esrd network of texas 2003 annual m eeting
TRANSCRIPT
Alex Rosenblum, BSRN, CNN, CPHQ
Quality Management CoordinatorESRD Network of Texas
[email protected]/www.esrdnetwork.org
AV Fistulas X Fewer Clotting Episodes X Fewer Hospitalizations X Fewer infections
Sponsored By the Centers Medicare & Medicaid Services
TO
Project Leadership & Project Leadership & Partners!Partners!
Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services
Institute For Healthcare Quality (IHI)Institute For Healthcare Quality (IHI)
Dialysis & Surgical Community Dialysis & Surgical Community
Network Medical Review BoardNetwork Medical Review Board
Network Executive CommitteeNetwork Executive Committee
MRB Vascular Access Advisory CommitteeMRB Vascular Access Advisory Committee
National Project Committee National Project Committee (Larry Spergel, MD, Chair )(Larry Spergel, MD, Chair )
Why the CMS Interest in Vascular Access?Why the CMS Interest in Vascular Access? Cost Containment:Cost Containment:
• Estimated costs for vascular access - related Estimated costs for vascular access - related complications are 1-2 billion. (~8k per patient)complications are 1-2 billion. (~8k per patient)
• Fistulas have ~ 8x LESS relative risk of Fistulas have ~ 8x LESS relative risk of hospitalizations & surgeries compared to AVGshospitalizations & surgeries compared to AVGs
• 20% of hospitalizations are related to VA 20% of hospitalizations are related to VA dysfunctiondysfunction
• Doubling of U.S. dialysis population by 2010Doubling of U.S. dialysis population by 2010
Why the CMS Interest in Vascular Access?Why the CMS Interest in Vascular Access?
Practice variationPractice variation::
• U.S. VA utilization varies compared to U.S. VA utilization varies compared to other countries (~80% AVF in Europe)other countries (~80% AVF in Europe)
• Lack of adherence to practice guidelines Lack of adherence to practice guidelines (K/DOQI)(K/DOQI)
Vascular Access GuidelinesVascular Access Guidelines
•Primary AVF should be constructed in at least Primary AVF should be constructed in at least 50% of all new ESRD patients50% of all new ESRD patients
•40% of prevalent patients should have an AVF40% of prevalent patients should have an AVF
Project ObjectivesProject Objectives
Project Outcome GoalsProject Outcome Goals
• CMS expects each ESRD Network to CMS expects each ESRD Network to attain at least 40% fistula use in their attain at least 40% fistula use in their prevalent patient population. prevalent patient population.
• By 2006, the Network should improve it’s By 2006, the Network should improve it’s rate by at least 50% to an overall rate of rate by at least 50% to an overall rate of about 32% about 32%
What Do We Know About What Do We Know About Fistula Use in Texas and U.S.?Fistula Use in Texas and U.S.?
Current Patterns of AVF Use Current Patterns of AVF Use by ESRD Networkby ESRD Network
0
10
20
30
40
50
60
U.S. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Prevalent Incident
Source: 2001 CPM Data
Incident
Prevalent
ESRD Networks
As of 2001As of 2001Texas had the lowest Fistula Rates in the U.S.!Texas had the lowest Fistula Rates in the U.S.!
Texas = 23% prevalence
As of 2001As of 2001Texas had the lowest Fistula Rates in the U.S.!Texas had the lowest Fistula Rates in the U.S.!
