Alex Rosenblum, BSRN, CNN, CPHQ Quality Management Coordinator ESRD Network of Texas  972-503-3215 Arosenblum@nw14.esrd.ne...
TO Project
Project Leadership & Partners! Centers for Medicare & Medicaid Services Institute For Healthcare Quality (IHI) Dialysis & ...
Why the CMS Interest in Vascular Access? <ul><li>Cost Containment:   </li></ul><ul><li>Estimated costs for vascular access...
Why the CMS Interest in Vascular Access? <ul><li>Practice variation :   </li></ul><ul><li>U.S. VA utilization varies compa...
Vascular Access Guidelines <ul><li>Primary AVF should be constructed in at least 50% of all new ESRD patients </li></ul><u...
Project Outcome Goals <ul><li>CMS expects each ESRD Network to attain at least 40% fistula use in their prevalent patient ...
What Do We Know About Fistula Use in Texas and U.S.?
Current Patterns of AVF Use  by ESRD Network Source:  2001 CPM Data Incident Prevalent ESRD Networks
As of 2001 Texas had the lowest Fistula Rates in the U.S.!   Texas = 23% prevalence
As of 2001 Texas had the lowest Fistula Rates in the U.S.!   Texas = 22% incidence
99 & 00 data source: Network #14 catheter project database 02 data source: Network Stenosis Project Database
Percent Fistula Utilization By Texas County December 2002   Goal : 40% of chronic patients using a fistula
Required Increased Numbers of Fistulas  TODAY   to meet 40% GOAL  126 240 (29.5) 814 Travis (10) 3,401 5,668 (25%) 22,674 ...
<ul><li>Average facility will need to add 10 + fistulas </li></ul><ul><li>Texas will need to add an average of 3 AVFs per ...
What Do We Know About Fistula Practices in Texas?
Facilities with 40% or more Fistulas as of December 2002 <ul><li>15% (41) of Texas facilities met 40% prevalence target </...
Characteristics of a 40% Fistula Facility   <ul><li>Physicians are major driver to increase AVF rates </li></ul><ul><li>Ph...
Characteristics of a 40% Fistula Facility   <ul><li>Identified willing surgeons! </li></ul><ul><li>Shared staff attitude t...
Characteristics of Low Fistula Facilities   <ul><li>Facility staff gave the following explanations: </li></ul><ul><ul><li>...
Characteristics of  Low Fistula Facilities   <ul><li>Facility staff gave the following explanations: </li></ul><ul><li>No ...
Network Activities & Strategies  2003-2006
<ul><li>Process flow charting of 40% AVF facilities  and identification of their affiliated surgeon  </li></ul><ul><li>Col...
<ul><li>Regional surgeon/nephrologist/nurse educational programs  </li></ul><ul><li>Development of professional and patien...
Recommended Strategies to Assist Dialysis & Surgical Professionals Increase AVF Rates  Source: NVAII National Vascular Acc...
NVAII Change Concepts <ul><li>Routine CQI review of vascular access </li></ul><ul><li>Early referral to nephrologist </li>...
1.   Routine CQI Review of Vascular Access <ul><li>Possible specific changes: </li></ul><ul><li>Facilities and/or hospital...
2.   Early Referral  to  Nephrologist <ul><li>Possible specific changes: </li></ul><ul><li>Primary care physicians use ESR...
3.   Early Referral to Surgeon for  “AVF Only” <ul><li>Possible specific changes: </li></ul><ul><li>Skilled nephrologist/n...
4.   Surgeon Selection <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists refer to vascular access surgeon...
5 .  Full Range of Appropriate Surgical Approaches <ul><li>Possible specific changes: </li></ul><ul><li>Surgeons utilize c...
6.  Secondary AVFs in AVG Patients <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists evaluate every AV gr...
7 .   AVF Placement in Catheter Patients <ul><li>Possible specific changes: </li></ul><ul><li>Regardless of prior access (...
