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

Catheter Wipeout Initiative: Updates

Lisle Mukai, QI CoordinatorAugust 2008

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DaVita 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 DaVita tracking tools and implement Fistula First Change Concepts to attain their goal.

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Project GoalTo reduce the total catheter rate by 20% in

each of the intervention facilities over an 8 month period (May – December 2008).

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.

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Facility-Specific Goals for Team Sue:

Facility

% Total Cath Baseline -

April 2008

10% Reduction in Total Catheter

Rate

20% Reduction in Total Cathter

RateLake Elsinore 22.0% 19.8% 17.6%Corona 34.9% 31.4% 28.0%Hemet 26.7% 24.0% 21.4%Valley View 25.9% 23.3% 20.7%Riverside 30.5% 27.5% 24.4%Temecula 26.7% 24.0% 21.4%Diamond Valley 29.5% 26.6% 23.6%Murrieta 23.9% 21.5% 19.1%Norco 38.5% 34.7% 30.8%Magnolia West 32.4% 29.7% 25.9%Yucaipa 17.4% 15.7% 13.9%

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Facility

% Total Cath

Baseline - April 2008

10% Reduction in Total

Catheter Rate


RateMountain Vista 33.8% 30.4% 27.0%HI- Desert 24.6% 22.1% 19.7%Banning 21.7% 18.9% 17.4%Victor Valley 26.5% 23.9% 21.2%Palm Springs 13.7% 36.1% 11.0%Citrus Valley 29.9% 26.9% 23.9%

Facility-Specific Goals for Team Franco:

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Facility-Specific Goals for Team Rosemarie:

Facility

% Total Cath

Baseline - April 2008


Rate


RateMontclair 28.9% 26.0% 22.4%Ontrario 42.9% 38.6% 34.3%Pomona 30.5% 27.5% 24.4%Chino 21.8% 19.6% 17.4%Upland Dialysis 20.7% 18.6% 16.6%Fontana 23.5% 21.2% 18.8%

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

Total Catheter Rate - Team Sue

0%

10%

20%

30%

40%

50%

052895 052661 052620 052807 052532 052735 052768 052730 552571 552553 552578

Facility

Per

cent

Cat

hete

rs U

sed

Jan 2008 Feb 2008 Mar 2008

Apr 2008 - Baseline May 2008 June 2008

July 2008 10% Reduction from Apr 20% Reduction from Apr

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Total Catheter Rate - Team Franco

0%

10%

20%

30%

40%

052743 052776 552520 052561 052541 552541

Facility

Perc

ent C

athe

ters

Use

d

Jan 2008 Feb 2008 Mar 2008 Apr 2008 - Baseline May 2008

June 2008 July 2008 10% Reduction from Apr 20% Reduction from Apr


Banning Dialysis (#552520) has consistently maintained a 10% reduction within the 3 months.

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Total Catheter Rate - Team Rosemarie

0%

10%

20%

30%

40%

50%

052804 552548 052591 052739 052552 052682

Facility

Perc

ent C

athete

rs U

sed

Jan 2008 Feb 2008 Mar 2008 Apr 2008 - Baseline May 2008June 2008 July 2008 10% Reduction from Apr 20% Reduction from Apr


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Team Goals:

% Total Cath Baseline -

April 2008


Rate20% Reduction in Total Catheter Rate

Team Franco 25.7% 23.1% 20.6%Team Rosemarie 27.7% 24.9% 22.2%

Team Sue 28.4% 25.6% 22.7%

Group Total: 27.6% 25.0% 22.2%

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DaVita Catheter Wipeout Initiative: Total Catheter Rates (SIMS data)

28.427.725.7

28.829.4

24.8

29.326.9

24.4

0

5

10

15

20

25

30

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Team Franco Team Rosemarie Team Sue

Perce

ntag

e of C

athete

rs Apr-08

May-08

Jun-08

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DaVita Catheter Wipeout Initiative: Group Vascular Access Trends (SIMS data)

22.3

27.6

49.7

22

28

50

22.4

27.5

50.1

0

10

20

30

40

50

60

AVF Total Catheter AVG

Perce

ntag

e of A

VF Apr-08

May-08

Jun-08

Basel

ine

Basel

ine

Basel

ine

CMS AVF Goal: 66%Network 18 AVF Goal: 55.1%

CMS/Network 18 Catheter Goal: < 10%

CMS/Network 18 AVG Goal: < 24%

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Change Concept # 5: Full Range of Appropriate Surgical

Approaches to AVF Evaluation & Placement

Fistula First Website: 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)

Commonly Used Permanent Vascular Access Codes (CPT codes)

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Change Concept # 5: Full Range of Appropriate Surgical Approaches to

AVF Evaluation & Placement (continued)

Make sure surgeons understand the logistics of cannulation so that they position the veins suitably and safely for cannulation “Cannulation of the Arteriovenous Fistula

(AVF)” DVD – Each facility should have received one DVD from your corporate office.

