PRESENTATION on BEST PRACTICES for VASCULAR ACCESS

<strong>PRESENTATION</strong> on BEST PRACTICESforVASCULAR ACCESSThe presentation will start at 10:00 amRoll call will not be takenYour participation will be verified by a post survey atthe end of the presentationAll lines MUST be muted throughout the presentation(*6) MutesAt the end of the presentation Questions will betaken, at that time all lines MUST be un-muted(*6) Un-Mutes1

SPREADING PRACTICESINNETWORK6By: Cyndy McCallus RN, BSNNetwork 6 Quality Improvement Nurse SpecialistOctober, 20122

VASCULAR ACCESS BEST PRACTICESOBJECTIVESAt the end of this webinar attendees will be ableto:• Understand the “CMS goal” for AV Fistulas• Discuss the importance of “AV Fistulas”• Review Best Practices used by your facilities• Verbalize the benefit of sharing/Utilizing “BestPractices”• Initiate a new process or add to a current process toimprove Vascular Access outcomes‐ “Sustain Gain”3

WHY is it IMPORTANTCenters for Medicare & Medicaid (CMS)implemented a high priority goal of 66% AV FistulaRate across the nation…WHY?CMS recognizes a well functioning vascular accessenables the hemo‐dialysis patient to receiveefficient/adequate dialysis treatments, enhancing theirquality of life; V550(5).4

The FFBI consists of the Centers of Medicare & MedicaidServices (CMS), ESRD Networks, and the entire renalcommunity, work together to ensure that every suitablepatient will receive the most optimal form of vascular access –which, most cases, will be a native AV fistula.Fistulas are the “Gold Standard” for establishing access to apatient’s circulatory system in order to provide life sustainingdialysis(CMS Administrator Mark B McClellan, MD, PHD)5

KDOQIKDOQI(National Kidney Foundation Disease Outcomes Quality Initiative)Vascular access continues to be a leading cause forhospitalization and morbidity in patients with CKDstage 5. Appropriate care of HD patients with CKDstage 5 requires constant attention to the maintenanceof vascular access patency and functionStudies consistently indicate that the AV Fistulahas the best patency rates and require fewerinterventions in comparison to other access typesGOALS: Increase the placement of native fistulaeDetect access dysfunction before access thrombosis6

GOAL66%7

Many say that 66% is UNREALISTICThat is a MYTH1) Other than the USA and Canada, everycountry in DOPPS (Europe, Japan, Aus, NZ) has aprevalent AVF rate >66%2)The NKF/KDOQI vascular accessworkgroup examined the evidence and supports thisgoal3) There are two Networks that havereached that goal in the USA, so it can be DONE8

AVF Rates by Network80.0%70.0%60.0%% Prevalent AVF by NetworkMarch 2011 compared to March 2012% AVF50.0%40.0%30.0%20.0%10.0%0.0%6 8 9 5 11 3 10 13 7 4 14 US 12 2 17 1 18 15 16March 2011 Rate 52.8 55.3 54.2 55.1 56.1 57.3 57.2 57.0 57.9 57.1 58.0 58.0 58.0 60.2 61.6 61.9 61.6 64.7 66.3March 2012 Rate 56.0 57.8 57.8 58.0 58.9 59.0 59.2 59.3 59.7 59.9 60.1 60.4 60.7 62.5 62.9 63.8 63.9 67.0 68.5Increase 3.2% 2.5% 3.6% 2.9% 2.8% 1.7% 2.0% 2.3% 1.8% 2.8% 2.1% 2.4% 2.7% 2.3% 1.3% 1.9% 2.3% 2.3% 2.2%

Catheters are associated with:Increased infectionsIncreased hospitalizationsIncreased deathsAV Grafts associated with:More complications (8x’s > risk) – American Society of NephrologyDecreased survival of accessIncreased interventionsHigher CostsTotal Care Costs:CVC - $79,364AVG - $72,729AVF - $58,588Source: USRDS Data Report ‐ Costs of ESRD

WHAT TO DO?BestPractices11

DEFINE BEST PRACTICESMethods and techniques that haveconsistently shown results superior thanthose achieved with other means, andwhich are used as benchmarks to strive for.12

BEST PRACTICESNo practice is best for everyone or inevery situation, and no best practiceremains best for very long as peoplekeep on finding better ways ofdoing things.13

VASCULAR ACCESS is NOT ONE SIZE FITS ALL14

Best Practices TO FOLLOWVein mapping, timely referral, Access CenterMaintain the access once established/AVF friendlysurgeonContinuous Quality Improvement/Tracking/SleevesupVascular access Coordinator, Monitoring andMaintenance15

Preserve future sites for vascular access/vesselpreservation/PICC/Epicardial FirstProvide education to patients, family, and staff,modified hospital systemsShare successes and failures/multi-disciplinarymeetingsCannulation techniques, self management,buttonhole16

