Catheter Wipeout Initiative: Updates Lisle Mukai, QI Coordinator August 2008

DaVita Catheter Wipeout Initiative The project addresses high catheter rates within the Riverside/San Bernardino area. The involved facilities are Surf-N-Sun Division facilities who are divided into 3 teams lead by their Regional Managers. The teams will be competing against each other for attaining the lowest catheter rates. The facilities will utilize DaVita tracking tools and implement Fistula First Change Concepts to attain their goal.

Project Goal To reduce the total catheter rate by 20% in each of the intervention facilities over an 8 month period (May – December 2008). Attained by implementing Change Concepts: #5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement #7: AVF Placement in Patients with Catheters Where Indicated #9: Monitoring & Maintenance to Ensure Adequate Access Function. The project was extended to December 2008 from October. Change Concepts were discussed during your “Kick-Off” meeting in April but we will elaborate on them a little more today.

Facility-Specific Goals for Team Sue: Baseline data is from the SIMS report (FF database)

Facility-Specific Goals for Team Franco:

Facility-Specific Goals for Team Rosemarie:

Blue bars are before Catheter Wipeout Project began. Pink bar is April 2008 Baseline. Yellow bars are the months following baseline. Light orange bar represents what a 10% reduction (from baseline) Dark orange bar represents what a 20% reduction (from baseline) Because of the fluctuations, interpretation of the data was difficult and our statistician could not give us any analysis on each facility’s progress at this time The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008)

Blue bars are before Catheter Wipeout Project began. Pink bar is April 2008 Baseline. Yellow bars are the months following baseline. Light orange bar represents what a 10% reduction (from baseline) Dark orange bar represents what a 20% reduction (from baseline) Because of the fluctuations, interpretation of the data was difficult and our statistician could not give us any analysis on each facility’s progress at this time The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008)  Banning Dialysis (#552520) has consistently maintained a 10% reduction within the 3 months.

Blue bars are before Catheter Wipeout Project began. Pink bar is April 2008 Baseline. Yellow bars are the months following baseline. Light orange bar represents what a 10% reduction (from baseline) Dark orange bar represents what a 20% reduction (from baseline) Because of the fluctuations, interpretation of the data was difficult and our statistician could not give us any analysis on each facility’s progress at this time. The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008)

Team Goals:

Based on SIMS data (FF data) so July has not been posted Based on SIMS data (FF data) so July has not been posted. NW is 2 months behind in reporting.

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement Fistula First Website: Surgical video series: “Creating AV Fistulae in All Eligible Hemodialysis Patients” Article: “Surgical salvage of the autogenous arteriovenous fistula (AVF). Autologous AVF Algorithm (Developed by Dr. Spergel, MD, Clinical Chair for the FFBI) Commonly Used Permanent Vascular Access Codes (CPT codes) Based on the evaluation forms received, the most common resource/education issue identified was more surgeon education. Surgical video series: FF website, “Where do I start?”, select profession – surgeon, under Educational Materials. ** You can find the Surgical Salvage article on this page as well Additional information for CPT codes can be found on the: Medicare Physician Fee Schedule on the CMS website (address on the bottom of the handout) Additional billing booklets with more information on other related procedures can be found at other medical societies: Society for Vascular Surgery American Society of Diagnostic & Interventional Nephrology Society of Interventional Radiology

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) Make sure surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation “Cannulation of the Arteriovenous Fistula (AVF)” DVD – Each facility should have received one DVD from your corporate office. Encourage acute nursing staff to become more assertive in asking the Nephrologist to order vein mapping before discharging the patients from the hospital. Share this FFBI cannulation video with your surgeons so that they will understand the cannualtion process and will hopefully create AVFs in easily reachable locations. We have always encouraged our Nephrologists to refer newly diagnosed in-hospital patients for vascular access evaluation prior to discharge. We should also communicate with the acute nursing staff to ensure that the Nephrologists are referring these patients. Nephrologists and Surgeons not only hear it from the facility but from the hospital as well. Hopefully they will get in the habit of always referring and evaluating and placing AVF accesses in patients prior to discharge from the hospital.