Texas = 22% incidence
64.8 60.956.755.4
43
16.920.723.6 25.6
31
18.3 18.219.1
18.4
26
0
10
20
30
40
50
60
70
% o
f Pat
ient
s
Graft Fistula Catheter
Texas Vascular Access Trends 1999-2002 Facility Average
Jul-99
Dec-00
Feb-02
Dec-02
2001 U.S .
99 & 00 data source: Network #14 catheter project database
02 data source: Network Stenosis Project Database
Percent Fistula Utilization By Texas CountyPercent Fistula Utilization By Texas CountyDecember 2002December 2002
Goal : 40% of chronic patients using a fistula
Required Increased Numbers of Fistulas Required Increased Numbers of Fistulas TODAYTODAY to meet 40% GOAL to meet 40% GOAL
County
(# facilities)
# of HD
Patients
# Fistula(%)
# AVFs needed to
reach 40%
Harris (47) 4,059 1,032 (25.4) 591
Dallas (21) 2,335 845(36.2) 89
Bexar (31) 2,228 324 (14.5) 567
Tarrant (17) 1,330 446(33.5) 86
El Paso (10) 965 336 (34.8) 50
Hidalgo (9) 935 182(19.5) 192
Travis (10) 814 240 (29.5) 126
Texas (299) 22,674 5,668 (25%) 3,401
Average facility will need to add 10 + fistulasAverage facility will need to add 10 + fistulas
Texas will need to add an average of 3 AVFs per Texas will need to add an average of 3 AVFs per
day over the next 3 yearsday over the next 3 years
Most AVFs will need to come from new patients Most AVFs will need to come from new patients
or experience a high number of conversions or experience a high number of conversions
In 2002- 7,300 new patients/5,200 deathsIn 2002- 7,300 new patients/5,200 deaths
FUN with NumbersFUN with Numbers
What Do We Know About What Do We Know About Fistula Practices in Texas?Fistula Practices in Texas?
Provider Number
Facility Name % Fistulas County
452644 FMC Cleburne Dialysis Center 40.1 Johnson 452817 Harlingen Dialysis 40.2 Cameron 452553 FMC Corsicana 40.3 Navarro 452655 Ameritech Kidney Center HEB 40.4 Tarrant 452583 Davita Bedford 40.6 Tarrant 452702 FMC Richardson Dialysis Center 40.7 Dallas 452503 National Nephrology Associates - Central 40.8 Travis 452809 RCG El Paso Kidney Center - West 41.2 El Paso 452651 Davita Central City Dialysis Center 41.6 El Paso 452709 FMC Westminster Dialysis 41.9 Harris 452754 Texas City Dialysis 42.0 Galveston 452511 FMC Abilene Area Dialysis Ctr 42.4 Taylor 452528 Denton Dialysis 42.9 Denton 452618 Ameri Tech Kidney Center 43.4 Tarrant 452736 Gambro UT Southwestern 43.7 Dallas 452824 North Texas Dialysis Services 43.8 Cooke 453502 Scott & White Artificial Kidney Unit 44.0 Bell 452737 RCG Brownsville Kidney Center 44.0 Cameron 452758 Davita Mesa Vista Dialysis 44.1 El Paso 452705 Gambro UKC 44.4 Harris 452592 South Arlington Dialysis Ctr 44.9 Tarrant 452783 Davita Moncrief Dialysis Center 44.9 Travis 453501 Scott & White Killeen Dialysis Unit 46.9 Bell 452693 FMC Swiss Ave Dialysis Center 47.5 Dallas 452594 FMC Southwest Fort Worth Dialysis Center 47.7 Tarrant 452690 FMC Town Gate Dialysis Center 47.8 Dallas 459000 TDJC – UTMB 49.3 Walker 452561 Irving Dialysis Center 49.4 Dallas 452648 Lewisville Dialysis Clinic 50.0 Denton 452703 Davita Elmbrook Kidney Center 50.9 Dallas 452784 Davita Houston Kidney Center Cypress 51.3 Harris 453503 Scott & White Round Rock Dialysis 51.5 Williamson 452749 RCG El Paso Kidney Center East 55.3 El Paso 452641 Gambro Brenham 57.4 Washington 453300 Cook Childrens Medical Center Dialysis Unit 60.0 Tarrant 450090 North Central Texas Dialysis Center 62.5 Cooke 452550 Gambro Bryan 64.3 Brazos 452665 Davita Denison 67.9 Grayson
Facilities with 40% or more Fistulas as of December 2002Facilities 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 FacilityCharacteristics of a 40% Fistula Facility Physicians are major driver to increase AVF Physicians are major driver to increase AVF ratesrates
Physicians believe all pts. should be considered Physicians believe all pts. should be considered for AVFfor AVF
Physicians provide specific direction to surgeonsPhysicians provide specific direction to surgeons
RNs play important role with:RNs play important role with:•Recognition of access needs Recognition of access needs •Timely referrals Timely referrals •Education of patients Education of patients •Knowing who the “best” surgeons are!Knowing who the “best” surgeons are!•Interacting independently with surgeon office staff & coordinators Interacting independently with surgeon office staff & coordinators
•Identified willing surgeons!Identified willing surgeons!
