Fistula First: AV Graft Conversion Project

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Fistula First AV Graft Conversion Project

• Svetlana (Lana) Kacherova, QI Director
• Lisle Mukai, QI Coordinator
• ESRD Network 18
• October 22, 2008

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Special Acknowledgement forContent
ContributionsFFBI Leadership Group RMS
Lifeline, Inc. DaVita, Inc. John White, RN,
Manager, Outreach and Education Laura
Adams Irina Goykhman, RN, MBA Lynda K. Ball, RN,
BSN, CNN QI Director, ESRD Network 16
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Fistula First Breakthrough Initiative (FFBI)
Partners

• Dialysis facilities
• Dialysis patients
• Nephrologists
• Surgeons
• CMS
• ESRD Networks
• State Survey Agencies
• QIOs
• And many more!

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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!

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Fistula First Goals (AVF Rates)

• CMS goal 66 by June 30, 2009
• Yearly Network 18 goal 55.1 by June 30, 2009
• Yearly Network Stretch Goal 56.0 by June 30,
  2009
• August 2008 AVF rates NW 18 53.7
• US
  50.7

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Tools Best PracticesFistula First Change
Concepts

1. Routine CQI Review of vascular access
2. Timely referral to nephrologist
3. Early referral to surgeon for AVF Only
4. Surgeon Selection
5. 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

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Improvement in Prevalent AVF Rates by ESRD
Network
FFBI AVF goal 6666
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FFBI Accomplishments

• Website Updates Ongoing (fistulafirst.org)
• Calendar of upcoming vascular meetings (including
  Networks)
• Tab for Patient Education materials (patient and
  professionals)
• New interventionist videos uploaded
• Country-wide workshop for surgeons (May)
• More Cannulation DVD reproduction in the works
• Distribution of new tools to NetworksFF Provider
  Resource List and FAQs
• FF Patient Resource List

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FFBI Accomplishments (cont).

• Information sheets on Change Concepts 6 9
  Monitoring and surveillance flowchart (CC9)
• Secondary AVF Protocols (CC6)
• Secondary AVF Sleeves Up Exam Checklist
• Access Managers (CC6) Additional Buttonhole
  slide set (sharp needles)

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FFBI Strategies to increase AVF rate and reduce
catheter rate

• Networks should mount an effort to re- educate
  and provide feedback on Change Package, to all
  Providers and Clinics that are below the mean,
  including the laggards
• attempt to focus on gaps in education and
  performance
• Everyone focus on Change Concepts 6 7 and
  related FF protocols (fistulafirst.org)

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Strategies to increase Secondary Fistulae

• Re-evaluation of all patients for AVF options
• Conversion of existing AVG to AVF, utilizing
  outflow vein of graft for AVF where feasible
  OR
• Exam Vessel Mapping for alternate options
• Secondary A-V Fistula Options
• K/DOQI guideline 29 Every patient should be
  evaluated for a secondary fistula after each
  episode of graft failure

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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

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Condition 494.110Quality Assessment and
Performance Improvement Project (QAPI)

• Interdisciplinary team (IDT)
• Must report problems to Medical Director and QAPI
• Outcome- focused
• Process continuous on-going
• Use community accepted standards as targets
• Include patient satisfaction, infection control,
  medical injuries medication errors
• Plan/Do/Check/Act Close the loop!

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PDCA /PDSA Style
PLAN
ACT
DO
CHECK/STUDY
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Interdisciplinary Team

• Show Me The Progress

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Performance Measures
(V629) Adequacy Kt/V, URR
(V630) Nutrition Albumin, body weight
(V631) Bone disease PTH, Ca, Phos
(V632) Anemia Hgb, Ferritin
(V633)Vascular access ?Fistula, ?catheter rate
(V634) Medical errors ?Frequency of specific errors
V635) Reuse ?Adverse outcomes
(V636) Pt satisfaction ?Survey scores
(V637) Infection control ?Infections, ?vaccination status
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Monitoring Performance Improvement

• (V638) The facility must
• Continuously monitor its performance
• Take actions that result in performance
  improvement
• Track to assure improvements are sustained over
  time

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Inclusion Criteria for Participating Facilities

• AVF rate lt 50 (April SIMS data)
• Highest percentage and number of AV Grafts
• Patients census gt 50 patients
• Administrative support All intervention
  facilities have a stable leadership

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Exclusion Criteria

• Patient census lt 50 patients
• Facilities already included in another QIWP
  project with the Network