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) Dialysis Access Clubs Presentations and discussions regarding creation, maintenance, and addressing complications of all types of vascular accesses are discussed. This is a great forum for surgeons and interventional radiologists to share or ask questions with their peers about vascular access situations they encounter. Dialysis Access Clubs are valuable resources for Vascular Access Surgeons and Interventional Radiologists because they can discuss specific procedures for surgery or how to deal with obstacles or complications they encounter, etc. in an open-discussion format.

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) Currently there are two active Dialysis Access Clubs: San Diego and Orange County. These clubs were started by Vascular Access Surgeons who are truly engaged in the Fistula First program. These meeting are usually held on a quarterly basis. Invitations are directly e-mailed to surgeons (the sponsoring organization has a vascular surgeon database they use to e-mail these invitations), because there is no Access Club in the Inland Empire as of yet, encourage your surgeons to contact their colleagues within the Orange County & San Diego County area and find out when these meetings occur. Hopefully this communication between colleagues will open opportunities for vascular access discussions and interest that will engage all surgeons. Attendees are not limited to just surgeons & interventional radiologists, nephrologists and nurses (usually management level) attend these meetings (also by invitation – usually referred by someone to have an invitation sent). In the future we hope to see more clubs within the Network 18 region. From what I last remember, the Inland Empire was trying to put an Access Club together, but I don’t know what the status of development is with that. Please encourage your surgeons to attend and participate in these meetings when you and/or your nephrologists they find out about them.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated Evaluation and mapping of catheter patients is crucial to facilitate the placement of AV fistulae. While catheters are necessary in some circumstances (e.g., while an AV fistula matures), the increasing prevalence of catheters is a serious health risk to patients. Per Dr. Nguyen: “Educate patients and their families. Patients don’t want to hear about the operation when they do not feel sick and yet early surgery for fistula is key to success. "I spend a lot of time talking to patients and their families," Nguyen says. "I always invite the whole family to come to the first visit. Convince the family, and they will beat on the patient to do it." Dr. Nguyen, Nephrologist from the Seattle area and a member of the FFBI Leadership Group has about 98% of his patients using a fistulae because he reduced the use of catheters. His approach was adopted by the Northwest Renal Network (ESRD Network 16) in 2002 as the basis for the Network’s VA Quality Improvement Program, as mandated by CMS. The example of his program can be found on the FF website under “Best Practice Examples”

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) “It’s important to explain the procedure in very simple terms” “Set expectations properly in case the first operation doesn’t do the job, since we are dealing with sicker and older patients with higher risk of fistula failure to mature properly, we tell them that another surgery may be needed.” Use diagrams when showing the patients where the catheter is located when educating them about their access. Upon review of the evaluation forms, one of your facilities requested pictures/posters of vascular accesses. Unfortunately we do not have a diagram of a catheter access. A while back I had heard of FMC having a poster posted in their lobbies that shows a catheter tip entering the heart with the words “ Do you really want this tube (catheter) in your heart?” Maybe you can contact an FMC facility within your area and see if they will be willing to share this poster with your facility. Maybe contact your local Vascular Access Center and see if they have a poster or flyer they can share with you also.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) FFBI Payer Packets have been posted to the Fistula First website http://www.fistulafirst.org/pdfs/FF_Intro_for_Payers.pdf The payer packet is a set of documents that you can use to communicate with your insurance companies about promoting catheter reduction and AVF placement. The documents includes: Introductory Letter for Payers Pay for Performance Summary Recommendations Fistula First Priority Recommendations PowerPoint slides