•Shared staff attitude that the AVF is best choice Shared staff attitude that the AVF is best choice
•Priority on vein mapping requests or referralsPriority on vein mapping requests or referrals
•Pre-ESRD education programs Pre-ESRD education programs
•Pre-ESRD fistula placement is not unusual Pre-ESRD fistula placement is not unusual
•Patients with limited VA options - considered for Patients with limited VA options - considered for PD PD
•Designated VA CoordinatorDesignated VA Coordinator
•QI priority on VA outcomesQI priority on VA outcomes
Characteristics of a 40% Fistula FacilityCharacteristics of a 40% Fistula Facility
•Facility staff gave the following explanations:Facility staff gave the following explanations:
•High percent diabetics, PVD & older patientsHigh percent diabetics, PVD & older patients
•Lack of insurance >90 day waitsLack of insurance >90 day waits
•Surgeon’s preference Surgeon’s preference
•Patients refuse to have permanent access Patients refuse to have permanent access placedplaced
•Quality of surgeon AVF skillsQuality of surgeon AVF skills
Characteristics of Low Fistula FacilitiesCharacteristics of Low Fistula Facilities
•Facility staff gave the following explanations:Facility staff gave the following explanations:
•No mapping practices No mapping practices
•Unresponsive surgeons to fix poorly functioning Unresponsive surgeons to fix poorly functioning AVFAVF
•MDs order AVF, but surgeon does not placeMDs order AVF, but surgeon does not place
•Hard to get patients to preferred facilitiesHard to get patients to preferred facilities
•RN must call MD to get ok to send patient RN must call MD to get ok to send patient
•Staff have trouble sticking AVF Staff have trouble sticking AVF
Characteristics of Low Fistula FacilitiesCharacteristics of Low Fistula Facilities
Network Activities & Strategies Network Activities & Strategies
2003-20062003-2006
•Process flow charting of 40% AVF facilities and Process flow charting of 40% AVF facilities and
identification of their affiliated surgeon identification of their affiliated surgeon
•Collect facility specific VA data and produce Collect facility specific VA data and produce
facility specific reports with comparison to facility specific reports with comparison to
statewide averagesstatewide averages
•Development of a Surgical/Radiology Advisory Development of a Surgical/Radiology Advisory
Committee Committee
Network Strategies to Increase AVF RatesNetwork Strategies to Increase AVF Rates
•Regional surgeon/nephrologist/nurse educational Regional surgeon/nephrologist/nurse educational
programs programs
•Development of professional and patient education Development of professional and patient education
resources resources
•Support and encourage changes in the Medicare Support and encourage changes in the Medicare
payment system as needed payment system as needed
Network Strategies to Increase AVF RatesNetwork Strategies to Increase AVF Rates
Recommended Strategies to Recommended Strategies to Assist Dialysis & Surgical Assist Dialysis & Surgical
Professionals Increase AVF Rates Professionals Increase AVF Rates
Source: NVAII National Vascular Access Work Group
NVAII Change ConceptsNVAII Change Concepts
1.1. Routine CQI review of Routine CQI review of vascular accessvascular access
2.2. Early referral to Early referral to nephrologistnephrologist
3.3. Early referral to surgeon Early referral to surgeon for “AVF only”for “AVF only”
4.4. Surgeon selectionSurgeon selection
5.5. Full range of appropriate Full range of appropriate surgical approachessurgical approaches
6.6. Secondary AVFs in AVG Secondary AVFs in AVG patientspatients
7.7. AVF placement in catheter AVF placement in catheter patientspatients
8.8. Cannulation trainingCannulation training
9.9. Monitoring and surveillanceMonitoring and surveillance
10.10.Continuing education: staff Continuing education: staff and patientand patient
11.11.Outcomes feedbackOutcomes feedback
1.1. Routine CQI Review of Vascular Routine CQI Review of Vascular AccessAccess
Possible specific changes:Possible specific changes:Facilities and/or hospitals designate staff Facilities and/or hospitals designate staff
member responsible for vascular access CQImember responsible for vascular access CQIAssemble multi-disciplinary vascular access Assemble multi-disciplinary vascular access
team in facility or hospitalteam in facility or hospitalInvestigate and track all non-AVF access Investigate and track all non-AVF access