8.  Cannulation Training <ul><li>Possible specific changes: </li></ul><ul><li>Facility uses best cannulators and best teac...
9.  Monitoring and Surveillance <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists and surgeons conduct po...
10.  Continuing Education:  Staff & Patient <ul><li>Possible specific changes: </li></ul><ul><li>Routine facility staff in...
11.  Outcomes  Feedback <ul><li>Possible specific changes: </li></ul><ul><li>Networks work with dialysis providers to give...
Consider The Following When Selecting Potential Strategies: <ul><li>Which of these am I already doing? </li></ul><ul><ul><...
<ul><li>Why Will This Project Succeed? </li></ul><ul><li>It’s the right thing to do for our patients </li></ul><ul><li>Oth...
How Do Facilities Attain 40% Fistula Rates? Process Review and Panel Discussions Elmbrook Kidney Center - Dallas Houston K...
<ul><li>Facility Specifics  </li></ul><ul><li>99 HD Patients / 25 PD patients </li></ul><ul><li>20 stations </li></ul><ul>...
Patient  Admitted ? Immature Fistula + Catheter Elmbrook Fistula Management Process & Strategies <ul><li>New Fistula Proto...
<ul><li>Unique or Other Notable Strategies and Processes to Increase Fistula Rate </li></ul><ul><li>Medical Director (s) a...
<ul><li>Facility  Specifics  </li></ul><ul><li>65 HD Patients / 7 PD patients </li></ul><ul><li>16 stations </li></ul><ul>...
Patient  Admitted ? Immature Fistula + Catheter Houston Kidney Center –Cypress Fistula Management Process & Strategies <ul...
<ul><li>Medical Director (s) and nurses recognize the importance of fistulas as 1 st  choice  for vascular access and have...
<ul><li>Treatment team holds daily meetings to discuss patients vascular access issues and discuss cannulation strategies....
<ul><li>Facility  Specifics  </li></ul><ul><li>107 HD Patients / 13 PD patients </li></ul><ul><li>18 stations </li></ul><u...
Patient  Admitted ? Immature Fistula + Catheter El Paso Kidney Center-East - Fistula Management Process & Strategies <ul><...
<ul><li>Medical Director (s) and nurses recognize the importance of fistulas as 1 st  choice  for vascular access and have...
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ESRD Network of Texas 2003 Annual M eeting

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  • Even though there has been gradual improvement in AVF rates over the past several years, we are still far away from meeting the K/DOQI and CMS guidelines: 50% incidence and 40% prevalence.
  • ESRD Network of Texas 2003 Annual M eeting

    1. 1. Alex Rosenblum, BSRN, CNN, CPHQ Quality Management Coordinator ESRD Network of Texas 972-503-3215 Arosenblum@nw14.esrd.net/www.esrdnetwork.org Sponsored By the Centers Medicare & Medicaid Services
    2. 2. TO Project
    3. 3. Project Leadership & Partners! Centers for Medicare & Medicaid Services Institute For Healthcare Quality (IHI) Dialysis & Surgical Community Network Medical Review Board Network Executive Committee MRB Vascular Access Advisory Committee National Project Committee (Larry Spergel, MD, Chair )
    4. 4. Why the CMS Interest in Vascular Access? <ul><li>Cost Containment: </li></ul><ul><li>Estimated costs for vascular access - related complications are 1-2 billion. (~8k per patient) </li></ul><ul><li>Fistulas have ~ 8x LESS relative risk of hospitalizations & surgeries compared to AVGs </li></ul><ul><li>20% of hospitalizations are related to VA dysfunction </li></ul><ul><li>Doubling of U.S. dialysis population by 2010 </li></ul>
    5. 5. Why the CMS Interest in Vascular Access? <ul><li>Practice variation : </li></ul><ul><li>U.S. VA utilization varies compared to other countries (~80% AVF in Europe) </li></ul><ul><li>Lack of adherence to practice guidelines (K/DOQI) </li></ul>
    6. 6. Vascular Access Guidelines <ul><li>Primary AVF should be constructed in at least 50% of all new ESRD patients </li></ul><ul><li>40% of prevalent patients should have an AVF </li></ul>Project Objectives
    7. 7. Project Outcome Goals <ul><li>CMS expects each ESRD Network to attain at least 40% fistula use in their prevalent patient population. </li></ul><ul><li>By 2006, the Network should improve it’s rate by at least 50% to an overall rate of about 32% </li></ul>
    8. 8. What Do We Know About Fistula Use in Texas and U.S.?
