Fistula First Update


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  • Vascular access is a principal determinant of the success and cost-effectiveness of hemodialysis…
  • Healthy People 2010 is a roadmap for improving the health of all people in the United States during the first decade of the 21st century. The Department of Health and Human Services has recognized its importance by incorporating vascular access (for the first time) in Healthy People 2010.
  • A single slide to show the importance of fistulas to the care of dialysis patients
  • The risk of death to diabetics with catheters is pretty dramatic. Considering that 45% of patients on dialysis are diabetic the morbidity could significantly impacted by using AV fistulas over catheters.
  • Not know the baseline knowledge of the audience I thought it may be helpful to review the commonly used types of vascular accesses for hemodialysis.
  • The first place the surgeon checks for adequate vasculature. Once the artery is connected to the vein all the forearm veins will become “arterialized” meaning that will grow in size & strength due to the strong arterial pressure thus these veins will be able to accommodate the large needles used for cannulation. 17 ga to start and then gradually increasing the size to 16 ga,15 ga to accomplish a blood flow of 400cc a min or more through the dialyzer
  • If there are no useable vessels in the forearm or upper arm the surgeon may transpose the brachiobasilic to the front of the arm
  • Pictures of both straight & looped double cannula catheters. One side is used to pump the blood to the dialyzed & the side is to return the “cleaned” blood.
  • The catheter tip enters the atrium of the heart
  • This slide is to show where our Network stood at the beginning of the Fistula First Initiative
  • 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.
  • 1998 data published by Network 1 - 240 new dialysis patients. Split into groups of those who had orderly progression to dialysis (Elective Start); those who were known to have renal disease but started dialysis due to an acute medical problem (Emergency Start); and those who were not known to have renal disease before presenting in renal failure (Previously Unknown)
  • Tool for better communications between acute nurses, discharge planners and chronic facilities
  • And finally a little visual aide to help you remember which is the better type of vascular access for patients. Thank for listening and are there any questions?
  • Fistula First Update

    1. 1. Fistula First A CMS Sponsored Quality Initiative What is it? Where are we now? Where do we need to go? How are we going to achieve the goals? Peggy Lynch, BSN, RN, CNN Quality Manager Network of New England
    2. 2. Fistula First :What is it? <ul><li>CMS in collaboration with the 18 ESRD Networks and the renal community started the Fistula First Quality Improvement project in 2003 </li></ul><ul><li>The goal is to improve the quality of life for hemodialysis patients by increasing the AV fistula rate in prevalent patients to greater than 40% and >50% in Incident patients nationally by 6/06 </li></ul>
    3. 3. Vascular Access Initiative: Rationale <ul><li>Vascular access is one of the most critical issues in improving dialysis quality: </li></ul><ul><ul><li>2003 trends: Access Patency, Morbidity/ Mortality, Costs </li></ul></ul><ul><ul><li>Attributable to: AVF, AVG, Catheters </li></ul></ul><ul><ul><li>Access type is a major determinant of patient outcomes as well as financial outcomes </li></ul></ul><ul><ul><li>Most VA-related morbidity & costs are due to grafts & catheters </li></ul></ul>
    4. 4. DHHS Healthy People 2010: Chronic Kidney Disease Overall Goal: Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs. Vascular Access Goal: Increase the proportion of hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access. National target for AVFs = 50% placement in incident patients 40% use in prevalent patients