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) Introductory Letter for Payers 1 page document that explains who the Fistula First Breakthrough Initiative is Why vascular access, specifically catheters, matters so much What the organization (insurance company) can do about it. Basically we are telling the insurance companies what they probably already know….Medical care for ESRD patients are expensive. It specifically identifies that the vascular access cost/patient/year with a catheter is $10,000 while an AVF is $4000. It states that “both clinicians and payers must address catheters, because they result in increased hospitalizations, longer lengths of stay, higher rates of infection, and increased mortality.” Introduces the concept of developing “internal incentives for practitioners” with suggestions on how to put an incentive program together in the “Priority Recommendation” document.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) Pay for Performance – Summary Recommendations This is a payment position paper submitted by FFBI for consideration by CMS and other payers. This is an educational item and not a final CMS decision for Pay for Performance. A comment on one of the evaluations suggested surgeon incentive from the Network. Unfortunately we cannot do that but, this payer packet communicates that concept with the insurance companies. Each facility or region should communicate with their insurance companies and see if they can start implementing some type of program. This will benefit all ESRD patients and help the dialysis facilities attaining their vascular access goals. This should also help the cause of decreasing AV grafts. This may make those surgeons who prefer to place graft accesses think twice before placing one.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) FFBI Priority Recommendations Recommendations by FFBI for developing and implementing an incentive program for practitioners. References to specific Change Concept elements.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) Slides The PowerPoint slides illustrates costs for care: Medicare costs per person per year Per person per year access costs by type of access Hospitalization admissions for vascular access complications per patient year Risk for infection comparison between catheters and AV fistulas Variation on costs for inpatient hospital services per Medicare enrollee Performance on Medicare Quality Indicators Basically we all know that what the insurance companies listen to is costs. By showing them these slides, you can hopefully impact their practices.

Reducing Catheter Rate Strategies: Surgical evaluation,vessel mapping (& placement) of permanent access during initial, acute hospitalization Patient education Engagement of surgeons Early recognition & intervention for non- maturing AVFs = Post-op exam @ 4 wks Protocol for catheter removal (FF website) Vessel mapping is re-imbursed. Perform BI-LATERAL vessel mapping to rule out if a patient is a candidate for AVF placement. If not a candidate, keep results in the patient’s chart because the State Survey Agencies may ask you why this patient has a catheter and may want to see proof.

Proactive strategies to reduce catheter rate: Surgical evaluation (& placement) of permanent access during initial hospitalization Vessel mapping/optimal vessel selection to increase successful (usable) AVFs & Reduce non-maturing (FTM) AVFs (post-op exam @ 4 wks) Monitoring & timely intervention for late failure/ aggressive salvage

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function AVF Maturation Process – Fistula maturation is defined as the process by which a fistula becomes adequately dilated and thick-walled to make it suitable for cannulation. Usually takes 8 – 12 weeks for a fistula to mature, but can take longer Should be able to feel strong thrill at the arterial anastamosis Listen for continuous low-pitched bruit Vessel diameter must be 4-6 mm, veins should be firm to touch an no prominent collateral veins

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) Most failing AVF’s can be identified on evaluation at 4 weeks Many early AVF failures can be salvaged if identified before thrombosis occurs If the AVF is patent but you are unable to cannulate the AVF or adequately dialyze the patient by 12 weeks, refer for exam/fistulogram to determine what intervention is needed

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) Each treatment should include a physical assessment of the new AVF: Look at the access and compare the access extremity to the other extremity Listen for bruit (USE A STETHESCOPE!) Feel for thrill Everyone should be listening for the bruit when assessing an access, including PCTs. I know through my own experiences that my techs never listened to a patient’s access prior to cannulating unless they couldn’t feel a thrill.

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) Abnormal Changes in the Access Extremity: Edema of the access extremity Cold to the touch with pain or numbness (possible Steal Syndrome) Warm to the touch (possible infection) Bruising Loss of continuous briut/or change in the bruit Change in the quality of the “thrill” or complete loss of thrill ACTION: Refer for exam to determine intervention needed

AVF Dysfunction/Failure to Mature (FTM) > 30% of new AVFs fail to mature (FTM) and may need some type of intervention before it can be used You can markedly reduce early failure rate and interventions in AVFs by: Early referral & CKD program Improved patient & vessel selection/standardized vessel mapping protocol Early recognition of FTM AVF by evaluation (Monitoring & Surveillance) at 4 wks & timely intervention = high salvage rate One facility pointed out in the evaluation that “90-95% of their fistulas do not fit the 4-6 weeks maturity time and that they need a much longer time to mature, plus some patients need a second surgery.” This is true. What we are emphasizing is that all newly created AVFs be evaluated in 4 weeks to ensure that they are maturing properly/adequately. If not, timely interventions can salvage the AVF access. They say that > 30% of new AVFs may fail to mature, but they also say that successful AVFs have had at least 1 revision done prior to maturity. So expect this to occur. Remember what Dr. Vo Nguyen said when dealing with his patients: “Set expectations properly in case the first operation doesn’t do the job, since we are dealing with sicker and older patients with higher risk of fistula failure to mature properly, we tell them that another surgery may be needed.”