    9. 9. Current Patterns of AVF Use by ESRD Network Source: 2001 CPM Data Incident Prevalent ESRD Networks
    10. 10. As of 2001 Texas had the lowest Fistula Rates in the U.S.! Texas = 23% prevalence
    11. 11. As of 2001 Texas had the lowest Fistula Rates in the U.S.! Texas = 22% incidence
    12. 12. 99 & 00 data source: Network #14 catheter project database 02 data source: Network Stenosis Project Database
    13. 13. Percent Fistula Utilization By Texas County December 2002 Goal : 40% of chronic patients using a fistula
    14. 14. Required Increased Numbers of Fistulas TODAY to meet 40% GOAL 126 240 (29.5) 814 Travis (10) 3,401 5,668 (25%) 22,674 Texas (299) 935 965 1,330 2,228 2,335 4,059 # of HD Patients 192 182(19.5) Hidalgo (9) 50 336 (34.8) El Paso (10) 86 446(33.5) Tarrant (17) 567 324 (14.5) Bexar (31) 89 845(36.2) Dallas (21) 591 1,032 (25.4) Harris (47) # AVFs needed to reach 40% # Fistula (%) County (# facilities)
    15. 15. <ul><li>Average facility will need to add 10 + fistulas </li></ul><ul><li>Texas will need to add an average of 3 AVFs per day over the next 3 years </li></ul><ul><li>Most AVFs will need to come from new patients or experience a high number of conversions </li></ul><ul><li>In 2002- 7,300 new patients/5,200 deaths </li></ul>FUN with Numbers
    16. 16. What Do We Know About Fistula Practices in Texas?
    17. 17. Facilities with 40% or more Fistulas as of December 2002 <ul><li>15% (41) of Texas facilities met 40% prevalence target </li></ul><ul><li>31% of facilities are independent or small local chain </li></ul>Facility list in Handouts
    18. 18. Characteristics of a 40% Fistula Facility <ul><li>Physicians are major driver to increase AVF rates </li></ul><ul><li>Physicians believe all pts. should be considered for AVF </li></ul><ul><li>Physicians provide specific direction to surgeons </li></ul><ul><li>RNs play important role with: </li></ul><ul><li>Recognition of access needs </li></ul><ul><li>Timely referrals </li></ul><ul><li>Education of patients </li></ul><ul><li>Knowing who the “best” surgeons are! </li></ul><ul><li>Interacting independently with surgeon office staff & coordinators </li></ul>
    19. 19. Characteristics of a 40% Fistula Facility <ul><li>Identified willing surgeons! </li></ul><ul><li>Shared staff attitude that the AVF is best choice </li></ul><ul><li>Priority on vein mapping requests or referrals </li></ul><ul><li>Pre-ESRD education programs </li></ul><ul><li>Pre-ESRD fistula placement is not unusual </li></ul><ul><li>Patients with limited VA options - considered for PD </li></ul><ul><li>Designated VA Coordinator </li></ul><ul><li>QI priority on VA outcomes </li></ul>
    20. 20. Characteristics of Low Fistula Facilities <ul><li>Facility staff gave the following explanations: </li></ul><ul><ul><li>High percent diabetics, PVD & older patients </li></ul></ul><ul><ul><li>Lack of insurance >90 day waits </li></ul></ul><ul><ul><li>Surgeon’s preference </li></ul></ul><ul><ul><li>Patients refuse to have permanent access placed </li></ul></ul><ul><ul><li>Quality of surgeon AVF skills </li></ul></ul>
    21. 21. Characteristics of Low Fistula Facilities <ul><li>Facility staff gave the following explanations: </li></ul><ul><li>No mapping practices </li></ul><ul><li>Unresponsive surgeons to fix poorly functioning AVF </li></ul><ul><li>MDs order AVF, but surgeon does not place </li></ul><ul><li>Hard to get patients to preferred facilities </li></ul><ul><li>RN must call MD to get ok to send patient </li></ul><ul><li>Staff have trouble sticking AVF </li></ul>
    22. 22. Network Activities & Strategies 2003-2006
