AV Graft Conversion Project: Summary and Lessons Learned Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 July 23, 2009

Additional Goal: Reduce Catheter Use! “Fistula First” GOAL Goal is to maximize autogenous AVF construction & success rate….. To achieve in the shorter term (2006) the initial K/DOQI minimum benchmark of AVF use in 40% of prevalent patients…. And in the long-term (2009), a 66% AVF rate in prevalent patients Additional Goal: Reduce Catheter Use!

Fistula First Goals (AVF Rates) CMS goal – 66% AVF Yearly Network 18 goal – 57.8 % by June 30, 2010 Yearly Network Stretch Goal – 58.0% by June 30, 2010 May 2009 AVF rates: NW 18 – 56.3% US – 52.6%

Tools & Best Practices: Fistula First Change Concepts Routine CQI Review of vascular access Timely referral to nephrologist Early referral to surgeon for “AVF Only” Surgeon Selection Full range of appropriate surgical approaches Secondary AVFs in AFG patients AVF evaluation/placement in catheter pts Cannulation training Monitoring and maintenance Continuing Education Outcomes feedback Although the major objective of the FFBI is to increase the prevalence of AVFs, the 11 Change concepts cover all areas of vascular access and include all of the ingredients needed for a comprehensive VAMP.

Inclusion Criteria for Participating Facilities AVF rate < 50% (April SIMS data) Highest percentage and number of AV Grafts Patients census > 50 patients Administrative support: All intervention facilities have a stable leadership

Exclusion Criteria Patient census < 50 patients Facilities already included in another QIWP project with the Network

Project Timelines Oct. 2008 – Environmental scan and WebEx Nov. 2008 – RCA and PDSA (steps 1-3) Dec. 2008 – 1st follow-up Jan-Feb. 2009 – 2nd follow- up March-Apr. 2009 – 3rd follow up May 2009 – final follow-up June 2009 – Project summary and closure

Network Role During the Project: Project Leader Supplied the templates for RCA & PDSA Supplied facilities with tools and knowledge Periodically monitored and provided feedback Conducted phone interviews to obtain facility-specific data Chased you for data & documentation    Assisted your facility to stay in compliance with the QAPI program requirements

V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... …The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS

Project Summary

Change Concept # 6: Secondary AVF Placement in Patients with AV Grafts Nephrologists evaluate every AV graft patient for possible secondary AV fistula, including mapping as indicated, and document plan in patient’s record. Dialysis facility staff and/or rounding nephrologists examine outflow vein of all forearm graft patients (“sleeves-up”) during dialysis treatments (minimum frequency = monthly) to identify patients

Change Concept # 6: Secondary AVF Placement in Patients with AV Grafts (continued) Nephrologist refers to surgeon for evaluation/placement of secondary AV fistula before failure of AV graft. Fistula First considers an AVG that has clotted at least once a FAILING GRAFT.

Summary of Facility QAPI Strategies Patients and Families: Educate patients and their families about the advantages of an AV fistula (staff and nephrologists) Patient-to-patient teaching Post posters and have handouts available in the lobby regarding types of vascular accesses and vascular access care

Summary of Facility QAPI Strategies (continued) Facility and Staff: Designate a Vascular Access Coordinator/ Manager to oversee the facility’s vascular access program Inform nephrologists and surgeons about the AV Graft Conversion Project Inform nephrologists and surgeons about the facility’s expectations in regards to vascular access

Summary of Facility QAPI Strategies (continued) Facility provide the Fistula First surgical video to surgeons to review Medical Director to interact with other nephrologists and vascular surgeons as needed Have nephrologists start expanding their vascular access surgeon pool in the area Nephrologists will identify successful surgeons outside the local area

Summary of Facility QAPI Strategies (continued) Educate staff and nephrologists on how to perform a “Sleeves Up” assessment – use video Initiate/implement the “Sleeves Up” assessment to identify patients (staff and nephrologists) Staff and nephrologists educate the patients Have nephrologists refer patients to surgeons

Summary of Facility QAPI Strategies (continued) Schedule vein mapping of AVG patients that have clotted at least once if not previously done Obtain a copy of the vein mapping results and keep in the patient’s chart Assist patient and families in scheduling vascular access related appointments Conduct stenosis monitoring and surveillance

Summary of Facility QAPI Strategies (continued) Document problems and observations and report to the Nephrologist Refer patients for fistulogram after fist sign of graft failure Maintain a monthly vascular access tracking log – type of access, events, and status of the access

Summary of Facility QAPI Strategies (continued) Review vascular access reports during QAPI meetings (URR, Kt/V, stenosis surveillance reports, dialysis prescription, etc.) Discuss the project and the facility’s progress during QAPI meetings and brainstorm other ideas for increasing the facility’s AVF rate Document all events that occur with the patient’s AVG and submit to the insurance company stating reasons for patient needing to have an AVF evaluation and placement

Activities that support successful conversion: Consider an AV graft with at least one clotting episode to be a failing graft The nephrologist should have the patient evaluated for a possible secondary AV fistula, including vein mapping as indicated

Series of activities that support successful conversion: (continued) 3. A secondary AVF plan should be discussed with the patient, family, staff, nephrologist and surgeon in anticipation of an AVF creation at the earliest evidence of graft failure and the plan should be documented in the patient’s chart 4. The facility should have a plan of care in place to avoid the need for a catheter when the graft fails and there is urgency for an immediate usable access

Series of activities that support successful conversion: (continued) 5. A “Sleeves-Up” exam should be performed monthly to identify patients who can be candidates for a graft to fistula conversion 6. At the sign of a second impeding AVG failure, the patient should be sent for an AV fistula conversion

Next Steps Ensure that all AVG patients are evaluated for secondary AVF placement Have a process in place for a secondary AV fistula placement for lower arm AVG patients Educate the patients, families, nephrologists and surgeons about the concept of a secondary AV fistula placement Refer to the Fistula First website for resources regarding this Change Concept. www.fistulafirst.org

Next Steps Have a process in place to ensure that the newly created AV fistula develops to maturity Perform physical assessment of the access with every treatment Send the patient for a 4 week follow-up with the surgeon/vascular access center to evaluate the maturation process If the access is not maturing, the surgeon can then revise or implement interventions to salvage the access.

Svetlana (Lana) Kacherova, QI Director skacherova@nw18.esrd.net Lisle Mukai, QI Coordinator lmukai@nw18.esrd.net 6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028 (323) 962-2020  (323) 962-2891/Fax  www.esrdnetwork18.org