Fistula First
Since the Fistula First Project was launched in 2003, each ESRD Network has experienced an increase in the prevalent AVF rate of use and met the individual targets assigned by the Centers for Medicare & Medicaid Services (CMS). The National rates continue to slowly rise each month.
As improvements were demonstrated, CMS increased the AVF prevalent goal to 66%. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF/K-DOQI) Guidelines for vascular access in 2006 recommend a 66% prevalent AVF rate. While these goals remain lower than the current rates in Japan or Europe only one ESRD Network reports a rate of 60% and many of the Networks report rates in the low 40 percentiles.
| Region Name | AVF Rate |
|---|---|
| Network 4 Overall | 53.2% |
| State of PA | 52.5% |
| State of DE | 61.7% |
Fistula Rates in Network 4
Our Chairman and Gold Preferred Lists (format: PDF, size: 183 kb) are now available online. Chairman Preferred means the unit have achieved a prevalent fistula rate of 66% or greater (surpasing CMS's goal). Gold Preferred means the unit has achieved a prevalent fistula rate between 55% and 66%. Check the list to see if you're on it!
Also, check out our current county map (format: PDF, size: 47 kb) showing Pennsylavnia and Delaware becoming "blue" states (no relation to politics ... we want all counties in our states to be "blue" because that represents a fistula rate of 66% or more).
Networks are expected to reduce the quality deficit in their regions in order to meet the CMS goal of 66% by 2009. Network 4 is expected to reach a target increase of 4% annually.
Those clinics that report high prevalent AVF rates have attributed their successful outcomes to the following practice changes:
- Increased nephrology leadership in vascular access planning
- Increased surgeon interest & skill, utilization of a full range of surgical approaches, and utilization of preoperative vein mapping
- Increased communication among the vascular access team members
- Appointing or hiring a Vascular Access Coordinator to monitor and follow up on all access and interventions
- A vascular access stenosis monitoring program
- Routine CQI review of vascular access with the involvement of the entire renal care team
How is Your Facility Monitoring Venous Stenosis?
According to the NKF-KDOQI guidelines, every dialysis facility should be monitoring vascular accesses for venous stenosis. Early intervention can extend the life of an access, especially if stenosis can be identified before the access completely fails. There are several methods of monitoring for venous stenosis. See the Venous Stenosis Monitoring Guide (format: PDF, size: 23 kb) for a list of current methods.
Barriers
There are many barriers that prevent early referral for AVF placement. Renal providers report multiple reasons for delays, such as no surgical referral prior to hospital discharge, delays in referring patient to the vascular surgeon once admitted to outpatient dialysis unit; prolonged time between call for sugical appointment and actual appointment, as surgeon groups often view vascular access procedures as low priority. Patient issues include missed appointments, financial or transportation issues, patient refusal, either from lock of awareness or buy-in of the AVF benefits. Many patients fear the use of needles, resist undergoing a sugical procedure, and are unwilling to commit the time and effort involved with preoperative evaluation and vessel mapping.
The Fistula Maturation Protocol (format: PDF, size: 108kb) was developed by Network 4’s Medical Review Board. Early recognition and intervention of the non-mature fistula are important steps for improved patient outcomes. Please consider using this tool as a resource in your Fistula First unit-specific quality improvement initiatives.
Fistula First Breakthrough Initiative
While the AV Fistula goal may seem insurmountable with the number of identified barriers, we believe it is achievable through collaorative efforts of all health care providers, partners and payers associated with chronic kidney disease patients. The Fistula First Breakthrough Initiative coalition members and the 18 ESRD Networks are working to address the barriers, nationally and regionally, through patient and provider educational effortrs and proposals to encourage changes in the payment system.
The Fistula First Breakthrough Initiative recently revised its Buttonhole Skills Checklist (format: PDF, size: 77kb). This checklist was also posted on the Fistula First website, under Change Concept 8, related tools.
Bruit Audio Clips!
The Fistula First website now has audio clips of normal bruits, bruits with stenosis (narrowing in blood vessels) and bruits with whistles. These sounds can teach hemodialysis patients and healthcare providers what to listen for when monitoring AV Fistulas and AV Grafts. Physical examinations should be performed at each dialysis treatment, using a stethoscope to assure the vascular access has blood flow. Find these audio clips under What's New.
Together We Can!
ESRD Network 4 is engaged to partner with you to achieve this goal, and is committed to the following projects, along with the Fistula First Change Package to break through the barriers and effectively implement best practices for the CKD patients by:
- Education in community healthcare settings for individuals with CKD
- Education of primary care physicians regarding early diagnosis of chronic kidney disease through an estimated glomerular filtration rate (eGFR) calculated by laboratories
- Increased communication / education with PCPs and nephrologists regarding CKD stages to ensure proper care delivery and timing of referral
- Increased recruitment and training of surgeons to perform vascular access procedures
- Continue to offer Cannulation Camps to improve cannulation techniques
- Coordinate surgeon workshops to provide updates in access management
- Continue to provide feedback to dialysis providers with Quarterly Fistula Comparative Performance Report
- Provide educational resources or technical assistance as requested
What Dialysis Providers Can Do
Dialysis providers can also participate in this change concept by:
- Early and continuous patient / family education regarding kidney replacement modalities, the requirement for access, and access types
- Social worker involvement, to assist patients with coping skills, financial and transportation issues
- Involvement of hospital caseworkers or discharge planners to schedule surgical appointments prior to discharge
- Increased and early communication between nephrologists and surgeons to develop a vascular access plan, to include completion of pre-op evaluation such as vessel mapping and cardiac clearance prior to surgical evaluation
- Increased education of the dialysis staff in vascular access assessment and cannulation techniques
- Adopt a vascular access stenosis monitoring protocol
- Develop a routine CQI review an action plan for vascular access.
Reduce Catheter Usage
Network 4 is actively looking at reducing the total number of catheters being utilized as the primary access for our dialysis patients. The following tools have been collected from a variety of sources and they may help to facilitate reducing your catheter rate. Feel free to use these as part of your CQI efforts.
- Catheter Reduction Tool (format: PDF, size: 25 kb)
- 90 Day Count Down Tool (format: PDF, size: 64 kb)
- Facility Action Steps Tool (format: PDF, size: 78 kb)
- Catheter Assessment Tool and Algorithm (format: PDF, size: 12 kb)
We Can Do This!
ESRD Network 4 applauds the efforts of patients and providers in our region as they continue to make efforts to improve vascular access outcomes and welcomes suggestions to share with others. The Network is available for assistance with vascular access improvement and any other issues or concerns of the renal community in Pennsylvania and Delaware. To request assistance, or for more information, contact the Network at (412) 325-2250.
-- Reminder --
For non-Large Dialysis Organization units, your Vascular Access Utilization Collection Form is due to the Network office by the 15th day of the following month -- Please fax your form to the attention of the "Quality Department" at (412) 325-1811.
