fistula
matures), the increasing prevalence of catheters
is a serious health risk to patients. - Per Dr. Nguyen
- Educate patients and their families. Patients
dont want to hear about the operation when they
do not feel sick and yet early surgery for
fistula is key to success. "I spend a lot of time
talking to patients and their families," Nguyen
says. "I always invite the whole family to come
to the first visit. Convince the family, and they
will beat on the patient to do it."
18Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- Its important to explain the procedure in very
simple terms - Set expectations properly in case the first
operation doesnt do the job, since we are
dealing with sicker and older patients with
higher risk of fistula failure to mature
properly, we tell them that another surgery may
be needed. - Use diagrams when showing the patients where the
catheter is located when educating them about
their access.
19Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- FFBI Payer Packets have been posted to the
Fistula First website - http//www.fistulafirst.org/pdfs/FF_Intro_for_Paye
rs.pdf - The payer packet is a set of documents that you
can use to communicate with your insurance
companies about promoting catheter reduction and
AVF placement. - The documents includes
- Introductory Letter for Payers
- Pay for Performance Summary Recommendations
- Fistula First Priority Recommendations
- PowerPoint slides
20Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- Introductory Letter for Payers
- 1 page document that explains who the Fistula
First Breakthrough Initiative is - Why vascular access, specifically catheters,
matters so much - What the organization (insurance company) can do
about it.
21Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- Pay for Performance Summary Recommendations
- This is a payment position paper submitted by
FFBI for consideration by CMS and other payers. - This is an educational item and not a final CMS
decision for Pay for Performance.
22Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- FFBI Priority Recommendations
- Recommendations by FFBI for developing and
implementing an incentive program for
practitioners. - References to specific Change Concept elements.
23Change Concept 7 AVF Placement in Patients with
Catheters Where Indicated (Continued)
- Slides
- The PowerPoint slides illustrates costs for care
- Medicare costs per person per year
- Per person per year access costs by type of
access - Hospitalization admissions for vascular access
complications per patient year - Risk for infection comparison between catheters
and AV fistulas - Variation on costs for inpatient hospital
services per Medicare enrollee - Performance on Medicare Quality Indicators
24Reducing Catheter Rate Strategies
- Surgical evaluation,vessel mapping ( placement)
of permanent access during initial, acute
hospitalization - Patient education
- Engagement of surgeons
- Early recognition intervention for non-
maturing AVFs Post-op exam _at_ 4 wks - Protocol for catheter removal (FF website)
25Proactive strategies to reduce catheter rate
- Surgical evaluation ( placement) of permanent
access during initial hospitalization - Vessel mapping/optimal vessel selection to
increase successful (usable) AVFs Reduce
non-maturing (FTM) AVFs (post-op exam _at_ 4 wks) - Monitoring timely intervention for late
failure/ aggressive salvage
26Change Concept 9 Monitoring Maintenance to
Ensure Adequate Access Function
- AVF Maturation Process
- Fistula maturation is defined as the
process by which a fistula becomes adequately
dilated and thick-walled to make it suitable for
cannulation. - Usually takes 8 12 weeks for a fistula to
mature, but can take longer - Should be able to feel strong thrill at the
arterial anastamosis - Listen for continuous low-pitched bruit
- Vessel diameter must be 4-6 mm, veins should be
firm to touch an no prominent collateral veins
27Change Concept 9 Monitoring Maintenance to
Ensure Adequate Access Function (Continued)
- Most failing AVFs can be identified on
evaluation at 4 weeks - Many early AVF failures can be salvaged if
identified before thrombosis occurs - If the AVF is patent but you are unable to
cannulate the AVF or adequately dialyze the
patient by 12 weeks, refer for exam/fistulogram
to determine what intervention is needed
28Change Concept 9 Monitoring Maintenance to
Ensure Adequate Access Function (Continued)
- Each treatment should include a physical
assessment of the new - AVF
- Look at the access and compare the access
extremity to the other extremity - Listen for bruit (USE A STETHESCOPE!)
