Fistula First A CMS Sponsored Quality Initiative

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Fistula First A CMS Sponsored Quality Initiative

• What is it?
• Where are we now?
• Where do we need to go?
• How are we going to achieve the goals?

Peggy Lynch, BSN, RN, CNN Quality Manager Network
of New England
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Fistula First What is it?

• CMS in collaboration with the 18 ESRD Networks
  and the renal community started the Fistula First
  Quality Improvement project in 2003
• The goal is to improve the quality of life for
  hemodialysis patients by increasing the AV
  fistula rate in prevalent patients to greater
  than 40 and gt50 in Incident patients nationally
  by 6/06

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Vascular Access Initiative Rationale

• Vascular access is one of the most critical
  issues in improving dialysis quality
• 2003 trends Access Patency, Morbidity/
  Mortality, Costs
• Attributable to AVF, AVG,
  Catheters
• Access type is a major determinant of patient
  outcomes as well as financial outcomes
• Most VA-related morbidity costs are due to
  grafts catheters

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DHHS Healthy People 2010 Chronic Kidney Disease
Overall GoalReduce new cases of chronic kidney
disease and its complications, disability, death,
and economic costs. Vascular Access
GoalIncrease the proportion of hemodialysis
patients who use arteriovenous fistulas as the
primary mode of vascular access. National target
for AVFs 50 placement in incident
patients 40 use in prevalent patients
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Why Fistula First ?

• There are over 385,000 patients on dialysis in
  the USA
• There are over 11,000 patients on dialysis in New
  England
• There are almost 5,000 patients on Dialysis in MA
• Only 30 or lt were dialyzing with a fistula in
  2003
• Vascular access complications are the major cause
  of hospitalizations, morbidity mortality in the
  dialysis population

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Why Fistulas First?
Risk of Infection with Various Access Types
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Why Fistulas First?
Relative Risk of Death by Access Type
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Questions to be Answered

• What types of Vascular Accesses are commonly
  used for chronic dialysis patients?
• What are the advantages and disadvantages of
  various types of accesses?
• What is the best Access and Why?

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What are the commonly created chronic Vascular
Accesses?

• AV Fistulas
• AV Grafts
• RIJ Catheters

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A direct surgical connection between a native
artery and vein with cannulation of the
patients own blood vessel for dialysis access
Fistula
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Where Fistulas are Placed

• Wrist
• Elbow
• Elbow with vein transposed
• Leg with vein transposed

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Sites for Native Fistulas
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Proximal radial artery AVF
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Brachiobasilic transposition
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A substance is interposed between an artery and a
vein and used to connect them. This material is
cannulated for dialysis.Usually the material
used is polytetrafluoroethylene (PTFE), but other
materials, artificial or organic, can be used.
AV-Graft
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Arm PTFE Grafts
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Site of Loop Graft
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Complications of AV Access

• Wound infection
• superficial or deep
• Prosthetic infection
• Cellulitis
• Seroma or hematoma
• Chronic drainage
• Wound dehiscence
• Neuralgia or paresthesia
• Vascular steal

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There are several types of Catheters but all have
in common the fact that the Catheter resides in a
vein and there is a break in the skin to allow
the catheter to enter . There in lies the main
problem prone to infection/thrombus
Temporary Catheter
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Hemodialysis Catheters
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Internal Jugular Double-Lumen Tunneled Dialysis
Catheter
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What are the characteristics of an Ideal Access?

• Few complications during creation
• Minimum time before being usable for dialysis
• Comfortable to initiate dialysis
• Quick to terminate treatment
• Minimum of care required to maintain access

Adapted from NKF-K/DOQI Guidelines Vascular
access Introduction
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Which is Closest to the Ideal Access?
close to ideal, - far from ideal
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Why is the AVF rate low if it is the gold
standard?