    23. 23. <ul><li>Process flow charting of 40% AVF facilities and identification of their affiliated surgeon </li></ul><ul><li>Collect facility specific VA data and produce facility specific reports with comparison to statewide averages </li></ul><ul><li>Development of a Surgical/Radiology Advisory Committee </li></ul>Network Strategies to Increase AVF Rates
    24. 24. <ul><li>Regional surgeon/nephrologist/nurse educational programs </li></ul><ul><li>Development of professional and patient education resources </li></ul><ul><li>Support and encourage changes in the Medicare payment system as needed </li></ul>Network Strategies to Increase AVF Rates
    25. 25. Recommended Strategies to Assist Dialysis & Surgical Professionals Increase AVF Rates Source: NVAII National Vascular Access Work Group
    26. 26. NVAII Change Concepts <ul><li>Routine CQI review of vascular access </li></ul><ul><li>Early referral to nephrologist </li></ul><ul><li>Early referral to surgeon for “AVF only” </li></ul><ul><li>Surgeon selection </li></ul><ul><li>Full range of appropriate surgical approaches </li></ul><ul><li>Secondary AVFs in AVG patients </li></ul><ul><li>AVF placement in catheter patients </li></ul><ul><li>Cannulation training </li></ul><ul><li>Monitoring and surveillance </li></ul><ul><li>Continuing education: staff and patient </li></ul><ul><li>Outcomes feedback </li></ul>
    27. 27. 1. Routine CQI Review of Vascular Access <ul><li>Possible specific changes: </li></ul><ul><li>Facilities and/or hospitals designate staff member responsible for vascular access CQI </li></ul><ul><li>Assemble multi-disciplinary vascular access team in facility or hospital </li></ul><ul><li>Investigate and track all non-AVF access placements and AVF failures </li></ul>
    28. 28. 2. Early Referral to Nephrologist <ul><li>Possible specific changes: </li></ul><ul><li>Primary care physicians use ESRD/CKD referral criteria to ensure timely referral to nephrologists </li></ul><ul><li>Nephrologists document AVF plan for all patients expected to require renal replacement therapy </li></ul><ul><li>Designated nephrology staff person educates family and patient to protect vessels </li></ul>
    29. 29. 3. Early Referral to Surgeon for “AVF Only” <ul><li>Possible specific changes: </li></ul><ul><li>Skilled nephrologist/nurse performs evaluation and physical exam </li></ul><ul><li>Nephrologist performs or refers patient for vessel mapping </li></ul><ul><li>Nephrologist refers patient to surgeon for “AVF only” </li></ul>
    30. 30. 4. Surgeon Selection <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists refer to vascular access surgeons willing to meet specific standards and expectations </li></ul><ul><li>Surgeons are evaluated on frequency, quality, and patency of access placements </li></ul>
    31. 31. 5 . Full Range of Appropriate Surgical Approaches <ul><li>Possible specific changes: </li></ul><ul><li>Surgeons utilize current techniques for AVF placement including vein transposition </li></ul><ul><li>Surgeons ensure mapping is performed if suitable vein not identified on physical exam </li></ul><ul><li>Surgeons work with nephrologists to plan and place secondary AVF in patients with AV graft </li></ul>
    32. 32. 6. Secondary AVFs in AVG Patients <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion </li></ul><ul><li>Dialysis facility staff and/or rounding nephrologists examine outflow vein of all graft patients (“sleeves up”) at least monthly </li></ul><ul><li>Nephrologists refer to surgeon for placement of secondary AVF before failure of AV graft </li></ul>
    33. 33. 7 . AVF Placement in Catheter Patients <ul><li>Possible specific changes: </li></ul><ul><li>Regardless of prior access (e.g. AV graft), nephrologists and surgeons evaluate all catheter patients as soon as possible for AVF </li></ul><ul><li>Facility implements protocol to track patients for early removal of catheter </li></ul>
