Title: Fistula First: AV Graft Conversion Project
1Fistula First AV Graft Conversion Project
- Svetlana (Lana) Kacherova, QI Director
- Lisle Mukai, QI Coordinator
- ESRD Network 18
- October 22, 2008
2Special 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
3Fistula First Breakthrough Initiative (FFBI)
Partners
- Dialysis facilities
- Dialysis patients
- Nephrologists
- Surgeons
- CMS
- ESRD Networks
- State Survey Agencies
- QIOs
- And many more!
4Fistula 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!
5Fistula 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 -
6 Tools Best PracticesFistula 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
7 Improvement in Prevalent AVF Rates by ESRD
Network
FFBI AVF goal 6666
8FFBI 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
9FFBI 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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11FFBI 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)
12Strategies 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
13V626 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
14 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!
15PDCA /PDSA Style
PLAN
ACT
DO
CHECK/STUDY
16Interdisciplinary Team
17Performance 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
18Monitoring 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
19Inclusion 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
20Exclusion Criteria
- Patient census lt 50 patients
- Facilities already included in another QIWP
project with the Network
21Environmental SCAN RESULTS
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26Sleeves Up Exam Followed by Fistulogram
27Planning for a secondary AVF is critical
28TIMING 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
29Continuum of Vascular Access Care
Assessment
Everyday Every shift, Every patient
Monitoring and Surveillance
Documentation
Vascular Access Program
Interventions
Angioplasty Fistulagram Thrombectomy
30 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
31Flow 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
32Color-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
33Ultrasound 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
34Dynamic 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)
35Static 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
36Other Methods
- On-Line-Clearance (OLC) conducted quarterly
Fresenious technology) - Magnetic Resonance Angiography
37 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)
38Aims to Action Conducting QAPI
utilizing Rapid-Cycle Improvement
39What 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
40Model 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
41Root-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.
42Root-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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44Plan-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.
45Model 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
46Developing 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
47Developing 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
48Examples 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
49Project 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.
50Three Ingredients of an Effective Team
System Leadership
Technical Expertise
Day-to-day Leadership
51Establishing 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)
52Interdisciplinary Team
53Applying 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
54Using Data for Improvement
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56Model 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
57Measurement 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
58Measures
- 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)
59Model 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
60Selecting 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
61Objective of the TestChange or No Change?
- Probably Change
- Test
- Redesign
- Eliminate
- Reduce
- Deliver
- Implement
- Probably No Change
- Recruit
- Distribute
- Continue
- Examine
- Discuss
- Teach
62Selecting 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
-
-
63To 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.
64Two Key Points
- Small scale ? small change
- Success (or failure) in one PDSA cycle ? success
or failure of the project
65Project 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!
66Network 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
67Facilities 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
68- 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