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Fistula First: AV Fistula Maturation Project. Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 July 22, 2009. “Fistula First” GOAL. Goal is to maximize autogenous AVF construction & success rate…..

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Fistula First: AV Fistula Maturation Project

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Fistula first av fistula maturation project l.jpg

Fistula First: AV Fistula Maturation Project

Svetlana (Lana) Kacherova, QI Director

Lisle Mukai, QI Coordinator

ESRD Network 18

July 22, 2009


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“Fistula 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)

  • 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 Facilities

  • 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 patients

  • Administrative support: All intervention facilities have a stable leadership


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Exclusion Criteria

  • Patient census < 50 patients

  • Facilities already included in another QIWP project with the Network


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AVF Maturation Project:Network Role:

  • Project Leader

  • Supplied the templates for RCA & PDSA

  • Supplied toolkits to facilities & evaluate their usefulness

  • Provided monthly feedback (Vascular Access SIMS reports)

  • Collected bi-monthly scans to obtain facility-specific data

  • Facility site visits for strugglers

  • Chased facilities for data & documentation 

  • Assisted participants to meet QAPI /PDSA requirements


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Facilities Roles and Responsibilities:

  • Returned agreement letter (signed by MD)

  • Reviewed toolkit and identified tool(s) to utilize in your facility

  • Followed the project timelines and completing all steps of the QAPI process (RCA, PDSA, etc)


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Project Timelines

  • Oct. 2008 – Environmental scan and WebEx

  • Nov. 208 – RCA and PDSA (steps 1-3)

  • Dec. 2008 – 1st follow-up

  • Jan-Feb. 2009 – 2nd follow- up

  • March-Apr. 2009 – 3rd follow up

  • May 2009 – final follow-up

  • June 2009 – Project summary and closure


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Project Summary


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Ensuring that Fistulas Mature

The key is early recognition of non-maturing

AVFs.

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

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

  • Necessary intervention for non-maturing AVFs

  • Track all new AVFs and their development


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Strategies Implemented by Facilities

  • Create Vascular Access Team (Interdisciplinary)

  • Designate Vascular Access Manager/ Coordinator

  • Educate 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


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  • 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


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  • 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


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  • 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


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Next Steps

  • Have a process in place to ensure maturation of newly placed AVFs

  • Learn strategies from other facilities to implement at your facility if appropriate

  • Educate patients and their families, staff and nephrologists about the maturation process and vascular access care

  • Refer to the Fistula First website for resources


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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.


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Svetlana (Lana) Kacherova, QI Director

[email protected]

Lisle Mukai, QI Coordinator

[email protected]

6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028

(323) 962-2020  (323) 962-2891/Fax  www.esrdnetwork18.org


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