placements and AVF failuresplacements and AVF failures
2.2. Early Referral Early Referral toto Nephrologist Nephrologist
Possible specific changes:Possible specific changes:Primary care physicians use ESRD/CKD referral Primary care physicians use ESRD/CKD referral
criteria to ensure timely referral to nephrologistscriteria to ensure timely referral to nephrologistsNephrologists document AVF plan for all Nephrologists document AVF plan for all
patients expected to require renal replacement patients expected to require renal replacement therapytherapy
Designated nephrology staff person educates Designated nephrology staff person educates family and patient to protect vesselsfamily and patient to protect vessels
3.3. Early Referral to Surgeon forEarly Referral to Surgeon for “AVF Only” “AVF Only”
Possible specific changes:Possible specific changes:Skilled nephrologist/nurse performs Skilled nephrologist/nurse performs
evaluation and physical examevaluation and physical examNephrologist performs or refers patient for Nephrologist performs or refers patient for
vessel mappingvessel mappingNephrologist refers patient to surgeon for Nephrologist refers patient to surgeon for
“AVF only” “AVF only”
4.4. Surgeon Selection Surgeon Selection
Possible specific changes:Possible specific changes:Nephrologists refer to vascular access Nephrologists refer to vascular access
surgeons willing to meet specific standards surgeons willing to meet specific standards and expectationsand expectations
Surgeons are evaluated on frequency, Surgeons are evaluated on frequency, quality, and patency of access placementsquality, and patency of access placements
55. Full Range of Appropriate Surgical . Full Range of Appropriate Surgical ApproachesApproaches
Possible specific changes:Possible specific changes:Surgeons utilize current techniques for AVF Surgeons utilize current techniques for AVF
placement including vein transpositionplacement including vein transpositionSurgeons ensure mapping is performed if Surgeons ensure mapping is performed if
suitable vein not identified on physical examsuitable vein not identified on physical examSurgeons work with nephrologists to plan Surgeons work with nephrologists to plan
and place secondary AVF in patients with and place secondary AVF in patients with AV graftAV graft
6. Secondary AVFs in AVG Patients6. Secondary AVFs in AVG Patients
Possible specific changes:Possible specific changes:Nephrologists evaluate every AV graft patient Nephrologists evaluate every AV graft patient
for possible secondary AV fistula conversionfor possible secondary AV fistula conversionDialysis facility staff and/or rounding Dialysis facility staff and/or rounding
nephrologists examine outflow vein of all graft nephrologists examine outflow vein of all graft patients (“sleeves up”) at least monthlypatients (“sleeves up”) at least monthly
Nephrologists refer to surgeon for placement Nephrologists refer to surgeon for placement of secondary AVF of secondary AVF beforebefore failure of AV graft failure of AV graft
7.. AVF Placement in Catheter PatientsAVF Placement in Catheter Patients
Possible specific changes:Possible specific changes:Regardless of prior access (e.g. AV graft), Regardless of prior access (e.g. AV graft),
nephrologists and surgeons evaluate all nephrologists and surgeons evaluate all catheter patients as soon as possible for catheter patients as soon as possible for AVFAVF
Facility implements protocol to track Facility implements protocol to track patients for early removal of catheterpatients for early removal of catheter
8. Cannulation Training8. Cannulation Training
Possible specific changes:Possible specific changes:Facility uses best cannulators and best teaching tools to teach Facility uses best cannulators and best teaching tools to teach
AVF cannulation to all facility staffAVF cannulation to all facility staffDialysis staff use specific protocols for initial dialysis treatments Dialysis staff use specific protocols for initial dialysis treatments
with new AVFs and assign the most skilled staff to such patientswith new AVFs and assign the most skilled staff to such patientsFacility offers option of self-cannulation to patients who are Facility offers option of self-cannulation to patients who are
interested and ableinterested and able