    5. 5. Why Fistula First ? <ul><li>There are over 385,000 patients on dialysis in the USA </li></ul><ul><li>There are over 11,000 patients on dialysis in New England </li></ul><ul><li>There are almost 5,000 patients on Dialysis in MA </li></ul><ul><li>Only 30% or < were dialyzing with a fistula in 2003 </li></ul><ul><li>Vascular access complications are the major cause of hospitalizations, morbidity & mortality in the dialysis population </li></ul>
    6. 6. Why Fistulas First? Risk of Infection with Various Access Types
    7. 7. Why Fistulas First? Relative Risk of Death by Access Type
    8. 8. Questions to be Answered <ul><li>What types of Vascular Accesses are commonly used for chronic dialysis patients? </li></ul><ul><li>What are the advantages and disadvantages of various types of accesses? </li></ul><ul><li>What is the best Access and Why? </li></ul>
    9. 9. What are the commonly created chronic Vascular Accesses? <ul><li>AV Fistulas </li></ul><ul><li>AV Grafts </li></ul><ul><li>RIJ Catheters </li></ul>
    10. 10. A direct surgical connection between a native artery and vein with cannulation of the patient’s own blood vessel for dialysis access Fistula
    11. 11. Where Fistulas are Placed <ul><li>Wrist </li></ul><ul><li>Elbow </li></ul><ul><li>Elbow with vein transposed </li></ul><ul><li>Leg with vein transposed </li></ul>
    12. 12. Sites for Native Fistulas
    13. 13. Proximal radial artery AVF
    14. 14. Brachiobasilic transposition
    15. 15. A substance is interposed between an artery and a vein and used to connect them. This material is cannulated for dialysis. Usually the material used is polytetrafluoroethylene (PTFE), but other materials, artificial or organic, can be used. AV-Graft
    16. 16. Arm PTFE Grafts
    17. 17. Site of Loop Graft
    18. 18. Complications of AV Access <ul><li>Wound infection </li></ul><ul><ul><li>superficial or deep </li></ul></ul><ul><li>Prosthetic infection </li></ul><ul><li>Cellulitis </li></ul><ul><li>Seroma or hematoma </li></ul><ul><li>Chronic drainage </li></ul><ul><li>Wound dehiscence </li></ul><ul><li>Neuralgia or paresthesia </li></ul><ul><li>Vascular steal </li></ul>
    19. 19. There are several types of Catheters but all have in common the fact that the Catheter resides in a vein and there is a break in the skin to allow the catheter to enter . There in lies the main problem: prone to infection/thrombus Temporary Catheter
    20. 20. Hemodialysis Catheters
    21. 21. Internal Jugular Double-Lumen Tunneled Dialysis Catheter
    22. 22. What are the characteristics of an “Ideal Access”? <ul><li>Few complications during creation </li></ul><ul><li>Minimum time before being usable for dialysis </li></ul><ul><li>Comfortable to initiate dialysis </li></ul><ul><li>Quick to terminate treatment </li></ul><ul><li>Minimum of care required to maintain access </li></ul>Adapted from NKF-K/DOQI Guidelines: Vascular access: Introduction
    23. 23. Which is Closest to the Ideal Access? + = close to ideal, - = far from ideal
    24. 24. Why is the AVF rate low if it is the “gold standard”? <ul><li>50% of patients start dialysis emergently, thus catheters are inserted for a quick vascular access to initiate hemodialysis </li></ul><ul><li>Patients may resist changing to an AVF due to fear of needles </li></ul><ul><li>Reimbursement for an AV graft is higher </li></ul><ul><li>AV Grafts can be used sooner than an AV fistula </li></ul>
    25. 25. How Did the USA Compare to the Rest of the World Prior to 2003?
    26. 26. Where we were in 2003? 42 % Prevalent AVF New England
    27. 27. Have we made any progress? Source: March 2006 Network Provider Fistula First Reports Network of New England=47.5%
    28. 28. Rates across USA & Possessions End Stage Renal Disease Network Regional Map Prevalent AVF Percentage Rates in US 38.1% 48% 44.2% 46.3% 58.5% 37.6% 40.7% 38.8% 36.3% 34.6% 41.5% 37.5% 47.5% 48.9% 39.5% 35% 40.4% Date Source: FF Dash Board 100% of facilities may not of reported in each Network US US Rate =
    29. 29. How are the New England States Doing?