• 50 of patients start dialysis emergently, thus
  catheters are inserted for a quick vascular
  access to initiate hemodialysis
• Patients may resist changing to an AVF due to
  fear of needles
• Reimbursement for an AV graft is higher
• AV Grafts can be used sooner than an AV fistula

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How Did the USA Compare to the Rest of the World
Prior to 2003?
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Where we were in 2003?
42 Prevalent AVF New England
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Have we made any progress?
Network of New England47.5
Source March 2006 Network Provider Fistula
First Reports
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Rates across USA Possessions
End Stage Renal Disease Network Regional
Map Prevalent AVF Percentage Rates in US
US
US Rate
47.5
58.5
37.6
48.9
46.3
39.5
40.7
40.4
38.8
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48
44.2
37.5
36.3
38.1
34.6
41.5
Date Source FF Dash Board100 of facilities may
not of reported in each Network
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How are the New England States Doing?
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Where Do We Go From Here?

• CMS National Goal for 200966
• AV Fistulas

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How are we going to get there?

• Need to educate healthcare professionals to be
  aware that CKD is becoming a major Public Health
  problem (Apr. 2006-CDC)
• Primary Care Physicians must routinely screen for
  kidney function and refer patients to the
  nephrologists when the GFR decreases. It is
  estimated that 19.2 million Americans are living
  with CKD (11 of the adult population)
• Nephrologists must refer sooner to the vascular
  surgeon for access evaluation for dialysis

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Stages of Chronic Kidney Disease
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Would Earlier Referrals Help?
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What else needs to change?

• Hospital staff need education to consider vein
  preservation reduce the use of PICC lines
  lab draws in high risk pts.
• The lab could automatically do a calculated GFR
  when a serum creatinine is 1.8(female) or
  2.0(male) thus triggering nephrology consult
• Diabetics, HTN Cardiac patients should have
  routine screening for CKD

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Can We Make Better Plans for Access During
Hospitalizations?

• Acute care nurses can assist by asking if vein
  mapping has been ordered for AVF evaluation prior
  to discharge of a stage 3-4 CKD patient
  considering hemodialysis
• Discharge planners need to be made aware that
  catheters are a bridge to a permanent access
  appointments need to be made with the vascular
  surgeon prior to discharge
• Patient education on the benefits of AVF
  potential dangers of catheters needs to improve

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And.

• Vascular Access coordination needs to be part of
  d/c planning of both CKD ESRD pts.
• Hospitals as part of their QI program could track
  outcomes for fistula placement in patients with a
  GFR of 30ml or less who are d/c from their
  institution
• To Reiterate NO IVS, No PICC lines, no
  venipunctures in potential AVF arm (usually non
  dominant arm)

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Spent to encourage AVFs
Payment for AVFs vs Grafts
AV Fistulas
?

• CPT Codes
• AVF (36821) 493.01
• Graft (36830) 643.49

• Fistula First
• Data on access cost for grafts vs AV Fistulas

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Strategies to Improve More

• The Networks and the QIOs are collaborating to
  get the Fistula First message out to the acute
  care hospitals nurses, discharge planners,
  quality managers and PCP office.
• National Task force has been created with a
  multi-faceted approach with all stakeholders
  included to broaden the scope.
• Encourage CMS to remove reimbursement barriers
  for the CKD patient increase the reimbursement
  for AVF over AVG

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As Hospital Caregivers What Can You Do?

• Collaborate with vascular surgery dept.
  nephrologists to create QIP for CKD ESRD pts.
  Vascular access placement
• In-service hospital staff on vein preservation in
  high risk groups
• Collaborate with discharge planners to assure
  vascular access planning is part of the d/c plan
• Become Familiar with the KDOQI guidelines for CKD
  ESRD (For the KDOQI guidelines go to NKF site
  http//www.kidney.org/professionals/)

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Fistula First at the National Local Level

• Visit the National Fistula First Project Website
  at
• http//www.fistulafirst.org
• Visit the Network Website at
• http//www.networkofnewengland.org
• Visit the MassPro website at
• http//www.masspro.org/

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AVF versus AVG