Fistula First: Implementation

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

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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.

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Facility-Specific Goals for Team Sue
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Facility-Specific Goals for Team Franco
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Facility-Specific Goals for Team Rosemarie
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• The circled facilities are those that have
  achieved a 10 or greater reduction in at least
  one post-baseline month (baseline April 2008)

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• 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.

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• The circled facilities are those that have
  achieved a 10 or greater reduction in at least
  one post-baseline month (baseline April 2008)

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Team Goals
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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)

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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.

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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.

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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.

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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."

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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.

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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

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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.

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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.

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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.

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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.

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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.

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Sleeves Up Exam
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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.

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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

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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

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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

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DaVita Vascular Access Tracking Tools

• Patient Report
• Facility Report
• Catheter Tracking tool
• Vascular Access Event Log

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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!

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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!

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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!

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• Lisle Mukai, RN,
• Quality Improvement Coordinator
• ESRD Network 18
• Phone [phone]
• Fax [phone]
• lmukai_at_nw18.esrd.net