Fistula First A Seminar for The Nephrology

Community Corpus Christi, Texas

July 31, 2004

Alamo City & Heart of Texas Chapters of The American

NephrologyNurses Association

Co Provided By:

Agenda

Noon Welcome & Introductions: Alan Saltarelli , RN, ANNA Alamo City Chapter -PresidentBalbi Godwin, RN, ANNA Heart of Texas Chapter -President

12:15 Fistula First Overview: Alex Rosenblum, RN, CNN

12:45 Vascular Access Surgery 101: Pho DO, MD {Supported with a unrestricted educational grant from Bard }

1:30 Interventional Techniques 101: Anwar Gerges, MD {Supported with a unrestricted educational grant from Cordis }

2:15 Break/Exhibits

2:45 The ABCs of AV Fistulas: Janet Holland, RN, CNN

4:00 Nurse to Nurse: Moderators-Janet Holland, Alex Rosenblum &Bobbie Knotek

A special opportunity to listen, learn and ask questions of nurses from facilities who have met the

Fistula First Goals of attaining 40% + AVF rates at their dialysis facility.

4:45 Adjourn

Goals of Today’s Conference

•Expand awareness of the Centers for

Medicare & Medicaid Services sponsored Fistula

First Quality Improvement Initiative.

•Review advanced surgical/endovascular techniques for placement and/or rescue of the AVF.

• Share practice experiences that appear to positively impact of AVF placement and patency rates.

• Empower participants to have confidence that they can & do play an active role in meeting project goals.

Reminder: Fistula First Resources in the Back of the Room

What are the ESRD

Networks?

•18 regional agencies under contract with the Centers for Medicare & Medicaid Services

•Developed in 1978 to assess/improve quality of care for ESRD patients

Who does the ESRD

Network of Texas serve?

• Quality Improvement

• Information Management

• Consumer Services

26,397 patients (2/2004)

24,254 In-Center HD patients

84 Home HD patients

2,055 PD patients

~ 7,000 Transplant patients

Nephrologists Robert Hootkins, MD, Chair

Jim Cotton, MDStuart Goldstein, MD

Denise Hart, MDDonald Molony, MD

Fernando Raudales, MDMouin Seikaly, MDRuben Velez, MD

Patients

Cynthia Hays

Transplant SurgeonsIngemar Davidson, MDCharles Van Buren, MD

Executive Committee

Richard Gibney, MD, Chair

Dionicio Alvarez, MD

John Bell, MD

Pat Dubose, RN

Amy Hackney, MBA

Robert Hootkins, MD

Melvin Laski, MD

Marlon Levy, MD

Susan Raulie, RN

NursesMolly Itty, RN, CNN

Jeanne Nishioka, RN, CNN

DietitiansAlice Chan, RD, LDEileen Mauk, PhD

Social WorkersMary Beth Callahan, LMSW

Linda Schacht, LMSW

Medical Review Board

End Stage Renal Disease Network of Texas Committees

Project Surgical/Interventional Radiology Advisory Committee

Gerald Beathard, MD

Mary Brandt, MD

Ronald Blumoff, MD

Ingemar Davidson, MD

Hector Diaz-Luna, MD

Greg Jaffers, MD

Edward Gomez, MD

Cary Munschauer

George Nassar, MD

Greg Pearl, MD

Eric Peden, MD

Wade Rosenberg, MD

Stephen Settle, MD

Michael Silva, MD

Alan Lumsden, MD, Chair

• Fewer infectious complications: AVFs: 4.4 - 12 x less infection rates than AVGs

• Fewer interventional procedures to keep patency: AVFs: 2.4 - 7.1 x less salvage procedures than AVGs

• Better 1 year primary patency in incident HD patients: 68% for AVFs & 49% for AVGs

Allon and Robbin. Kidney Int. 62:1109-1124, 2002.Nassar and Ayus . Kidney Int. 60:1-13, 2001.Pisoni RL, et al. Kidney Int. 61:305-316, 2002.

Why is CMS Focusing on Hemodialysis Vascular Access?

Quality of Care/Public Health Concerns:

Why is CMS Focusing on Hemodialysis Vascular Access?

• Cost Containment:

• Estimated costs for VA related complications = $1-2 billion (~8k per patient) 200-250K procedures per year

• 20% of hospitalizations related to VA dysfunction

• ESRD = ~0.5% of Medicare population & 5% of budget

• Doubling of dialysis population by 2010 (50k in Texas)

VA Practice variations:

•AVF variation between states, Networks and countries (80% AVF in Europe/Asia)

Message for the Surgeon - By a Surgeon Why only AV Fistulas?Why only AV Fistulas?