    34. 34. 8. Cannulation Training <ul><li>Possible specific changes: </li></ul><ul><li>Facility uses best cannulators and best teaching tools to teach AVF cannulation to all facility staff </li></ul><ul><li>Dialysis staff use specific protocols for initial dialysis treatments with new AVFs and assign the most skilled staff to such patients </li></ul><ul><li>Facility offers option of self-cannulation to patients who are interested and able </li></ul><ul><li>In case of infiltration, facility has written procedures for the management of bleeding along with educational materials for patients/family to learn more about minimizing swelling and bruising </li></ul>
    35. 35. 9. Monitoring and Surveillance <ul><li>Possible specific changes: </li></ul><ul><li>Nephrologists and surgeons conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure/refer for intervention </li></ul><ul><li>Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF </li></ul><ul><li>Medical team adopts standard criteria for appropriate extent of intervention in existing access before placing new access </li></ul>
    36. 36. 10. Continuing Education: Staff & Patient <ul><li>Possible specific changes: </li></ul><ul><li>Routine facility staff in-servicing and education program in vascular access </li></ul><ul><li>Continuing education for all care-givers including in-services by nephrologists, surgeons, and interventionalists </li></ul><ul><li>Facilities educate patients to improve quality of care and outcomes (e.g. prepping puncture sites, applying pressure at needle sites, etc.) </li></ul>
    37. 37. 11. Outcomes Feedback <ul><li>Possible specific changes: </li></ul><ul><li>Networks work with dialysis providers to give specific feedback to all decision-makers on incident and prevalent rates of AVF, AVG, and catheter use </li></ul><ul><li>Review data monthly or quarterly in facility staff meetings </li></ul>
    38. 38. Consider The Following When Selecting Potential Strategies: <ul><li>Which of these am I already doing? </li></ul><ul><ul><li>Could I strengthen how I perform these? </li></ul></ul><ul><li>Which new changes could I make that would cause an improvement? </li></ul><ul><li>Where will adopting a change require new ways of working, e.g., communication, coordination, clinical skills? </li></ul><ul><li>What kind of knowledge and support might I need and where could I find it? </li></ul>
    39. 39. <ul><li>Why Will This Project Succeed? </li></ul><ul><li>It’s the right thing to do for our patients </li></ul><ul><li>Others have already shown us the way </li></ul><ul><li>The incentives will drive change </li></ul><ul><li>Texans hates to loose </li></ul>
    40. 40. How Do Facilities Attain 40% Fistula Rates? Process Review and Panel Discussions Elmbrook Kidney Center - Dallas Houston Kidney Center Cypress - Houston El Paso Kidney Center East - El Paso
    41. 41. <ul><li>Facility Specifics </li></ul><ul><li>99 HD Patients / 25 PD patients </li></ul><ul><li>20 stations </li></ul><ul><li>Corporate facility/urban unit </li></ul><ul><li>3 physicians </li></ul><ul><li>Utilization of OP VA clinic </li></ul><ul><li>Medical Director: Jeff Thompson, MD </li></ul><ul><li>Nurse Manager: David Turner, RN </li></ul><ul><li>Primary Surgeons: Stan Henry, MD, Ralph Parker, MD </li></ul>Elmbrook Dialysis Facility Specific and Access Data <ul><li>Vascular Access Data (5/03) </li></ul><ul><li>48% Fistulas </li></ul><ul><li>35% Grafts </li></ul><ul><li>16% Catheters </li></ul><ul><ul><li>8 (50%) fistulas maturing </li></ul></ul><ul><ul><li>2 graft maturing </li></ul></ul><ul><ul><li>4 awaiting graft or fistula placement </li></ul></ul><ul><ul><li>2 patients with no AV options </li></ul></ul><ul><li>0.6 clotting episodes per patient - per month thrombosis rate. </li></ul>