DIALYSIS AVF FEUD17

22.2% 26.3%Network 6• Increased Medical Director/Nephrologist/CorporateInvolvement•Increased Patient Education•Vessel Mapping•Change in referral patterns•Dedicated Vascular Access Coordinator19

39.4% 53.6%Network 6•Dedicated Vascular Access Coordinator•Utilization of Vascular Access Center•Referring to different Surgeons•Vascular access tracking/trending20

34.3 %Network 650.6%• Increased Surgeon Involvement• Reassessment of all AVG patients• Increased Patient Education• Vessel Mapping• Increased CKD Education/Early Referral21

46.9 % 59.4%Network 6• Vascular Access Tracking/Trending• Utilization of Vascular Access Centers• Increased Patient Education• AVF placement in patients with catheterswhen indicated (regardless of prior access)22

36.8% 44.6%Network 6• Designated Staff Member as Access Coordinator• Increased Medical Director/Nephrologist/CorporateInvolvement• Vascular Access tracking/trending• Increased Cannulation Training23

29.2% 55.7%Network 6•Educational Learning Sessions focusing ontopic with pre and post test to assessknowledge•Celebrations of access placement•Surgeon and/or interventional team presentingto staff on cannulation•Buttonhole technique education•Reiteration of the CVC placement24

37.5% 53.0%Network 6•Dedicated Vascular Access Coordinator•Utilization of Vascular Access Center•Trending Vascular Surgeon results•Referral to “Fistula Friendly” VascularSurgeons only25

SPREAD SOLUTIONS/OUTCOMESSHARE RESOURCES, STATISTICS, IDEAS, THOUGHTS26

Why Spread Ideas?•Enhancement of effectiveness and efficiency by spreadinggood ideas and practices•Time savings –Learn from others mistakes•Bonds connection – strengthens problem solvingtechniques•More sophisticated ideas, insights, results in bettersolutions•Provides innovation and discovery, increases engagement,motivation•Satisfaction from sharing knowledge•Benefits the facility, patient and family27

•Follow up with Vascular Surgeon for start date ofcannulation•Medical Director to meet with local surgeons. Also,scheduled vein mapping prior to hospital discharge•Frequent Review•Referring New Patients for access placement with in thefirst 2 treatments and referring to the “Right Surgeon” isthe best way to get the patient on board and to get AVFinstead of AVG 28

•Buttonhole cannulation program•Vascular Coordinator and Nephrology Nurse Practionerfull time at hospital responsible for CKD education, timelyreferral to Vascular surgeon•Vessel mapping and access placement prior to admissionto facility•Monthly Access reporting and conference calls withVascular Team29

Road Blocks to Best PracticesSystem• Pt.’s without Medical Insurance• Waiting time for Insurancecoverage• Non Cooperative Surgeons/NotAVF friendly• Communication betweenSurgeon/Hospital/Access Center• Lack of Knowledge of AttendingMD• AVF not Maturing, Late referral• Discharged with no AVF plan/veinmappingPatient• Fear of Needles• Exhausted sites• Lack of Knowledge• Refusing• Catheter Culture• Non‐compliant• Language Barriers• Transportation• Co‐Morbidities/Age30

POSSIBLE SOLUTIONSSystem• Establish relationship withInsurance contacts• Collaborate with Surgeonsoffice• Work with local primary carepractitioners and hospitals• Training for SurgeonNephrologist/Medical Director• Early referral for AVF, veinmapping, utilize tracking tools,algorithms• Meet with hospital dischargeteamPatient• Patient, family education beinventive in delivery• Follow up with patients thatrefuse• Terminology with catheters –Permanent vs. Temporarymaybe use Cuffed/non‐Cuffed• AMA forms –document, careplan meetings, involve family• Utilize SW to help withtransportation, languagebarriers31

SUSTAIN your GAINSustainability: Locking in the progress that you havemade already and continually building upon it:ANDSpread: Actively disseminating BEST PRACTICE andknowledge about every intervention andimplementing each intervention in every availablesetting32

Improving AVF Rates• Follow your Comprehensive Action Plan• Address the Problem• Have Goals• Root Causes/Barriers• Interventions• Responsible parties• Regular Updates/QAPI meetings• Documentation• New Ideas/Thoughts/Implement/SHARE/SPREAD33

Network 6MissionImprove the livesof People with orat risk of ESRDby promotingand AdvancingQuality of Care34

RESOURCES• www.myskc.org• http://www.fistulafirst.org/• www.kidney.org35

QUESTIONSIf you have any questions please contactCyndy McCallus RN, BSNDebra Evans RN, BSNatinfo@nw6.esrd.netComplete Participation Survey:http://www.surveymonkey.com/s/BestPract36