• You should do this because:• Patients with AVFs live

longer• Patients with AVFs have 8x

fewer access complications

• You will like:• High patient and

nephrologist satisfaction• Simple, safe outpatient

procedures

Avoid or markedly decrease hospital admissions and emergency operations for infection, bleeding, steal syndrome, and thrombosis.

William Jennings, MD, Tulsa Vascular Access Surgeon

What Do We Know About Hemodialysis Vascular Access

Utilization in the US?

Percent of Prevalent Patientswith AV Fistula As of Feb 2004

52.4

43 42.8 42.138.9 37.3 37.1 36.3 36 34.5 33.6 33.1 31.8 31.4 30.7 30 29.4 28 26.7

0

10

20

30

40

50

60

16 15 1 2 18 3 17 10 7 US 4 12 6 9 5 11 8 13 14

Network

% o

f Pat

ient

s

CMS FF Dashboard

What Do We Know About Hemodialysis Vascular Access

Utilization in the World?

Top 10 City AVF Prevalent RatesAs of April 2004

New York 44%

Los Angeles 41%

Chicago NR

Houston 25.7%

Philadelphia 28.5%

Phoenix 37.5%

San Diego 39.1%

San Antonio 22.1%

Dallas 36.9%

Detroit 18%

Data Source: Network #14 Data base collected informally from regional ESRD Networks

AVF Utilization Among Prevalent HD Patients By Country As of Sept. 2003

9186 84

79 78

7168

60 5854

30

0

10

20

30

40

50

60

70

80

90

100

JPN IT GE SP FR ANZ UK BE SW CA U.S.

Country

% o

f Pat

ient

s

AVF Utilization Among Incident HD Patients By Country As of Sept. 2003

79

49 49

1916

0

10

20

30

40

50

60

70

80

90

JPN EUR ANZ CA U.S.

Country

% o

f Pat

ient

s

What Do We Know About Hemodialysis

Vascular Access Utilization in Texas?

28.6

35.5

49.4

41

20.2

27

0

10

20

30

40

50

60

70

80

90

100

% P

ati

ents

Fistula Graft Catheter

December 2002 December 2002 December 2003

May 2004 U.S. 2004

Vascular Access Utilization

Texas Prevalence Trends: December 2000-May 2004

Percent Fistula Utilization By County as of March 2004

Tarrant34.1%

(32.7%)

Dallas37.6%

(38.0%)

Jefferson13.3%

(13.0%)

Harris24.7%

(25.2%)

Galveston32.6%

(30.9%)Fort Bend30.2%

(27.8%)

El Paso37.5%

(39.9%)

Lubbock26.6%

(15.4%)

McLennon21.0%

(21.4%)

Bell39.6%

(41.0%)

Liberty23.0%

(22.2%)

Brazoria25.7%

(22.8%)

Nueces22.1%

(22.9%)

Cameron36.3%

(31.4%)

Hidalgo19.3%

(20.6%)

Webb20.1%

(19.1%)

Bexar22.1%

(17.4%)

Travis27.0%

(28.0%)Hays27.9%

(23.8%)

10-19% 20-29%30-39%40-49%

Fistula Utilization

Counties with 2 or less facilities censored

Smith10.7%

(13.5%)