    42. 42. Patient Admitted ? Immature Fistula + Catheter Elmbrook Fistula Management Process & Strategies <ul><li>New Fistula Protocol Initiated </li></ul><ul><li>Vascular access history and plan record initiated by MD. </li></ul><ul><li>Patient education, exercise training. </li></ul><ul><li>Minimum 6-8 weeks maturation time before 1 st cannulation and upon MD approval. </li></ul><ul><li>Initial cannulation is single needle with tourniquet by experienced nurse or technician. </li></ul><ul><li>2 needle cannulation as BFR allows. </li></ul><ul><li>If low BFR or inability to cannulate, refer back to surgeon for evaluation. </li></ul><ul><li>Patency monitored monthly via Kt/V results. </li></ul><ul><li>Vascular access status and plan reviewed by team and documented monthly on QA tracking form. </li></ul><ul><li>Catheter Only Protocol Initiated </li></ul><ul><li>Vascular access history & plan record initiated by MD. </li></ul><ul><li>If no appointment for permanent access - MD/nurse schedules ASAP with radiology for mapping. </li></ul><ul><li>MD reviews mapping results, and coordinates with surgeon for appropriate access type and location. </li></ul><ul><li>Aggressive patient education & permanent access encouragement by all staff members. </li></ul><ul><li>Vascular access status and plan reviewed by team and documented monthly on tracking form. </li></ul>Yes ? Catheter Only Yes
    43. 43. <ul><li>Unique or Other Notable Strategies and Processes to Increase Fistula Rate </li></ul><ul><li>Medical Director (s) and nurses recognize the importance of fistulas as 1 st choice for vascular access and have implemented QI activity to meet the K/DOQI fistula targets. </li></ul><ul><li>About 40% of patients start in unit with fistula. </li></ul><ul><li>Medical Director (s) have excellent working relationship with a small group of surgeons who work in collaboration to provide their patients the best access option. </li></ul><ul><li>Medical Director(s) is very proactive in referring pre-ESRD patients to radiology for vein mapping. </li></ul><ul><li>Documenting patient vascular access status and plans in medical record and in QI provides an ongoing stimulus to team to focus on vascular access. </li></ul><ul><li>Facility maintains a vascular access record for each patient that includes access type, procedures. dates, and physician. </li></ul><ul><li>CKD program being initiated. </li></ul>Unique or Other Notable Strategies and Processes to Increase Fistula Rate
    44. 44. <ul><li>Facility Specifics </li></ul><ul><li>65 HD Patients / 7 PD patients </li></ul><ul><li>16 stations </li></ul><ul><li>Corporate facility/urban unit </li></ul><ul><li>7 physicians </li></ul><ul><li>Medical Director: Steve Fadem, MD </li></ul><ul><li>Nurse Manager: Fariba Rafieha, RN </li></ul><ul><li>Primary Surgeon: George Letsou, MD </li></ul>HKC Cypress Dialysis Facility Specific and Access Data <ul><li>Vascular Access Information (7/03) </li></ul><ul><li>40% Fistulas </li></ul><ul><li>38% Grafts </li></ul><ul><li>13% Catheters </li></ul><ul><ul><li>3 fistulas maturing </li></ul></ul><ul><ul><li>1 graft maturing </li></ul></ul><ul><ul><li>2 awaiting graft or fistula placement </li></ul></ul><ul><ul><li>2 patients with no AV options </li></ul></ul>