In case of infiltration, facility has written procedures for the In case of infiltration, facility has written procedures for the management of bleeding along with educational materials for management of bleeding along with educational materials for patients/family to learn more about minimizing swelling and patients/family to learn more about minimizing swelling and bruisingbruising
9. Monitoring and Surveillance9. Monitoring and Surveillance
Possible specific changes:Possible specific changes:Nephrologists and surgeons conduct post-Nephrologists and surgeons conduct post-
operative physical evaluation of AVFs in 4 weeks operative physical evaluation of AVFs in 4 weeks to detect early signs of failure/refer for to detect early signs of failure/refer for interventionintervention
Facilities adopt standard procedures for Facilities adopt standard procedures for monitoring, surveillance, and timely referral for monitoring, surveillance, and timely referral for the failing AVFthe failing AVF
Medical team adopts standard criteria for Medical team adopts standard criteria for appropriate extent of intervention in existing appropriate extent of intervention in existing access before placing new accessaccess before placing new access
10. Continuing Education: 10. Continuing Education: Staff & PatientStaff & Patient
Possible specific changes:Possible specific changes:Routine facility staff in-servicing and education Routine facility staff in-servicing and education
program in vascular accessprogram in vascular accessContinuing education for all care-givers including Continuing education for all care-givers including
in-services by nephrologists, surgeons, and in-services by nephrologists, surgeons, and interventionalistsinterventionalists
Facilities educate patients to improve quality of Facilities educate patients to improve quality of care and outcomes (e.g. prepping puncture sites, care and outcomes (e.g. prepping puncture sites, applying pressure at needle sites, etc.)applying pressure at needle sites, etc.)
11. Outcomes 11. Outcomes FeedbackFeedback
Possible specific changes:Possible specific changes:Networks work with dialysis providers to Networks work with dialysis providers to
give specific feedback to all decision-makers give specific feedback to all decision-makers on incident and prevalent rates of AVF, on incident and prevalent rates of AVF, AVG, and catheter useAVG, and catheter use
Review data monthly or quarterly in Review data monthly or quarterly in facility staff meetingsfacility staff meetings
Consider The Following When Consider The Following When Selecting Potential Strategies:Selecting Potential Strategies:
Which of these am I already doing?Which of these am I already doing?Could I strengthen how I perform these?Could I strengthen how I perform these?
Which new changes could I make that would Which new changes could I make that would cause an improvement?cause an improvement?
Where will adopting a change require new Where will adopting a change require new ways of working, e.g., communication, ways of working, e.g., communication, coordination, clinical skills?coordination, clinical skills?
What kind of knowledge What kind of knowledge andand support might I support might I need and where could I find it?need and where could I find it?
Why Will This Project Succeed?Why Will This Project Succeed?
It’s the right thing to do for our patientsIt’s the right thing to do for our patients
Others have already shown us the wayOthers have already shown us the way
The incentives will drive changeThe incentives will drive change
Texans hates to looseTexans hates to loose
AV Fistulas X Fewer Clotting Episodes X Fewer Hospitalizations X Fewer infections
How Do Facilities Attain 40% Fistula Rates?How Do Facilities Attain 40% Fistula Rates?
Process Review and Panel DiscussionsProcess Review and Panel Discussions
Elmbrook Kidney Center - DallasElmbrook Kidney Center - Dallas
Houston Kidney Center Cypress - HoustonHouston Kidney Center Cypress - Houston
El Paso Kidney Center East - El PasoEl 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, MDNurse 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 1st 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 1st 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, MDNurse 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 1st 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 1st 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, MDNurse 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 1st 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 1st 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