Catheter Wipeout Initiative Updates Lisle Mukai QI Coordinator

Catheter Wipeout Initiative: Updates Lisle Mukai, QI Coordinator August 2008

Da. Vita Catheter Wipeout Initiative The project addresses high catheter rates within the Riverside/San Bernardino area. The involved facilities are Surf-N-Sun Division facilities who are divided into 3 teams lead by their Regional Managers. The teams will be competing against each other for attaining the lowest catheter rates. The facilities will utilize Da. Vita tracking tools and implement Fistula First Change Concepts to attain their goal. 2

Project Goal To reduce the total catheter rate by 20% in each of the intervention facilities over an 8 month period (May – December 2008). Ø Attained by implementing Change Concepts: § #5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement § #7: AVF Placement in Patients with Catheters Where Indicated § #9: Monitoring & Maintenance to Ensure Adequate Access Function. 3

Facility-Specific Goals for Team Sue: 4

Facility-Specific Goals for Team Franco: 5

Facility-Specific Goals for Team Rosemarie: 6

The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008) 7

The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008) Banning Dialysis (#552520) has consistently maintained a 10% reduction within the 3 months. 8

The circled facilities are those that have achieved a 10% or greater reduction in at least one post-baseline month (baseline = April 2008) 9

Team Goals: 10

11

12

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement 1. Fistula First Website: 1. 2. 3. Surgical video series: “Creating AV Fistulae in All Eligible Hemodialysis Patients” Article: “Surgical salvage of the autogenous arteriovenous fistula (AVF). Autologous AVF Algorithm (Developed by Dr. Spergel, MD, Clinical Chair for the FFBI) 4. Commonly Used Permanent Vascular Access Codes (CPT codes) 13

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) n Make surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation n “Cannulation of the Arteriovenous Fistula (AVF)” DVD – Each facility should have received one DVD from your corporate office. n Encourage acute nursing staff to become more assertive in asking the Nephrologist to order vein mapping before discharging the patients from the hospital. 14

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) 1. Dialysis Access Clubs n n Presentations and discussions regarding creation, maintenance, and addressing complications of all types of vascular accesses are discussed. This is a great forum for surgeons and interventional radiologists to share or ask questions with their peers about vascular access situations they encounter. 15

Change Concept # 5: Full Range of Appropriate Surgical Approaches to AVF Evaluation & Placement (continued) n n Currently there are two active Dialysis Access Clubs: San Diego and Orange County. These clubs were started by Vascular Access Surgeons who are truly engaged in the Fistula First program. These meeting are usually held on a quarterly basis. Invitations are directly e-mailed to surgeons (the sponsoring organization has a vascular surgeon database they use to e-mail these invitations), because there is no Access Club in the Inland Empire as of yet, encourage your surgeons to contact their colleagues within the Orange County & San Diego County area and find out when these meetings occur. Hopefully this communication between colleagues will open opportunities for vascular access discussions and 16 interest that will engage all surgeons.

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated n Evaluation and mapping of catheter patients is crucial to facilitate the placement of AV fistulae. While catheters are necessary in some circumstances (e. g. , while an AV fistula matures), the increasing prevalence of catheters is a serious health risk to patients. n Per Dr. Nguyen: n “Educate patients and their families. Patients don’t want to hear about the operation when they do not feel sick and yet early surgery for fistula is key to success. "I spend a lot of time talking to patients and their families, " Nguyen says. "I always invite the whole family to come to the first visit. Convince the family, and they will beat on the patient to do it. " 17

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n n § “It’s important to explain the procedure in very simple terms” “Set expectations properly in case the first operation doesn’t do the job, since we are dealing with sicker and older patients with higher risk of fistula failure to mature properly, we tell them that another surgery may be needed. ” Use diagrams when showing the patients where the catheter is located when educating them about their access. 18

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n FFBI Payer Packets have been posted to the Fistula First website http: //www. fistulafirst. org/pdfs/FF_Intro_for_Payers. pdf n n The payer packet is a set of documents that you can use to communicate with your insurance companies about promoting catheter reduction and AVF placement. The documents includes: n Introductory Letter for Payers n Pay for Performance Summary Recommendations n Fistula First Priority Recommendations n Power. Point slides 19

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n Introductory Letter for Payers n n n 1 page document that explains who the Fistula First Breakthrough Initiative is Why vascular access, specifically catheters, matters so much What the organization (insurance company) can do about it. 20

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n Pay for Performance – Summary Recommendations n n This is a payment position paper submitted by FFBI for consideration by CMS and other payers. This is an educational item and not a final CMS decision for Pay for Performance. 21