( ) = November 2003 AVF rates

McAllenMissionSan AntonioTemple

Weslaco10.7

El Paso

Dallas

Fort Worth 884

1444194

100427.1

225 40.9

37130.3

37.5

36.918.5

23.8407

Edinburg

BrownsvilleCorpus Christi

323

City # Patients % Fistulas City

182 21.8

Amarillo 14.8

798 38213.6

43.1Arlington 301 204Huntsville

# Patients % Fistulas311

25.742.3

19.6

202

Longview

44.8

HarlingenHouston 3518

207 28.32297 21.2

227189 46.6 283 13.3Garland

Tyler

27.0

586

Laredo

Lubbock

AustinBeaumont

Abilene

20.1

26.6317

35.3217

Percent Fistula Utilization By City as of March 2004

Cities with less than 80 patients excluded

Facility # Patients % AVFs Facility # Patients % AVFsDAVITA - DENISON 83 69.9 AUDI MURPHY VAMC HOSPITAL 31 45.2GAMBRO - BRYAN/COLLEGE STATION 143 67.8 TEXAS CITY DIALYSIS 38 44.7TDC MONTFORD MEDICAL UNIT PRISON 29 58.6 THE DIALYSIS COTTAGE 18 44.4GAMBRO - BRENHAM 43 58.1 DAVITA - CENTRAL CITY DIALYSIS 90 44.4RCG - IRVING DIALYSIS 105 57.6 GAMBRO - OAKCLIFF 188 44.1TARRANT DIALYSIS - ARLINGTON 72 54.2 RCG - BROWNSVILLE 93 44.1RCG - HARLINGEN 46 52.2 NORTH TEXAS DIALYSIS SERVICES 14 42.9SCOTT & WHITE - TEMPLE 188 52.1 SCOTT & WHITE - KILLEEN DIALYSIS 70 42.9RCG - EL PASO EAST 102 51.0 DAVITA MONCRIEF DIALYSIS 61 42.6SCOTT & WHITE - ROUND ROCK 55 50.9 DAVITA - PEARLAND DIALYSIS 40 42.5LEWISVILLE DIALYSIS CLINIC 107 50.5 FMC - CORSICANA 59 42.4FMC - SWISS AVENUE 153 50.3 FMC - RICHARDSON 114 42.1DAVITA - ELMBROOK KIDNEY CENTER 94 50.0 UNIVERSITY DIALYSIS - WEST 110 41.8DAVITA - MESA VISTA DIALYSIS 96 50.0 FMC - COLLIN COUNTY 139 41.7FMC - INGRAM 12 50.0 CHRISTUS CHILDRENS KIDNEY CENTER 12 41.7TDC HUNTSVILLE MEDICAL UNIT PRISON 145 49.0 SOUTH ARLINGTON DIALYSIS 149 41.6DAVITA - LOMA VISTA DIALYSIS 198 48.0 AMERITECH KIDNEY CENTER - HEB 92 41.3GAMBRO - DALLAS EAST 86 47.7 FMC - TERRELL 61 41.0GAMBRO - UT SOUTHWESTERN 179 47.5 TARRANT DIALYSIS - GRAND PRAIRIE 61 41.0FMC - GRAPEVINE 19 47.4 SHANNON DIALYSIS SERVICES 22 40.9HARLINGEN DIALYSIS 127 47.2 FMC - CLEBURNE 59 40.7FMC - DALLAS EAST 32 46.9 GRAND PRAIRIE DIALYSIS CENTER 32 40.6FMC - TOWN GATE 189 46.6 DENTON DIALYSIS 85 40.0RCG EL PASO KIDNEY CENTER - WEST 65 46.2 DAVITA - HEB DIALYSIS CENTER 65 40.0FMC - ENNIS 44 45.5 FMC - WAXAHACHIE 70 40.0

Texas Facilities with 40% or More Prevalent AV Fistulas N = 50 Facilities* as of March 2004

Note: *Facilities w ith a prevalent AVF rate of 40% or higher for tw o consecutive months

The Network MRB has identified facilities with an AVF rate in this range as having an improvement opportunity!

The MRB has identified facilities with 40% AVF rate for 2 + months as "Benchmark"

74

# of Facilities

314 100.0

Page 2

> 40 47315All Texas Facilities

17.199.8

14.930-39

5450 15.9 16.5

77 23.537.6

24.438.1

5.111/03 3/04

20-29 120

3/0421

% of Facility Patients

Facility Variation In the % of Prevalent Patients with AVF% of Facilities

11/0316 6.7<10

10-1911852

5.6

8.4

5.1

8.9

0

2

4

6

8

10

Per

cen

t o

f P

reva

len

t P

atie

nts

TX November 2003 TX March 2004

Suggested Strategies to Increase AVF Rates

FistulaFistula First Change Concepts First Change Concepts

1.1. Routine CQI review of Routine CQI review of vascular accessvascular access

2.2. Early referral to Early referral to nephrologistnephrologist

3.3. Early referral to surgeon Early referral to surgeon for “AVF only”for “AVF only”

4.4. Surgeon selectionSurgeon selection

5.5. Full range of appropriate Full range of appropriate surgical approachessurgical approaches

6.6. Secondary AVFs in AVG Secondary AVFs in AVG patientspatients

7.7. AVF placement in catheter AVF placement in catheter patientspatients

8.8. Cannulation trainingCannulation training

9.9. Monitoring and surveillanceMonitoring and surveillance

10.10. Continuing education: staff Continuing education: staff and patientand patient

11.11. Outcomes feedbackOutcomes feedback

Please refer to handouts

P r o v e n S t r a t e g i e s T o I n c r e a s e F i s t u l a R a t e s

F a c i l i t y S e l f - A s s e s s m e n t

D o e s Y o u r F a c i l i t y . . .