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Environmental SCAN RESULTS
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Sleeves Up Exam Followed by Fistulogram
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Planning for a secondary AVF is critical
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TIMING of Conversion AVG to a Secondary AVF

• 1st AVG failure triggers evaluation for
  conversion to a secondary AVFand a plan is
  established..
• 2nd AVG failure triggers conversion to an AVF
  using the fistulogram from the AVG study to
  evaluate the outflow veins

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Continuum of Vascular Access Care
Assessment

• Look, Listen,
• Feel

Everyday Every shift, Every patient
Monitoring and Surveillance
Documentation
Vascular Access Program
Interventions
Angioplasty Fistulagram Thrombectomy
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Is the Access Working Properly?

• Clearances (URR) greater than 65
• Access flow greater than 600
• Venous pressure at 200 BRF less than 125
• Able to run prescription
• Other signs and symptoms of access pathology
• Recirculation
• Difficulty cannulating and pain in the access
• Changes in thrill and bruit
• Prolonged bleeding post-dialysis

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Flow Methods in Dialysis Access

• Duplex Doppler Ultrasound (DDU)
• Magnetic Resonance Angiography (MRA)
• Variable Flow Doppler Ultrasound
• Ultrasound Dilution (Transonics) UDT
• Crit-Line III or Crit-Line II
• Glucose Pump Infusion
• Urea Dilution
• Differential Conductivity (Gambro) (HDM)
• In-line Dialysate (FMC) - DD

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Color-Flow Doppler

• Outpatient radiological procedure done quarterly
• Also called duplex ultrasound or duplex Doppler
  study
• Evaluates access flow patterns as well as areas
  of access stenosis

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Ultrasound Dilution Technique (Transonics)

• Conducted quarterly or as necessary
• AKA Crit-Line III or Crit-line TKA
• Very popular, but not all facilities have
  transonics on-site

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Dynamic Venous Pressure (DVP)

• Conducted and recorded at the beginning of each
  treatment at a specified blood flow rate using
  specified/consistent needle size
• Non-standardized dynamic venous pressure are
  considered as unacceptable monitoring method by
  the K/DOQI workgroup
• Acceptable method for AVFs only! (KDOQI 2006)

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Static Venous Pressure (SVP)

• Following a unit-specific procedure for
  measurement of venous and arterial measures at
  zero blood flow
• Conducted at least every 2 weeks
• Measurements plugged into mathematical formula
• Ratio gt 0.5 is considered abnormal
• Refer for fistulagram after 3 abnormal readings

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Other Methods

• On-Line-Clearance (OLC) conducted quarterly
  Fresenious technology)
• Magnetic Resonance Angiography

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Medicare Guidelines for Referral

• Venous outflow
• Elevated venous pressure
• Prolonged bleeding
• Decreased URR
• Decreased Kt/V
• Recirculation
• Swelling of the extremity
• Pulsatile graft
• Loss of thrill
• Aneurysms
• Difficult or painful cannulation

• Arterial inflow
• Low pressure in graft when outflow is occluded
• Ischemic changes in extremity
• Diminished intra-access flow (AKA arterial
  pulling negative)

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Aims to Action Conducting QAPI
utilizing Rapid-Cycle Improvement
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What is Rapid Cycle Improvement?

• Variant of process improvement that
• relies on existing knowledge
• dramatically shortens discovery process
• works on rapid trial learn method
• relies heavily on action

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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Aim
Act
Plan
Study
Do
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Root-Cause ANALYSIS (Fishbone Diagram)

• Determine the problem and create a problem
  statement (effect). Write it at the right center
  of the chart
• Brainstorm the major categories of causes of the
  problem. Write them as the main branches
  steaming from the center line
• Brainstorm all possible causes of the problem.
  Ask Why did this happen? about each cause.

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Root-Cause ANALYSIS (Fishbone Diagram cont).

• Write sub-causes stemming from the category of
  causes
• Collect data to confirm root-cause
• If no further causes can be identified, then you
  found the root causes of the problem

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Plan-Do-Study-Act

• Plan Identify Opportunity and plan for change
• Do Implement the Change on a small scale
• Study Use data to analyze for the change and
  determine whether it made a difference
• Act If the change was successful, implement the
  plan and continuously monitor results. If the
  change did not work start the process again.