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n FFBI Priority Recommendations n n Recommendations by FFBI for developing and implementing an incentive program for practitioners. References to specific Change Concept elements. 22

Change Concept #7: AVF Placement in Patients with Catheters Where Indicated (Continued) n Slides n The Power. Point slides illustrates costs for care: n Medicare costs person per year n Per person per year access costs by type of access n Hospitalization admissions for vascular access complications per patient year n Risk for infection comparison between catheters and AV fistulas n Variation on costs for inpatient hospital services per Medicare enrollee n Performance on Medicare Quality Indicators 23

Reducing Catheter Rate Strategies: n n n Surgical evaluation, vessel mapping (& placement) of permanent access during initial, acute hospitalization Patient education Engagement of surgeons Early recognition & intervention for non- maturing AVFs = Post-op exam @ 4 wks Protocol for catheter removal (FF website) 24

Proactive strategies to reduce catheter rate: n n n Surgical evaluation (& placement) of permanent access during initial hospitalization Vessel mapping/optimal vessel selection to increase successful (usable) AVFs & Reduce nonmaturing (FTM) AVFs (post-op exam @ 4 wks) Monitoring & timely intervention for late failure/ aggressive salvage 25

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function AVF Maturation Process – Fistula maturation is defined as the process by which a fistula becomes adequately dilated and thick-walled to make it suitable for cannulation. § § Usually takes 8 – 12 weeks for a fistula to mature, but can take longer Should be able to feel strong thrill at the arterial anastamosis Listen for continuous low-pitched bruit Vessel diameter must be 4 -6 mm, veins should be firm to touch an no prominent collateral veins 26

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) § § § Most failing AVF’s can be identified on evaluation at 4 weeks Many early AVF failures can be salvaged if identified before thrombosis occurs If the AVF is patent but you are unable to cannulate the AVF or adequately dialyze the patient by 12 weeks, refer for exam/fistulogram to determine what intervention is needed 27

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) Each treatment should include a physical assessment of the new AVF: § § § Look at the access and compare the access extremity to the other extremity Listen for bruit (USE A STETHESCOPE!) Feel for thrill 28

Change Concept #9: Monitoring & Maintenance to Ensure Adequate Access Function (Continued) Abnormal Changes in the Access Extremity: § § § Edema of the access extremity Cold to the touch with pain or numbness (possible Steal Syndrome) Warm to the touch (possible infection) Bruising Loss of continuous briut/or change in the bruit Change in the quality of the “thrill” or complete loss of thrill ACTION: Refer for exam to determine intervention needed 29

AVF Dysfunction/Failure to Mature (FTM) n > 30% of new AVFs fail to mature (FTM) and may need some type of intervention before it can be used n You can markedly reduce early failure rate and interventions in AVFs by: n Early referral & CKD program n Improved patient & vessel selection/standardized vessel mapping protocol n Early recognition of FTM AVF by evaluation (Monitoring & Surveillance) at 4 wks & timely intervention = high salvage rate 30

All patients should be taught how to: n n Feel for thrill – Report absence to staff immediately! Listen for bruit - Report absence to staff immediately! Look and recognize signs & symptoms of infection - Report signs/symptoms to staff immediately! Exercise the fistula arm with some resistance to venous flow n n n Squeezing a rubber ball with or without a lightly applied tourniquet may increase flow, thereby enhancing vein maturation, and has been shown to significantly increase forearm vessel size, thereby potentially increasing flow through the AVF. Avoid carrying heavy items and wearing occlusive clothing (occlusive bands/elastic over access areas) Avoid sleeping on the access arm 31

Success Stories n n RMS Lifeline Outpatient Vascular Access Center will remove catheters for Emergency Medi-Cal patients with a working AVF access free of charge! Documentation of all access events can justify reason for request of AVF evaluation & placement for patients with Emergency Medi-Cal. 32

Fistula First AVF Goals n CMS Goal – 66% by June 30, 2009 n Yearly Network 18 Goal – 55. 1% by March 31, 2009 n Yearly Network Stretch Goal – 56% by March 31, 2009 n June 2008 AVF rates: NW 18 – 53. 4 % US – 50. 3% 33

34

Fistula First Change Concepts 1. 2. 3. 4. 5. 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 6. 7. 8. 9. 10. 11. Secondary AVFs in AVG patients AVF evaluation/placement in catheter pts where indicated Cannulation training Monitoring and maintenance Continuing Education Outcomes feedback 35