All patients should be taught how to: Feel for thrill – Report absence to staff immediately! Listen for bruit - Report absence to staff immediately! Look and recognize signs & symptoms of infection - Report signs/symptoms to staff immediately! Exercise the fistula arm with some resistance to venous flow Squeezing a rubber ball with or without a lightly applied tourniquet may increase flow, thereby enhancing vein maturation, and has been shown to significantly increase forearm vessel size, thereby potentially increasing flow through the AVF. Avoid carrying heavy items and wearing occlusive clothing (occlusive bands/elastic over access areas) Avoid sleeping on the access arm

Success Stories RMS Lifeline Outpatient Vascular Access Center will remove catheters for Emergency Medi-Cal patients with a working AVF access free of charge! Documentation of all access events can justify reason for request of AVF evaluation & placement for patients with Emergency Medi-Cal. Are there any other success stories anyone would like to share?

Fistula First AVF Goals CMS Goal – 66% by June 30, 2009 Yearly Network 18 Goal – 55.1% by March 31, 2009 Yearly Network Stretch Goal – 56% by March 31, 2009 June 2008 AVF rates: NW 18 – 53.4 % US – 50.3% Just a reminder of the CMS & Network AVF goals. With a decrease in catheter rates, there should be an increase in AVF rates. Ultimately, what we all want is to increase our AVF rate!

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 AVG patients AVF evaluation/placement in catheter pts where indicated Cannulation training Monitoring and maintenance Continuing Education Outcomes feedback The major objective of the FFBI is to increase the prevalence of AVFs. The 11 Change concepts cover all areas of vascular access to help facilities achieve higher AVF rates and improve vascular access care for their patients in the process. The recent focus in improving vascular access care are on Change Concept #6 and Change Concept #7. Your Catheter Wipeout Initiative focuses on Change Concept #7.

Change Concept #6: Secondary AVF Placement in Patients with AV Grafts Convincing a patient, Nephrologist, and Vascular Access Surgeon to evaluate and place a secondary AVF can be difficult, especially when a problem has not been experienced. Education is key. It is well known that when an AV graft clots or problems occur, they will more likely happen again. The Fistula First Breakthrough Initiative and Network 18 would like to emphasize the importance of monitoring and surveillance for stenosis. By monitoring and tracking problems with an AV graft the Nephrologist can easily refer the patient for a secondary AVF evaluation and placement before failure of the AV graft. Converting to an AVF will help improve patient care by decreasing missed treatment time for frequent interventions/revisions thus improving the patient’s quality of life and increasing the performance of the access. Lana discussed this Change Concept at your kick-off meeting in April. Wanted to remind all facilities that although the Catheter Wipeout Initiate focuses on catheters, all facilities should have a vascular access program in place. And, reducing AVGs by converting to secondary AVFs should be considered in that program. FFBI considers an AVG that has clotted at least once as a “Failing AVG”.

Change Concept #6: Secondary AVF Placement in Patients with AV Grafts (Continued) Nephrologist should evaluate every AVG patient for an AVF. Conducting the “Sleeves Up” exam monthly will help identify if a patient with an AVG may be a candidate for an AVF conversion. (Protocol was distributed at the Kick-off meeting in April) Vessel mapping if suitable veins are not identified on physical exam. A secondary AVF plan should be documented in the chart and discussed with the patient, family, staff, nephrologists, & surgeons in anticipation of AVF construction on the earliest evidence of AVG failure. Team Sue asked if surgeons get paid for placing secondary AVFs in patients with working AVGs because some surgeons refused to do it thinking that they will not be reimbursed. YES. They are reimbursed. You must fully document that the AVG is failing and that justifies placement of a new AVF access. Per FFBI, an AVG that has clotted at least once is considered a failing AVG.

Sleeves Up Exam The “Sleeves Up” exam identifies arterialized upper outflow vein of a forearm graft that can be converted into an AVF. This conversion opportunity should be looked for and considered in all forearm graft patients.