    45. 45. Patient Admitted ? Immature Fistula + Catheter Houston Kidney Center –Cypress Fistula Management Process & Strategies <ul><li>New Fistula Protocol Initiated </li></ul><ul><li>Ongoing education and support for exercise education, exercise training. </li></ul><ul><li>Periodic follow-up visits to surgeon office. </li></ul><ul><li>Minimum 3 month maturation time before 1 st cannulation with surgeon approval. </li></ul><ul><li>If fully mature,initial cannulation is double needle with tourniquet by experienced nurse or technician who have demonstrated fistula cannulation skills. </li></ul><ul><li>If not fully mature,initial cannulation is single needle with tourniquet by experienced nurse or technician who have demonstrated fistula cannulation skills </li></ul><ul><li>200 BFR for minimum three treatments . </li></ul><ul><li>If low BFR or inability to cannulate, refer back to surgeon for evaluation. </li></ul><ul><li>Facility policy requires use of tourniquet for most fistulas to minimize infiltration incidents. </li></ul><ul><li>Facility has written infiltration procedures and educational materials provided to patient </li></ul><ul><li>Patency monitored monthly via URR results. If decreased three consecutive tests, refer to surgeon </li></ul><ul><li>Nurses and PCTs place stethoscope on fistulas prior to cannulation and after cannulation to evaluate for flow changes. </li></ul><ul><li>Vascular access status and plan reviewed by team and documented monthly on QA tracking form. </li></ul><ul><li>Catheter Only Protocol Initiated </li></ul><ul><li>Staff begin process of educating patient as to best access choice. </li></ul><ul><li>If no appointment is scheduled for permanent access, nurse schedules ASAP with surgeon for mapping and surgery. </li></ul><ul><li>Facility faxes patient information to surgeon’s office. </li></ul><ul><li>Surgeon reviews mapping results, and makes determination for appropriate fistula location. </li></ul><ul><li>Following surgery, patient is provided with instructions to exercise arm with squeeze ball. </li></ul><ul><li>Surgeon faxes back diagram of access flow and date when ok to use fistula. </li></ul><ul><li>Refer to new fistula protocol. </li></ul>Yes ? Catheter Only Yes Pre-ESRD Education & AVF Placement Efforts
    46. 46. <ul><li>Medical Director (s) and nurses recognize the importance of fistulas as 1 st choice for vascular access and have implemented QI activity to meet the K/DOQI fistula targets. </li></ul><ul><li>Facility nephrologists are focusing additional attention on pre-ESRD fistula placement. </li></ul><ul><li>Nurse manager took it upon herself to identify a surgeon willing to place fistulas and coordinated with nephrologists to begin making referrals. </li></ul><ul><li>Affiliated surgeon requests mapping on 100% of patients. </li></ul><ul><li>Over 80% of fistulas placed are in the upper arm. </li></ul><ul><li>Surgeon has provided in-services for facility staff upon request. </li></ul><ul><li>MORE </li></ul>Unique or Other Notable Strategies and Processes to Increase Fistula Rate
    47. 47. <ul><li>Treatment team holds daily meetings to discuss patients vascular access issues and discuss cannulation strategies. </li></ul><ul><li>Documenting patient vascular access status and plans in medical record and in QI provides an ongoing stimulus to team to focus on vascular access. </li></ul><ul><li>Facility maintains a vascular access record for each patient that includes access type, procedures, dates and physician. </li></ul><ul><li>Staff are proponents of fistulas and encourage patients to consider them to avoid hospitalizations, travel expenses and surgery. </li></ul>Unique or Other Notable Strategies and Processes to Increase Fistula Rate