Change Concept #6: Secondary AVF Placement in Patients with AV Grafts § Convincing a patient, Nephrologist, and Vascular Access Surgeon to evaluate and place a secondary AVF can be difficult, especially when a problem has not been experienced. Education is key. It is well known that when an AV graft clots or problems occur, they will more likely happen again. § The Fistula First Breakthrough Initiative and Network 18 would like to emphasize the importance of monitoring and surveillance for stenosis. Ø § By monitoring and tracking problems with an AV graft the Nephrologist can easily refer the patient for a secondary AVF evaluation and placement before failure of the AV graft. Converting to an AVF will help improve patient care by decreasing missed treatment time for frequent interventions/revisions thus improving the patient’s quality of life and increasing the performance of the access. 36

Change Concept #6: Secondary AVF Placement in Patients with AV Grafts (Continued) n n Nephrologist should evaluate every AVG patient for an AVF. Conducting the “Sleeves Up” exam monthly will help identify if a patient with an AVG may be a candidate for an AVF conversion. (Protocol was distributed at the Kick-off meeting in April) Vessel mapping if suitable veins are not identified on physical exam. A secondary AVF plan should be documented in the chart and discussed with the patient, family, staff, nephrologists, & surgeons in anticipation of AVF construction on the earliest evidence of AVG failure. 37

Sleeves Up Exam 38

Timing of AVG conversion to a secondary AVF n 1 st AVG failure triggers evaluation for conversion to a secondary AVF n A plan of care should be developed in anticipation of AVG failure n At the sign of a second impeding AVG failure, the patient should be sent for an AV fistula conversion. Any delay in conversion beyond this point is likely to result in loss of the window of opportunity for this AVF option. 39

FFBI Strategies to increase Secondary AV Fistulae: n n n Re-evaluation of all patients for AVF n K/DOQI guideline 29: Every patient should be evaluated for a secondary fistula after each episode of graft failure n Physical exam, vessel mapping and/or fistulogram Develop plan of care for anticipation of AVG failure Conversion of existing AVG to AVF, utilizing outflow vein of graft for AVF where feasible 40

System Roadblocks Identified by Facilities n n n Patients without medical insurance Med-Cal only patients Restricted Medi. Cal HMO (ex. RMC, PMD) that requires authorization No good surgeons Not all surgeons accept Med-Cal and those who accept require long waiting time Patient Roadblocks Identified by Facilities: n n n Afraid of needles Comfortable with catheter Exhausted sites Language barriers Forgetting follow-ups and missing appointments Lack of education More Roadblocks: n n n Lack of knowledge and effort from the PCP offices Communication between dialysis unit and surgeon’s office Problems with the newly placed AVF (does not mature or clots) 41

Possible Solutions: n n n n n Educate patients Vessel mapping for everyone Establish “Sleeves-up” Monday and Tuesday (At least monthly) Utilize Outpatient Vascular Access Center Establish relationship with surgeon’s office Establish relationship with HMO contacts Early follow-up on newly placed AVFs (As early as 4 weeks) Address every single catheter Documentation is the key! n n n Visit www. fistulafirst. org website for resources & tools Utilize FFBI tools and tools that are available through Da. Vita Recognize issues and address them early Empower your staff by delegating roles Share successes and approach vascular access as one community Call your Network for help 42

Da. Vita Vascular Access Tracking Tools n n Patient Report Facility Report Catheter Tracking tool Vascular Access Event Log 43

Ongoing Issues n n n No surgeons in the area Patients with no medical insurance No access placed prior to starting dialysis (CKD) or long-term dialysis patients Language barriers Patient’s noncompliance These are some issues we may not be able to solve alone but we can try and find ways together to solve them or at least work around them. If you find successful ways to deal with some of these issues…. PLEASE SHARE THEM WITH EVERYONE! 44

Action Plan n n n Use the FFBI Payer Packet to communicate with your insurance carries about the benefits of having an AVF placed for ESRD patients. (If all your facilities have the same insurance companies, all facilities communicate this concern and urgency. ) Find ways to engage your surgeons (i. e. Share your facility specific data that you receive from the Network, inform them about the vascular access clubs, etc. ). If your facilities all use the same surgeon(s), all facilities should communicate the same message/urgency regarding AVF placement. Share the Cannulation DVD with the surgeons so that they understand the logistics of cannulation and can position the veins suitably and safely for cannulation. Educate both the patient and the FAMILY about vascular access – specifically AVFs. Share best practices with everyone! 45

Conclusion: • We are all partners • We are on the right track • Utilize available recourses and steal shamelessly (Best practices) • Visit the FFBI website for more resources • Call your Network for help • Share successes • It CAN be done! 46

Lisle Mukai, RN, Quality Improvement Coordinator ESRD Network 18 Phone: 323 -962 -2020 Fax: 323 -962 -2891 lmukai@nw 18. esrd. net 47