Fistula First: AV Fistula Fistula First: AV Fistula Maturation ProjectMaturation Project

Svetlana (Lana) Kacherova, QI DirectorLisle Mukai, QI CoordinatorESRD Network 18July 22, 2009

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““Fistula First” GOALFistula 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!

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Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)

CMS goal – 66% by June 30, 2009 Yearly Network 18 goal – 57.8 % by

June 30, 2010 Yearly Network Stretch Goal – 58.0%

by June 30, 2010 May 2009 AVF rates: NW 18 – 56.3% US – 52.6%

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Inclusion Criteria for Participating Inclusion Criteria for Participating FacilitiesFacilities

AVF rate < 50% (April 08 SIMS data)Highest percentage and number of AV

Fistulas placed but not used (source: SIMS vascular access monthly reports)

Patients census > 50 patientsAdministrative support: All intervention

facilities have a stable leadership

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ExclusionExclusion Criteria CriteriaPatient census < 50 patientsFacilities already included in another

QIWP project with the Network

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AVF Maturation Project:AVF Maturation Project:Network Role:Network Role:

Project Leader Supplied the templates for RCA & PDSASupplied toolkits to facilities & evaluate their

usefulnessProvided monthly feedback (Vascular Access SIMS

reports)Collected bi-monthly scans to obtain facility-

specific dataFacility site visits for strugglersChased facilities for data & documentation Assisted participants to meet QAPI /PDSA

requirements6

Facilities Roles and Facilities Roles and Responsibilities:Responsibilities:

Returned agreement letter (signed by MD)Reviewed toolkit and identified tool(s) to

utilize in your facilityFollowed the project timelines and

completing all steps of the QAPI process (RCA, PDSA, etc)

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Project TimelinesProject TimelinesOct. 2008 – Environmental scan and

WebExNov. 208 – RCA and PDSA (steps 1-3)Dec. 2008 – 1st follow-upJan-Feb. 2009 – 2nd follow- upMarch-Apr. 2009 – 3rd follow up May 2009 – final follow-up June 2009 – Project summary and closure

Project SummaryProject Summary

Ensuring that Fistulas MatureEnsuring that Fistulas MatureThe key is early recognition of non-maturing AVFs.

1. Physically assess the access each treatment (Look, Listen, Feel).

2. Send patient for 4 week follow-up evaluation of the access

3. Necessary intervention for non-maturing AVFs

4. Track all new AVFs and their development

Strategies Implemented by FacilitiesStrategies Implemented by FacilitiesCreate Vascular Access Team

(Interdisciplinary)Designate Vascular Access Manager/

CoordinatorEducate staff and patients about what to

look for and expect during AVF maturation process (physical assessment and vascular access care)

Refer to surgeon or Vascular Access Center for vein mapping

Schedule surgical appointment and 4 week follow-up

Obtain results of evaluation findings from the surgeon and maintain a copy in the patients charts as well as discuss during QAPI meetings

Track all newly placed AVFs and discuss/review during QAPI meetings

Physical exam (Look, Listen, & Feel) of AVFs every treatment by staff

Schedule follow-up evaluation for AVFs @ 4 weeks post placement of AVF

Track success rates from each vascular access surgeon – refer to surgeons with best results

Conduct stenosis monitoring & surveillance (See KDOQI Guidelines for appropriate surveillance methods.)

Create check-off list for each patient noting the steps of the plan

Monthly report of all new AVFs being cannulated – review during QAPI meetings

Utilize corporate vascular access tools (resources and tools)

Educate patients regarding catheters and fistulas (pros/cons)

Have MDs talk to patients about their vascular access and care for their access.

Involve SW for insurance issues

Next StepsNext StepsHave a process in place to ensure

maturation of newly placed AVFsLearn strategies from other facilities to

implement at your facility if appropriateEducate patients and their families, staff

and nephrologists about the maturation process and vascular access care

Refer to the Fistula First website for resources

Next Steps (Continued)Next Steps (Continued)

Together we can make a difference and find possible solutions for issues we can impact

Thank you for all your continuous efforts in improving vascular access care given to our

ESRD population.

Svetlana (Lana) Kacherova, QI Directorskacherova@nw18.esrd.net

Lisle Mukai, QI Coordinatorlmukai@nw18.esrd.net

6255 Sunset Boulevard Suite 2211 Los Angeles CA 90028(323) 962-2020 (323) 962-2891/Fax

www.esrdnetwork18.org