- Feel for thrill
29Change Concept 9 Monitoring Maintenance to
Ensure Adequate Access Function (Continued)
- Abnormal Changes in the Access Extremity
- Edema of the access extremity
- Cold to the touch with pain or numbness (possible
Steal Syndrome) - Warm to the touch (possible infection)
- Bruising
- Loss of continuous briut/or change in the bruit
- Change in the quality of the thrill or complete
loss of thrill - ACTION Refer for exam to determine
intervention needed
30AVF Dysfunction/Failure to Mature (FTM)
- gt 30 of new AVFs fail to mature (FTM) and may
need some type of intervention before it can be
used - You can markedly reduce early failure rate and
interventions in AVFs by - Early referral CKD program
- Improved patient vessel selection/standardized
vessel mapping protocol - Early recognition of FTM AVF by evaluation
(Monitoring Surveillance) at 4 wks timely
intervention high salvage rate
31All patients should be taught how to
- Feel for thrill Report absence to staff
immediately! - Listen for bruit - Report absence to staff
immediately! - Look and recognize signs symptoms of infection
- Report signs/symptoms to staff immediately! - Exercise the fistula arm with some resistance to
venous flow - Squeezing a rubber ball with or without a lightly
applied tourniquet may increase flow, thereby
enhancing vein maturation, and has been shown to
significantly increase forearm vessel size,
thereby potentially increasing flow through the
AVF. - Avoid carrying heavy items and wearing occlusive
clothing (occlusive bands/elastic over access
areas) - Avoid sleeping on the access arm
32Success Stories
- RMS Lifeline Outpatient Vascular Access Center
will remove catheters for Emergency Medi-Cal
patients with a working AVF access free of
charge! - Documentation of all access events can justify
reason for request of AVF evaluation placement
for patients with Emergency Medi-Cal.
33Fistula First AVF Goals
- CMS Goal 66 by June 30, 2009
- Yearly Network 18 Goal 55.1 by March 31, 2009
- Yearly Network Stretch Goal 56 by March 31,
2009 - June 2008 AVF rates NW 18 53.4
- US
50.3 -
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35Fistula First Change Concepts
- Secondary AVFs in AVG patients
- AVF evaluation/placement in catheter pts where
indicated - Cannulation training
- Monitoring and maintenance
- Continuing Education
- Outcomes feedback
- Routine CQI Review of vascular access
- Timely referral to nephrologist
- Early referral to surgeon for AVF Only
- Surgeon Selection
- Full range of appropriate surgical approaches
36Change Concept 6 Secondary AVF Placement in
Patients with AV Grafts
- Convincing a patient, Nephrologist, and Vascular
Access Surgeon to evaluate and place a secondary
AVF can be difficult, especially when a problem
has not been experienced. Education is key. It
is well known that when an AV graft clots or
problems occur, they will more likely happen
again. - The Fistula First Breakthrough Initiative and
Network 18 would like to emphasize the importance
of monitoring and surveillance for stenosis. - By monitoring and tracking problems with an AV
graft the Nephrologist can easily refer the
patient for a secondary AVF evaluation and
placement before failure of the AV graft. - Converting to an AVF will help improve patient
care by decreasing missed treatment time for
frequent interventions/revisions thus improving
the patients quality of life and increasing the
performance of the access.
37Change Concept 6 Secondary AVF Placement in
Patients with AV Grafts (Continued)
- Nephrologist should evaluate every AVG patient
for an AVF. - Conducting the Sleeves Up exam monthly will
help identify if a patient with an AVG may be a
candidate for an AVF conversion. (Protocol was
distributed at the Kick-off meeting in April) - Vessel mapping if suitable veins are not
identified on physical exam. - A secondary AVF plan should be documented in the
chart and discussed with the patient, family,
staff, nephrologists, surgeons in anticipation
of AVF construction on the earliest evidence of
AVG failure.