Encourage acute nursing staff to become more assertive in asking the Nephrologist to order vein mapping before discharging the patients from the hospital.

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Dialysis Access Clubs 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.

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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 interest that will engage all surgeons.

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Change Concept #7: AVF Placement in Patients with Catheters Where

Indicated 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.

Per Dr. Nguyen: “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."

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Indicated (Continued) “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.

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Indicated (Continued) FFBI Payer Packets have been posted to

the Fistula First websitehttp://www.fistulafirst.org/pdfs/

FF_Intro_for_Payers.pdf

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: Introductory Letter for Payers Pay for Performance Summary Recommendations Fistula First Priority Recommendations PowerPoint slides

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Indicated (Continued)

Introductory Letter for Payers

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.

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Pay for Performance – Summary Recommendations

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.

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FFBI Priority Recommendations

Recommendations by FFBI for developing and implementing an incentive program for practitioners.

References to specific Change Concept elements.

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Slides

The PowerPoint slides illustrates costs for care: Medicare costs per person per year Per person per year access costs by type of access Hospitalization admissions for vascular access

complications per patient year Risk for infection comparison between catheters

and AV fistulas Variation on costs for inpatient hospital services per

Medicare enrollee Performance on Medicare Quality Indicators

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Reducing Catheter Rate Strategies:

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)

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Proactive strategies to reduce catheter rate:

Surgical evaluation (& placement) of permanent access during initial hospitalization

Vessel mapping/optimal vessel selection to increase successful (usable) AVFs & Reduce non-maturing (FTM) AVFs (post-op exam @ 4 wks)

Monitoring & timely intervention for late failure/ aggressive salvage

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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

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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

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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

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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

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AVF Dysfunction/Failure to Mature (FTM)

> 30% of new AVFs fail to mature (FTM) and may need some type of intervention before it can be used

You can markedly reduce early failure rate and interventions in AVFs by: Early referral & CKD program Improved patient & vessel

selection/standardized vessel mapping protocol Early recognition of FTM AVF by evaluation

(Monitoring & Surveillance) at 4 wks & timely intervention = high salvage rate

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All patients should be taught how to:

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 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

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Success Stories 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.

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Fistula First AVF Goals

CMS Goal – 66% by June 30, 2009

Yearly Network 18 Goal – 55.1% by March 31, 2009

Yearly Network Stretch Goal – 56% by March 31, 2009

June 2008 AVF rates: NW 18 – 53.4 % US – 50.3%

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Network 18 AVF Trend

49.7 49.7 50.1 49.9 50.6 50.6 51.1 51.3 51.6 51.6 52.1 52 52.1 52.4 52.4 52.9 53 53.4

30

35

40

45

50

55

60

65

70

Jan-07 Feb-07 Mar-07

Apr-07

May-07

Jun-07 Jul-07 Aug-07

Sept-07

Oct-07 Nov-07

Dec-07

Jan-08 Feb-08 Mar-08

Apr-08

May-08

Jun-08

Perc

entag

e of A

VFs

Minimum CMS Goal: 66%

Minimum Network 18 Goal: 55.1%

Minimum Facility Goal: 50%

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Fistula 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 Selection5. Full range of

appropriate surgical approaches

6. Secondary AVFs in AVG patients

7. AVF evaluation/placement in catheter pts where indicated

8. Cannulation training9. Monitoring and

maintenance10. Continuing Education11. Outcomes feedback

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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. 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.

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Change Concept #6: Secondary AVF Placement in Patients with AV Grafts

(Continued)

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.

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Sleeves Up Exam

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Timing of AVG conversion to a secondary AVF

1st AVG failure triggers evaluation for conversion to a secondary AVF A plan of care should be developed in

anticipation of AVG failure

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.

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FFBI Strategies to increase Secondary AV Fistulae:

Re-evaluation of all patients for AVF K/DOQI guideline 29: Every patient

should be evaluated for a secondary fistula after each episode of graft failure

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

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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

System Roadblocks Identified by Facilities

Afraid of needles Comfortable with

catheter Exhausted sites Language

barriers Forgetting follow-

ups and missing appointments

Lack of education

Patient Roadblocks Identified by Facilities:

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)

More Roadblocks:

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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!

Visit www.fistulafirst.org website for resources & tools

Utilize FFBI tools and tools that are available through DaVita

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

Possible Solutions:

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DaVita Vascular Access Tracking Tools

Patient Report Facility Report Catheter Tracking tool Vascular Access Event Log

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Ongoing Issues 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!

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Action Plan 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!

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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!

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Lisle Mukai, RN,

Quality Improvement Coordinator

ESRD Network 18

Phone: 323-962-2020

Fax: 323-962-2891

[email protected]

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

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