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ESRD Network of Texas 2003 Annual M eeting
 

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 ESRD Network of Texas 2003 Annual M eeting Presentation Transcript

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