38Sleeves Up Exam
39Timing of AVG conversion to a secondary AVF
- 1st AVG failure triggers evaluation for
conversion to a secondary AVF - A plan of care should be developed in
anticipation of AVG failure - At the sign of a second impeding AVG failure, the
patient should be sent for an AV fistula
conversion. - Any delay in conversion beyond this point is
likely to result in loss of the window of
opportunity for this AVF option.
40FFBI Strategies to increase Secondary AV Fistulae
- Re-evaluation of all patients for AVF
- K/DOQI guideline 29 Every patient should be
evaluated for a secondary fistula after each
episode of graft failure - Physical exam, vessel mapping and/or fistulogram
- Develop plan of care for anticipation of AVG
failure - Conversion of existing AVG to AVF, utilizing
outflow vein of graft for AVF where feasible
41System Roadblocks Identified by Facilities
Patient Roadblocks Identified by Facilities
More Roadblocks
- Afraid of needles
- Comfortable with catheter
- Exhausted sites
- Language barriers
- Forgetting follow-ups and missing appointments
- Lack of education
- Lack of knowledge and effort from the PCP offices
- Communication between dialysis unit and surgeons
office - Problems with the newly placed AVF (does not
mature or clots)
- Patients without medical insurance
- Med-Cal only patients
- Restricted Medi-Cal
- HMO (ex. RMC, PMD) that requires authorization
- No good surgeons
- Not all surgeons accept Med-Cal and those who
accept require long waiting time
42Possible Solutions
- Educate patients
- Vessel mapping for everyone
- Establish Sleeves-up Monday and Tuesday (At
least monthly) - Utilize Outpatient Vascular Access Center
- Establish relationship with surgeons office
- Establish relationship with HMO contacts
- Early follow-up on newly placed AVFs (As early as
4 weeks) - Address every single catheter
- Documentation is the key!
- Visit www.fistulafirst.org website for resources
tools - Utilize FFBI tools and tools that are available
through DaVita - Recognize issues and address them early
- Empower your staff by delegating roles
- Share successes and approach vascular access as
one community - Call your Network for help
43DaVita Vascular Access Tracking Tools
- Patient Report
- Facility Report
- Catheter Tracking tool
- Vascular Access Event Log
44Ongoing Issues
- No surgeons in the area
- Patients with no medical insurance
- No access placed prior to starting dialysis (CKD)
or long-term dialysis patients - Language barriers
- Patients noncompliance
- These are some issues we may not be able to solve
alone but we can try and find ways together to
solve them or at least work around them. If you
find successful ways to deal with some of these
issues. - PLEASE SHARE THEM WITH EVERYONE!
45Action Plan
- Use the FFBI Payer Packet to communicate with
your insurance carries about the benefits of
having an AVF placed for ESRD patients. (If all
your facilities have the same insurance
companies, all facilities communicate this
concern and urgency.) - Find ways to engage your surgeons (i.e. Share
your facility specific data that you receive from
the Network, inform them about the vascular
access clubs, etc.). - If your facilities all use the same surgeon(s),
all facilities should communicate the same
message/urgency regarding AVF placement. - Share the Cannulation DVD with the surgeons so
that they understand the logistics of cannulation
and can position the veins suitably and safely
for cannulation. - Educate both the patient and the FAMILY about
vascular access specifically AVFs. - Share best practices with everyone!
46Conclusion
- We are all partners
- We are on the right track
- Utilize available recourses and steal shamelessly
(Best practices) - Visit the FFBI website for more resources
- Call your Network for help
- Share successes
- It CAN be done!
47- Lisle Mukai, RN,
- Quality Improvement Coordinator
- ESRD Network 18
- Phone 323-962-2020
- Fax 323-962-2891
- lmukai_at_nw18.esrd.net