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

2. 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!

3. 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%

4. 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.

5. 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

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

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

8. 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

9. 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

10. Project Summary

11. 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

12. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. Svetlana (Lana) Kacherova, QI Director skacherova@nw18.esrd.net
Lisle Mukai, QI Coordinator
6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028
(323)  (323) /Fax 