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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Aim
Act
Plan
Study
Do
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Developing Your Aim

• Write a clear statement of aim--make the
  target for improvement unambiguous
• Include numeric goals
• Set stretch aims
• Focus on issues that are important to your
  organization - choose appropriate goals

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Developing Your Aim

• Improvement relies on intention to improve
• Senior leaders set align aim with strategic
  goals (involve Medical Director!)
• Agreement on aim is critical
• Include a specific time frame for accomplishing
  your aim

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Examples of Aims

• 100 of all dialysis patients with failing grafts
  will be converted to secondary fistulae by XYZ
  date
• To increase the number of patients utilizing AVF
  as a primary vascular access for hemodialysis by
  6 percentage points between June and December
  2007

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Project Goal

• Decrease in the AVG rate of at least 4 percentage
  points within 8 months (October 2008 May 2009)
  within the group of participating facilities by
  converting AVGs to AVFs.
• Primary target patients lower forearm AVG with
  a history of at least one clotting episode.

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Three Ingredients of an Effective Team
System Leadership
Technical Expertise
Day-to-day Leadership
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Establishing Your Team

• Have day-to-day, system, and technical expertise
• Day-to-day leader gives at least 20 (loses
  sleep)
• System leader can arrange for the resources to do
  the work
• Technical experts know the subject matter--often
  bedside people
• Use interdisciplinary team (IDT)

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Interdisciplinary Team

• Show Me The Progress

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Applying The Model Aims to Action

• Work together in twos or threes (Vascular Access
  Coordinator is the leader)
• Identify your project
• Identify
• A strong, clear aim statement to guide your
  improvement work on your project
• An aim that has a numeric, stretch goal included
• How you will form your team using the three
  ingredients of an effective team
• Give feedback to each other in the large group

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Using Data for Improvement
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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Measure
Act
Plan
Study
Do
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Measurement Guidelines

• The key measures should clarify the aim and make
  it tangible
• Use outcome and process measures
• Integrate measurement into the daily routine
• Use qualitative as well as quantitative data
• Seek usefulness, not perfection

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Measures

• Process
• Identify patients with lower forearm AVG
• Perform sleeves up
• Refer for vessel mapping support documentation
  re access problems
• Obtain Vessel mapping results and act
• Monitor newly created AVF for maturation

• Outcome
• Decrease in number of AVG
• Increase in number of AVF (converted from AVG)

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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Act
Plan
Select Changes
Study
Do
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Selecting Changes

• Blatantly steal Use the literature, the
  experience of others, hunches and theories (FFBI
  suggestions)
• Be strategic Set priorities based on the aim,
  known problems, and feasibility

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Objective of the TestChange or No Change?

• Probably Change
• Test
• Redesign
• Eliminate
• Reduce
• Deliver
• Implement

• Probably No Change
• Recruit
• Distribute
• Continue
• Examine
• Discuss
• Teach

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Selecting Changes

• Test the changes on a small scale
• - By next Tuesday
• - Capitalize on curiosity
• - Have a bias for the doable
• Use change concepts
• -Simplify
• -Error-proof
• -Minimize the hand-offs

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To Be Considered a Real Test

• Test was planned, including a plan for collecting
  data.
• Plan was attempted and data was collected.
• Time was set aside to analyze data and study the
  results.
• Action was taken, based on what was learned.

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Two Key Points

• Small scale ? small change
• Success (or failure) in one PDSA cycle ? success
  or failure of the project

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Project Changes and Steps

• Identify all patients with lower AVG previously
  clotted at least once
• Perform Sleeves Up exam and refer for the vessel
  mapping
• Be persistent educate patients at every
  opportunity
• Engage Medical Director!

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Network Responsibilities

• Project Leader (change agent)
• Supply the templates for RCA PDSA
• Supply toolkits to facilities evaluate their
  usefulness
• Provide monthly feedback (Vascular Access SIMS
  reports)
• Conduct monthly phone interviews to obtain
  facility-specific data
• Facility site visits for strugglers

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Facilities Responsibilities

• Return agreement letter (signed by MD)
• Return scans ASAP (those who did not return yet)
• RCA PDSA due to the Network by November 14,
  2008 (PDSA must be signed by MD)
• Review toolkit and identify tools that would work
  in your facility
• Follow the project timelines

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• We are all partners!
• Thank you!
• For questions please contact
• Svetlana (Lana) Kacherova, RN, MPH, CPHQ
• Quality Improvement Director
• ESRD Network 18
• 323-962-2020
• skacherova_at_nw18.esrd.net