Timing of AVG conversion to a secondary AVF 1st AVG failure triggers evaluation for conversion to a secondary AVF A plan of care should be developed in anticipation of AVG failure At the sign of a second impeding AVG failure, the patient should be sent for an AV fistula conversion. Any delay in conversion beyond this point is likely to result in loss of the window of opportunity for this AVF option. Further AVG intervention may likely damage or utilize the outflow veins.

FFBI Strategies to increase Secondary AV Fistulae: Re-evaluation of all patients for AVF K/DOQI guideline 29: Every patient should be evaluated for a secondary fistula after each episode of graft failure Physical exam, vessel mapping and/or fistulogram Develop plan of care for anticipation of AVG failure Conversion of existing AVG to AVF, utilizing outflow vein of graft for AVF where feasible

System Roadblocks Identified by Facilities Patient Roadblocks Identified by Facilities: More Roadblocks: Afraid of needles Comfortable with catheter Exhausted sites Language barriers Forgetting follow-ups and missing appointments Lack of education Lack of knowledge and effort from the PCP offices Communication between dialysis unit and surgeon’s office Problems with the newly placed AVF (does not mature or clots) Patients without medical insurance Med-Cal only patients Restricted Medi-Cal HMO (ex. RMC, PMD) that requires authorization No good surgeons Not all surgeons accept Med-Cal and those who accept require long waiting time

Possible Solutions: Educate patients Vessel mapping for everyone Establish “Sleeves-up” Monday and Tuesday (At least monthly) Utilize Outpatient Vascular Access Center Establish relationship with surgeon’s office Establish relationship with HMO contacts Early follow-up on newly placed AVFs (As early as 4 weeks) Address every single catheter Documentation is the key! Visit www.fistulafirst.org website for resources & tools Utilize FFBI tools and tools that are available through DaVita Recognize issues and address them early Empower your staff by delegating roles Share successes and approach vascular access as one community Call your Network for help In addition…. Payer Packet Additional surgeon educational resources on FF website Participation in Access Clubs Know AVF maturation process

DaVita Vascular Access Tracking Tools Patient Report Facility Report Catheter Tracking tool Vascular Access Event Log

Ongoing Issues No surgeons in the area Patients with no medical insurance No access placed prior to starting dialysis (CKD) or long-term dialysis patients Language barriers Patient’s noncompliance These are some issues we may not be able to solve alone but we can try and find ways together to solve them or at least work around them. If you find successful ways to deal with some of these issues…. PLEASE SHARE THEM WITH EVERYONE!

Action Plan Use the FFBI Payer Packet to communicate with your insurance carries about the benefits of having an AVF placed for ESRD patients. (If all your facilities have the same insurance companies, all facilities communicate this concern and urgency.) Find ways to engage your surgeons (i.e. Share your facility specific data that you receive from the Network, inform them about the vascular access clubs, etc.). If your facilities all use the same surgeon(s), all facilities should communicate the same message/urgency regarding AVF placement. Share the Cannulation DVD with the surgeons so that they understand the logistics of cannulation and can position the veins suitably and safely for cannulation. Educate both the patient and the FAMILY about vascular access – specifically AVFs. Share best practices with everyone! A facility in the Santa Barbara area who has limited surgeons in their area shared their vascular access reports they received from the Network with their surgeon. The facility manager set up a meeting with the surgeon and discussed their facility vascular access outcomes, expectations of CMS, Network, and the facility, and what can be done. The surgeon couldn’t believe that the outcomes were so low that he contacted the Network asking if there were any conferences/seminars he can attend to learn more about vascular access creations. Because there were none being conducted at the time, we referred him to the Universities in the area that teach vascular access creations within their surgical programs and also informed him about the Vascular Access Clubs. We also referred the facility manager to a successful facility in the Thousand Oaks area and both the facility manager and the surgeon met with the Thousand Oaks Nurse Manager and surgeon to discuss vascular access. We were told that the meeting was very successful. This facility got their surgeon engaged!

Conclusion: We are all partners We are on the right track Utilize available recourses and steal shamelessly (Best practices) Visit the FFBI website for more resources Call your Network for help Share successes It CAN be done!

Quality Improvement Coordinator Lisle Mukai, RN, Quality Improvement Coordinator ESRD Network 18 Phone: 323-962-2020 Fax: 323-962-2891 lmukai@nw18.esrd.net