S c o r e

H a v e a n a s s i g n e d s t a f f m e m b e r r e s p o n s i b l e f o r m o n i t o r i n g f a c i l i t y v a s c u l a r a c c e s s ( V A ) o u t c o m e s ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , e v a l u a t e a l l n o n - A V F a c c e s s e s a s p a r t o f t h e C Q I p r o c e s s ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , d e v e l o p a n d d o c u m e n t A V F p l a n s f o r a l l p o t e n t i a l l y e l i g i b l e p a t i e n t s ?

T r e n d v a s c u l a r p l a c e m e n t b y s u r g e o n m o n t h l y i n Q A ?

E v a l u a t e t h e s t a t u s o f p e r m a n e n t v a s c u l a r a c c e s s p l a c e m e n t p l a n s w i t h i n t h e f i r s t t h r e e t r e a t m e n t s f o r n e w p a t i e n t s a d m i t t e d w i t h a “ c a t h e t e r o n l y ” a n d d o c u m e n t f i n d i n g s ?

I n c o l l a b o r a t i o n w i t h y o u r p h y s i c i a n , r o u t i n e l y e v a l u a t e a l l A V G s ( p r i o r t o c l o t t i n g e p i s o d e s ) f o r p o s s i b l e s e c o n d a r y A V F c o n v e r s i o n a n d d o c u m e n t f i n d i n g s ?

R e f e r t o s u r g e o n s t h a t a r e s u p p o r t i v e a n d s k i l l e d i n p l a c i n g s e c o n d a r y A V F s ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , r e f e r p a t i e n t s f o r v e s s e l m a p p i n g ( i f n o t a l r e a d y p e r f o r m e d ) t o a s s i s t s u r g e o n w i t h a c c e s s t y p e p l a c e m e n t e v a l u a t i o n ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , s e l e c t s u r g e o n s b a s e d o n w i l l i n g n e s s , s k i l l a n d o u t c o m e s w i t h A V F ’ s ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , i n d i c a t e i n w r i t i n g o n a l l v a s c u l a r a c c e s s s u r g i c a l r e f e r r a l s t h a t t h e p r e f e r r e d p e r m a n e n t a c c e s s t y p e i s a n “ A V F O n l y ” ?

P r o v i d e w r i t t e n v a s c u l a r a c c e s s h i s t o r y i n f o r m a t i o n t o s u r g e o n s / r a d i o l o g i s t s w h e n p a t i e n t s a r e r e f e r r e d f o r e v a l u a t i o n ?

D i s c u s s s p e c i f i c c r i t e r i a w i t h i n t e r v e n t i o n a l r a d i o l o g i s t s / i n t e r v e n t i o n a l n e p h r o l o g i s t s a n d s u r g e o n s f o r d e t e r m i n i n g a l l o w a b l e d e g r e e o f i n t e r v e n t i o n b e f o r e a n e w a c c e s s s h o u l d b e c o n s i d e r e d ?

R e q u e s t w r i t t e n p o s t - s u r g i c a l i n f o r m a t i o n f r o m s u r g e o n / r a d i o l o g i s t – t y p e / r e s u l t s o f V A i n t e r v e n t i o n s , a d e s c r i p t i o n / d r a w i n g o f a c c e s s l o c a t i o n , d i r e c t i o n o f b l o o d f l o w & c a r e i n s t r u c t i o n s ?

R e f e r t o s u r g e o n s w h o a r e w i l l i n g t o r e c e i v e a n d t r a c k d a t a o n t h e i r v a s c u l a r a c c e s s r a t e s a n d o u t c o m e s ?

I n c o l l a b o r a t i o n w i t h p h y s i c i a n , r e f e r a l l A V F s w i t h “ f a i l u r e t o m a t u r e ” a t 4 w e e k s p o s t - o p t o a s u r g e o n o r r a d i o l o g i s t ?

R o u t i n e l y m o n i t o r A V F a n d A V G f l o w r a t e s / p r e s s u r e s f o r s t e n o s i s u s i n g K / D O Q I r e c o m m e n d e d p r o c e d u r e s ?