    30. 30. Where Do We Go From Here? <ul><li>CMS National Goal for 2009=66% </li></ul><ul><li>AV Fistulas </li></ul>
    31. 31. How are we going to get there? <ul><li>Need to educate healthcare professionals to be aware that CKD is becoming a major Public Health problem (Apr. 2006-CDC) </li></ul><ul><li>Primary Care Physicians must routinely screen for kidney function and refer patients to the nephrologists when the GFR decreases. It is estimated that 19.2 million Americans are living with CKD (11% of the adult population) </li></ul><ul><li>Nephrologists must refer sooner to the vascular surgeon for access evaluation for dialysis </li></ul>
    32. 32. Stages of Chronic Kidney Disease Renal replacement therapy: dialysis or kidney transplant <15 Kidney failure 5 Preparation for renal replacement therapy,vascular access 15-29 Severe drop in GFR 4 Evaluate & Treat complications. DM should start vascular access now 30-59 Moderate decrease in GFR 3 Estimate progression 60-90 Kidney damage with mild decrease in GFR 2 Diagnosis,treatment of co-morbid conditions, slow progression >90 Kidney damage with normal GFR 1 Action GFR(mL/min/1.73 Description Stage
    33. 33. Would Earlier Referrals Help?
    34. 34. What else needs to change? <ul><li>Hospital staff need education to consider vein preservation & reduce the use of PICC lines & lab draws in high risk pts. </li></ul><ul><li>The lab could automatically do a calculated GFR when a serum creatinine is 1.8(female) or 2.0(male) thus triggering nephrology consult </li></ul><ul><li>Diabetics, HTN & Cardiac patients should have routine screening for CKD </li></ul>
    35. 35. Can We Make Better Plans for Access During Hospitalizations? <ul><li>Acute care nurses can assist by asking if vein mapping has been ordered for AVF evaluation prior to discharge of a stage 3-4 CKD patient considering hemodialysis </li></ul><ul><li>Discharge planners need to be made aware that catheters are a bridge to a permanent access & appointments need to be made with the vascular surgeon prior to discharge </li></ul><ul><li>Patient education on the benefits of AVF & potential dangers of catheters needs to improve </li></ul>
    36. 36. And…. <ul><li>Vascular Access coordination needs to be part of d/c planning of both CKD & ESRD pts. </li></ul><ul><li>Hospitals as part of their QI program could track outcomes for fistula placement in patients with a GFR of 30ml or less who are d/c from their institution </li></ul><ul><li>To Reiterate: NO IVS, No PICC lines, no venipunctures in potential AVF arm (usually non dominant arm) </li></ul>
    37. 37. <ul><li>Fistula First </li></ul><ul><li>Data on access cost for grafts vs AV Fistulas </li></ul><ul><li>CPT Codes </li></ul><ul><li>AVF (36821) = $493.01 </li></ul><ul><li>Graft (36830) = $643.49 </li></ul>AV Fistulas ? $ Spent to encourage AVFs…… Payment for AVFs vs Grafts……
    38. 38. Strategies to Improve More <ul><li>The Networks and the QIOs are collaborating to get the Fistula First message out to the acute care hospitals nurses, discharge planners, quality managers and PCP office. </li></ul><ul><li>National Task force has been created with a multi-faceted approach with all stakeholders included to broaden the scope. </li></ul><ul><li>Encourage CMS to remove reimbursement barriers for the CKD patient & increase the reimbursement for AVF over AVG </li></ul>
    39. 39. As Hospital Caregivers What Can You Do? <ul><li>Collaborate with vascular surgery dept. & nephrologists to create QIP for CKD & ESRD pts. Vascular access placement </li></ul><ul><li>In-service hospital staff on vein preservation in high risk groups </li></ul><ul><li>Collaborate with discharge planners to assure vascular access planning is part of the d/c plan </li></ul><ul><li>Become Familiar with the KDOQI guidelines for CKD & ESRD ( For the KDOQI guidelines go to: NKF site </li></ul>
    40. 40. Fistula First at the National & Local Level <ul><li>Visit the National Fistula First Project Website at: </li></ul><ul><li> </li></ul><ul><li>Visit the Network Website at: </li></ul><ul><li> </li></ul><ul><li>Visit the MassPro website at: </li></ul><ul><li> </li></ul>
    41. 41. AVF versus AVG