Transcript Document

Sponsored By the Centers Medicare & Medicaid Services
Alex Rosenblum, BSRN, CNN, CPHQ
Quality Management Coordinator
ESRD Network of Texas
972-503-3215
[email protected]/www.esrdnetwork.org
AV Fistulas
X Fewer C l o t t i n g E p i s o d e s
X Fewer H o s p i t a l i z a t i o n s
X Fewer i n f e c t i o n s
TO
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)
Project Objectives
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 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
60
Prevalent
Incident
50
Incident
Prevalent
40
30
20
10
0
U.S. 1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18
ESRD Networks
Source: 2001 CPM Data
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
Texas Vascular Access Trends 1999-2002
% of Patients
Facility Average
70 64.8
60.9
60
56.755.4
Jul-99
50
Feb-02
Dec-00
43
Dec-02
40
31
30
20.7
20
23.6 25.6
16.9
2001 U.S.
26
18.3 18.2 19.1 18.4
10
0
Graft
99 & 00 data source: Network #14 catheter project database
02 data source: Network Stenosis Project Database
Fistula
Catheter
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
# AVFs
needed to
reach 40%
County
# of HD
# Fistula
(# facilities)
Patients
(%)
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
FUN with Numbers
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
What Do We Know About
Fistula Practices in Texas?
Facilities with 40% or more Fistulas as of December 2002
Provider
Number
452644
452817
452553
452655
452583
452702
452503
452809
452651
452709
452754
452511
452528
452618
452736
452824
453502
452737
452758
452705
452592
452783
453501
452693
452594
452690
459000
452561
452648
452703
452784
453503
452749
452641
453300
450090
452550
452665
Facility Name
FMC Cleburne Dialysis Center
Harlingen Dialysis
FMC Corsicana
Ameritech Kidney Center HEB
Davita Bedford
FMC Richardson Dialysis Center
National Nephrology Associates - Central
RCG El Paso Kidney Center - West
Davita Central City Dialysis Center
FMC Westminster Dialysis
Texas City Dialysis
FMC Abilene Area Dialysis Ctr
Denton Dialysis
Ameri Tech Kidney Center
Gambro UT Southwestern
North Texas Dialysis Services
Scott & White Artificial Kidney Unit
RCG Brownsville Kidney Center
Davita Mesa Vista Dialysis
Gambro UKC
South Arlington Dialysis Ctr
Davita Moncrief Dialysis Center
Scott & White Killeen Dialysis Unit
FMC Swiss Ave Dialysis Center
FMC Southwest Fort Worth Dialysis Center
FMC Town Gate Dialysis Center
TDJC – UTMB
Irving Dialysis Center
Lewisville Dialysis Clinic
Davita Elmbrook Kidney Center
Davita Houston Kidney Center Cypress
Scott & White Round Rock Dialysis
RCG El Paso Kidney Center East
Gambro Brenham
Cook Childrens Medical Center Dialysis Unit
North Central Texas Dialysis Center
Gambro Bryan
Davita Denison
% Fistulas
County
40.1
40.2
40.3
40.4
40.6
40.7
40.8
41.2
41.6
41.9
42.0
42.4
42.9
43.4
43.7
43.8
44.0
44.0
44.1
44.4
44.9
44.9
46.9
47.5
47.7
47.8
49.3
49.4
50.0
50.9
51.3
51.5
55.3
57.4
60.0
62.5
64.3
67.9
Johnson
Cameron
Navarro
Tarrant
Tarrant
Dallas
Travis
El Paso
El Paso
Harris
Galveston
Taylor
Denton
Tarrant
Dallas
Cooke
Bell
Cameron
El Paso
Harris
Tarrant
Travis
Bell
Dallas
Tarrant
Dallas
Walker
Dallas
Denton
Dallas
Harris
Williamson
El Paso
Washington
Tarrant
Cooke
Brazos
Grayson
•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
Network Strategies to Increase AVF Rates
•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
Recommended Strategies to Assist
Dialysis & Surgical Professionals
Increase AVF Rates
Source: NVAII National Vascular Access Work Group
NVAII Change Concepts
1. Routine CQI review of
vascular access
6. Secondary AVFs in AVG
patients
2. Early referral to
nephrologist
7. AVF placement in
catheter patients
3. Early referral to
8. Cannulation training
surgeon for “AVF only” 9. Monitoring and
4. Surgeon selection
surveillance
5. Full range of
appropriate surgical
approaches
10.Continuing education:
staff and patient
11.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 postoperative 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
AV Fistulas
X Fewer C l o t t i n g E p i s o d e s
X Fewer H o s p i t a l i z a t i o n s
X Fewer i n f e c t i o n s
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
Elmbrook Dialysis Facility Specific and Access Data
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
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.
Elmbrook Fistula Management Process & Strategies
Patient
Admitted
?
Immature Fistula
+ Catheter
?
Catheter Only
Yes
Yes
New Fistula Protocol Initiated
Catheter Only Protocol Initiated
•Vascular access history and plan record initiated by MD.
•Vascular access history & plan record initiated by MD.
• Patient education, exercise training.
•If no appointment for permanent access - MD/nurse
schedules ASAP with radiology for mapping.
•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.
•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.
Unique or Other Notable Strategies and Processes to Increase
Fistula Rate
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.
HKC Cypress Dialysis Facility Specific and Access Data
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
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
Houston Kidney Center –Cypress Fistula Management Process & Strategies
Pre-ESRD Education &
AVF Placement Efforts
Patient
Admitted
?
?
Immature Fistula
+ Catheter
Catheter Only
Yes
Yes
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.
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.
•Facility nephrologists are focusing additional attention on preESRD 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.
El Paso Kidney Center -East - Facility Specific and Access Data
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
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
El Paso Kidney Center-East - Fistula Management Process & Strategies
Pre-ESRD Education &
AVF Placement Efforts
Patient
Admitted
?
?
Immature Fistula
+ Catheter
Catheter Only
Yes
Yes
New Fistula Protocol Initiated
•Ongoing education and support for exercise education, exercise training.
Catheter Only Protocol Initiated
•3 week follow-up with surgeons office to evaluate maturity
•Staff begin process of educating patient as to best access
choice
•Minimum 3 months maturation time before 1st cannulation with surgeon
approval
•If no appointment is scheduled for permanent access, nurse
schedules ASAP with surgeon for mapping and surgery
•Initial cannulation is single needle with tourniquet by experienced nurse
or technician who have demonstrated fistula cannulation skills
•Fax patient information to surgeon’s office
•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
•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
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.
• 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.