H a v e a v a s c u l a r a c c e s s m a n a g e m e n t p l a n f o r e a c h p a t i e n t t h a t f a c i l i t a t e s t i m e l y r e f e r r a l f o r c o m p l i c a t i o n s ?

P r o v i d e r o u t i n e i n - s e r v i c e s f o r s t a f f o n A V F c a n n u l a t i o n t e c h n i q u e s ?

R e q u i r e t h a t p e r s o n n e l u s e s p e c i f i c p r o t o c o l s d u r i n g i n i t i a l t r e a t m e n t s f o r p a t i e n t s w h o h a v e a n e w A V F ? ( e . g . n e e d l e s i z e , B F R , t o u r n i q u e t u s e ) ?

A s s i g n t h e m o s t s k i l l e d s t a f f t o p a t i e n t s w h o h a v e a n e w A V F ?

O f f e r t h e o p t i o n o f s e l f - c a n n u l a t i o n t o p a t i e n t s w i l l i n g t o p u r s u e t h i s o p t i o n ?

H a v e a p r o c e d u r e f o r t r e a t i n g V A i n f i l t r a t i o n s t h a t i n c l u d e s w r i t t e n p a t i e n t i n s t r u c t i o n s ?

U s e t h i s s e l f - a s s e s s m e n t g u i d e t o r a t e y o u r f a c i l i t y ’ s u s e o f s t r a t e g i e s d e s i g n e d t o i n c r e a s e f i s t u l a r a t e s R e a d t h e s t a t e m e n t s b e l o w & a s s i g n t h e s c o r e t h a t b e s t m a t c h e s y o u r f a c i l i t y ’ s c u r r e n t s i t u a t i o n

1 = N o t u n d e r c o n s i d e r a t i o n 3 = I n s t a r t - u p p r o c e s s 5 = W o r k i n g w e l l 2 = U n d e r c o n s i d e r a t i o n ; n o t s t a r t e d 4 = W o r k i n g , a t l e a s t i n p a r t

Welcome to the ESRD Network of Texas Inc. (#14) Website.

Mission: Support quality dialysis and kidney transplant healthcare through patient services, education, quality improvement and data exchange.

www.esrdnetwork.org

The ESRD Network of Texas Web Site

ESRD Network Web Resources •Fistula First Video and CEU form

•Hemodialysis Access Referral Form To Surgery/Radiology

• Procedure Report Form From Radiology/Surgeon to Dialysis Clinic

• Recommended AVF Cannulation Recommended Protocol

• Use of Clamps on AVFs Recommended Protocol

• Secondary AVF Procedures “Sleeves Up Recommended Protocol”

• Local Medical Review Policy Related to Vascular Access

• List of Facilities with 40% AVF Rate and Associated Surgeon or Surgical Group

• Physical Examination of the AVF Article

What We Have Learned From the Project So Far!

•Without a Medical Director/Nephrologist taking an active role in improving vascular access process, the facility will struggle and patients may receive sub par care.

•You must have access to one or more surgeons with the experience, willingness & tenacity to place AVFs in appropriate patients.

• Pre-surgery blood vessel mapping greatly improves the chances of successful AVF placements.

• Early referral of patients for mapping and surgery improve AVF placement opportunities.

•Comprehensive cannulation training is a necessity

• Delegating a staff member to be responsible for monitoring access rates and planned procedures is very helpful.

• Educate and motivate patients and their families that AVFs may help keep them out of the hospital or worse

• Very complicated project!

What We Have Learned From the Project So Far!

“We have just begun to fight”Planned initiatives formally begun in March/April 2004

Distribution of Resources

Distribution of Facility Specific Charts

Distribution of Surgeon Specific Charts

Surgeon Conferences

Nurse Conferences

Next Steps!Continued

Nurse Educational Conferences/Awareness Campaign

Distributing charts and statewide report highlighting benchmark facilities, county rates & facility distribution.

Highlighting names of surgeons associated with “Benchmark” facilities

Distributing resource updates and reminders of availability

Seeking opportunities to assist/support/encourage use of Change Package strategies.

Next Steps!•New

Seek input from EC, MRB, Committees

Market information on Revised Mapping Policy

Focus on largest cities (Houston, San Antonio)

Initiate “collaboratives” with LDOs to mentor laggard facilities

Nephrologist seminar in Houston

Partnering/educating hospitals to review policy