Fistula First: Implementation - PowerPoint PPT Presentation

1 / 47
About This Presentation
Title:

Fistula First: Implementation

Description:

Listen for continuous low-pitched bruit ... Loss of continuous briut/or change in the bruit ... Listen for bruit - Report absence to staff immediately! ... – PowerPoint PPT presentation

Number of Views:166
Avg rating:3.0/5.0
Slides: 48
Provided by: vickie80
Category:

less

Transcript and Presenter's Notes

Title: Fistula First: Implementation


1
Catheter Wipeout Initiative Updates
Lisle Mukai, QI Coordinator August 2008
2
DaVita 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.

3
Project 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.

4
Facility-Specific Goals for Team Sue
5
Facility-Specific Goals for Team Franco
6
Facility-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)

10
Team Goals
11
(No Transcript)
12
(No Transcript)
13
Change 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)

14
Change 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.

15
Change 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.

16
Change 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.

17
Change 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."

18
Change 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.

19
Change 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

20
Change 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.

21
Change 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.

22
Change 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.

23
Change 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

24
Reducing 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)

25
Proactive 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

26
Change 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

27
Change 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

28
Change 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

29
Change 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

30
AVF 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

31
All 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

32
Success 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.

33
Fistula 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

34
(No Transcript)
35
Fistula 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
  1. Routine CQI Review of vascular access
  2. Timely referral to nephrologist
  3. Early referral to surgeon for AVF Only
  4. Surgeon Selection
  5. Full range of appropriate surgical approaches

36
Change 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.

37
Change 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.

38
Sleeves Up Exam
39
Timing 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.

40
FFBI 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

41
System 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

42
Possible 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

43
DaVita Vascular Access Tracking Tools
  • Patient Report
  • Facility Report
  • Catheter Tracking tool
  • Vascular Access Event Log

44
Ongoing 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!

45
Action 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!

46
Conclusion
  • 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
Write a Comment
User Comments (0)
About PowerShow.com