Alex Rosenblum, BSRN, CNN, CPHQ Quality Management Coordinator ESRD Network of Texas Sponsored By the Centers Medicare & Medicaid Services

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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:  Cost Containment: Estimated costs for vascular access - related complications are 1-2 billion. (~8k per patient) 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 Fistulas have ~ 8x LESS relative risk of hospitalizations & surgeries compared to AVGs 20% of hospitalizations are related to VA dysfunction 20% of hospitalizations are related to VA dysfunction Doubling of U.S. dialysis population by 2010 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) U.S. VA utilization varies compared to other countries (~80% AVF in Europe) Lack of adherence to practice guidelines (K/DOQI) Lack of adherence to practice guidelines (K/DOQI)

Vascular Access Guidelines Primary AVF should be constructed in at least 50% of all new ESRD patientsPrimary AVF should be constructed in at least 50% of all new ESRD patients 40% of prevalent patients should have an AVF40% 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%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 County (# facilities) # of HD Patients # Fistula (%) # AVFs needed to reach 40% Harris (47)4,0591,032 (25.4)591 Dallas (21)2,335845(36.2)89 Bexar (31)2, (14.5)567 Tarrant (17)1,330446(33.5)86 El Paso (10) (34.8)50 Hidalgo (9)935182(19.5)192 Travis (10) (29.5)126 Texas (299)22,6745,668 (25%)3,401

Average facility will need to add 10 + fistulas 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 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 Most AVFs will need to come from new patients or experience a high number of conversions In ,300 new patients/5,200 deaths In ,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 % (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 needsRecognition of access needs Timely referralsTimely referrals Education of patientsEducation of patients Knowing who the “best” surgeons are!Knowing who the “best” surgeons are! Interacting independently with surgeon office staff & coordinatorsInteracting independently with surgeon office staff & coordinators

Identified willing surgeons!Identified willing surgeons! Shared staff attitude that the AVF is best choiceShared staff attitude that the AVF is best choice Priority on vein mapping requests or referralsPriority on vein mapping requests or referrals Pre-ESRD education programsPre-ESRD education programs Pre-ESRD fistula placement is not unusualPre-ESRD fistula placement is not unusual Patients with limited VA options - considered for PDPatients with limited VA options - considered for PD Designated VA CoordinatorDesignated VA Coordinator QI priority on VA outcomesQI priority on VA outcomes Characteristics 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 preferenceSurgeon’s preference Patients refuse to have permanent access placedPatients refuse to have permanent access placed Quality of surgeon AVF skillsQuality of surgeon AVF skills Characteristics of Low Fistula Facilities

Facility staff gave the following explanations:Facility staff gave the following explanations: No mapping practicesNo mapping practices Unresponsive surgeons to fix poorly functioning AVFUnresponsive surgeons to fix poorly functioning AVF 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 patientRN must call MD to get ok to send patient Staff have trouble sticking AVFStaff have trouble sticking AVF Characteristics of Low Fistula Facilities

Network Activities & Strategies

Process flow charting of 40% AVF facilities and identification of their affiliated surgeonProcess 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 averagesCollect facility specific VA data and produce facility specific reports with comparison to statewide averages Development of a Surgical/Radiology Advisory CommitteeDevelopment of a Surgical/Radiology Advisory Committee Network Strategies to Increase AVF Rates

Regional surgeon/nephrologist/nurse educational programsRegional surgeon/nephrologist/nurse educational programs Development of professional and patient education resourcesDevelopment of professional and patient education resources Support and encourage changes in the Medicare payment system as neededSupport 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 1.Routine CQI review of vascular access 2.Early referral to nephrologist 3.Early referral to surgeon for “AVF only” 4.Surgeon selection 5.Full range of appropriate surgical approaches 6.Secondary AVFs in AVG patients 7.AVF placement in catheter patients 8.Cannulation training 9.Monitoring and surveillance 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

. AVF Placement in Catheter Patients 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