    48. 48. <ul><li>Facility Specifics </li></ul><ul><li>107 HD Patients / 13 PD patients </li></ul><ul><li>18 stations </li></ul><ul><li>Corporate facility Urban unit </li></ul><ul><li>2 physicians </li></ul><ul><li>Medical Director: Manuel Lopez, MD </li></ul><ul><li>Nurse Manager: Jaime Loya, RN </li></ul><ul><li>Primary Surgeon: Edward Gomez, MD </li></ul>El Paso Kidney Center -East - Facility Specific and Access Data <ul><li>Vascular Access Information (7/03) </li></ul><ul><li>50% Fistulas </li></ul><ul><li>26% Grafts </li></ul><ul><li>24% Catheters </li></ul><ul><ul><li>6 fistulas maturing </li></ul></ul><ul><ul><li>0 grafts maturing </li></ul></ul><ul><ul><li>6 awaiting graft or fistula placement </li></ul></ul><ul><ul><li>6 patients with no AV options </li></ul></ul><ul><ul><li>3 Patient refusing AV placement </li></ul></ul>
    49. 49. Patient Admitted ? Immature Fistula + Catheter El Paso Kidney Center-East - Fistula Management Process & Strategies <ul><li>New Fistula Protocol Initiated </li></ul><ul><li>Ongoing education and support for exercise education, exercise training. </li></ul><ul><li>3 week follow-up with surgeons office to evaluate maturity </li></ul><ul><li>Minimum 3 months maturation time before 1 st cannulation with surgeon approval </li></ul><ul><li>Initial cannulation is single needle with tourniquet by experienced nurse or technician who have demonstrated fistula cannulation skills </li></ul><ul><li>200 BFR for minimum three – six treatments </li></ul><ul><li>If low BFR or inability to cannulate, refer back to surgeon for evaluation </li></ul><ul><li>Required use of tourniquet for most fistulas to minimize infiltration incidents </li></ul><ul><li>Written infiltration procedures and educational materials provided to patient </li></ul><ul><li>Patency monitored via transonic, refer to surgeon if decreased flow identified </li></ul><ul><li>Vascular access status and plan reviewed by team and documented monthly on QA tracking form </li></ul><ul><li>Catheter Only Protocol Initiated </li></ul><ul><li>Staff begin process of educating patient as to best access choice </li></ul><ul><li>If no appointment is scheduled for permanent access, nurse schedules ASAP with surgeon for mapping and surgery </li></ul><ul><li>Fax patient information to surgeon’s office </li></ul><ul><li>Surgeon reviews mapping results and makes determination for appropriate fistula location </li></ul><ul><li>If fistula placed…patient is provided with instructions to exercise arm with squeeze ball </li></ul><ul><li>Refer to new fistula protocol </li></ul>Yes ? Catheter Only Yes Pre-ESRD Education & AVF Placement Efforts
    50. 50. <ul><li>Medical Director (s) and nurses recognize the importance of fistulas as 1 st choice for vascular access and have implemented QI activity to meet the K/DOQI fistula targets. </li></ul><ul><li>Facility nephrologist focusing a great deal of effort on CKD patients and the placement of pre-ESRD fistula placement. </li></ul><ul><li>Facility uses one primary surgeon for VA group. </li></ul><ul><li>Affiliated surgeon requests mapping on 100% of patients. </li></ul><ul><li>Over 80% of patients are admitted with a fistula in place. </li></ul><ul><li>During last 2 years - 2 grafts placed. </li></ul><ul><li>Surgeon has provided in-services for facility staff upon request and makes facility patient visits to evaluate access. </li></ul><ul><li>Documenting patient vascular access status and plans in medical record and in QI provides an ongoing stimulus to team to focus on vascular access. </li></ul><ul><li>Facility maintains a vascular access record for each patient that includes access type, procedures, dates and physician. </li></ul><ul><li>Patient’s have recognized the preferred access and surgeon. </li></ul>Unique or Other Notable Strategies and Processes to Increase Fistula Rate

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