Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.
Fistula First  A CMS Sponsored Quality Initiative What is it? Where are we now? Where do we need to go? How are we going t...
Fistula First :What is it? <ul><li>CMS in collaboration with the 18 ESRD Networks and the renal community started the Fist...
Vascular Access Initiative: Rationale <ul><li>Vascular access is one of the most critical issues in improving dialysis qua...
DHHS Healthy People 2010:   Chronic Kidney Disease Overall Goal: Reduce new cases of chronic kidney disease and its compli...
Why Fistula First ? <ul><li>There are over 385,000 patients on dialysis in the USA </li></ul><ul><li>There are over 11,000...
Why  Fistulas First? Risk of Infection with Various Access Types
Why Fistulas First? Relative Risk of Death by Access Type
Questions to be Answered <ul><li>What types of  Vascular Accesses are commonly used for chronic dialysis patients? </li></...
What are the commonly created chronic Vascular Accesses? <ul><li>AV Fistulas </li></ul><ul><li>AV Grafts </li></ul><ul><li...
A direct surgical connection between a native artery and  vein with cannulation of the patient’s own blood vessel for dial...
Where Fistulas are Placed <ul><li>Wrist </li></ul><ul><li>Elbow </li></ul><ul><li>Elbow with vein transposed </li></ul><ul...
Sites for Native Fistulas
Proximal radial artery AVF
Brachiobasilic transposition
A substance is interposed between an artery and a vein and used to connect them.  This material is cannulated for dialysis...
Arm PTFE Grafts
Site of Loop Graft
Complications of AV Access <ul><li>Wound infection </li></ul><ul><ul><li>superficial or deep </li></ul></ul><ul><li>Prosth...
There are several types of Catheters but all have in common the fact that the Catheter resides in a vein and there is  a b...
Hemodialysis Catheters
Internal Jugular Double-Lumen Tunneled Dialysis Catheter
What are the characteristics of an “Ideal Access”? <ul><li>Few complications during creation </li></ul><ul><li>Minimum tim...
Which is Closest to the Ideal Access? + = close to ideal, - = far from ideal
Why is the AVF rate low if it is the “gold standard”? <ul><li>50% of patients start dialysis emergently, thus catheters ar...
How Did the USA Compare to the Rest of the World Prior to 2003?
Where we were in 2003? 42 % Prevalent AVF New England
Have we made any progress? Source: March  2006  Network Provider Fistula First Reports Network of New England=47.5%
Rates across USA & Possessions End Stage Renal Disease Network Regional Map Prevalent AVF Percentage Rates in US 38.1% 48%...
How are the New England States Doing?
Where Do We Go From Here? <ul><li>CMS National Goal for 2009=66%  </li></ul><ul><li>AV Fistulas </li></ul>
How are we going to get there? <ul><li>Need to educate healthcare professionals to be aware that CKD is becoming a major P...
Stages of Chronic Kidney Disease Renal replacement therapy: dialysis or kidney transplant <15 Kidney failure 5 Preparation...
Would Earlier Referrals Help?
What else needs to change? <ul><li>Hospital staff need education to consider vein preservation & reduce the use of PICC li...
Can We Make Better Plans for Access During Hospitalizations? <ul><li>Acute care nurses can assist by asking if vein mappin...
And…. <ul><li>Vascular Access coordination needs to be part of d/c planning of both CKD & ESRD pts. </li></ul><ul><li>Hosp...
<ul><li>Fistula First </li></ul><ul><li>Data on access cost for grafts vs AV Fistulas </li></ul><ul><li>CPT Codes </li></u...
Strategies to Improve More <ul><li>The Networks and the QIOs are collaborating to get the Fistula First message out to the...
As Hospital Caregivers What Can You Do? <ul><li>Collaborate with vascular surgery dept. & nephrologists to create QIP for ...
Fistula First at the  National & Local Level <ul><li>Visit the National Fistula First Project Website at: </li></ul><ul><l...
AVF  versus  AVG
Nächste SlideShare
Wird geladen in …5
×

Fistula First Update

3.537 Aufrufe

Veröffentlicht am

  • Als Erste(r) kommentieren

Fistula First Update

  1. 1. Fistula First A CMS Sponsored Quality Initiative What is it? Where are we now? Where do we need to go? How are we going to achieve the goals? Peggy Lynch, BSN, RN, CNN Quality Manager Network of New England
  2. 2. Fistula First :What is it? <ul><li>CMS in collaboration with the 18 ESRD Networks and the renal community started the Fistula First Quality Improvement project in 2003 </li></ul><ul><li>The goal is to improve the quality of life for hemodialysis patients by increasing the AV fistula rate in prevalent patients to greater than 40% and >50% in Incident patients nationally by 6/06 </li></ul>
  3. 3. Vascular Access Initiative: Rationale <ul><li>Vascular access is one of the most critical issues in improving dialysis quality: </li></ul><ul><ul><li>2003 trends: Access Patency, Morbidity/ Mortality, Costs </li></ul></ul><ul><ul><li>Attributable to: AVF, AVG, Catheters </li></ul></ul><ul><ul><li>Access type is a major determinant of patient outcomes as well as financial outcomes </li></ul></ul><ul><ul><li>Most VA-related morbidity & costs are due to grafts & catheters </li></ul></ul>
  4. 4. DHHS Healthy People 2010: Chronic Kidney Disease Overall Goal: Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs. Vascular Access Goal: Increase the proportion of hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access. National target for AVFs = 50% placement in incident patients 40% use in prevalent patients
  5. 5. Why Fistula First ? <ul><li>There are over 385,000 patients on dialysis in the USA </li></ul><ul><li>There are over 11,000 patients on dialysis in New England </li></ul><ul><li>There are almost 5,000 patients on Dialysis in MA </li></ul><ul><li>Only 30% or < were dialyzing with a fistula in 2003 </li></ul><ul><li>Vascular access complications are the major cause of hospitalizations, morbidity & mortality in the dialysis population </li></ul>
  6. 6. Why Fistulas First? Risk of Infection with Various Access Types
  7. 7. Why Fistulas First? Relative Risk of Death by Access Type
  8. 8. Questions to be Answered <ul><li>What types of Vascular Accesses are commonly used for chronic dialysis patients? </li></ul><ul><li>What are the advantages and disadvantages of various types of accesses? </li></ul><ul><li>What is the best Access and Why? </li></ul>
  9. 9. What are the commonly created chronic Vascular Accesses? <ul><li>AV Fistulas </li></ul><ul><li>AV Grafts </li></ul><ul><li>RIJ Catheters </li></ul>
  10. 10. A direct surgical connection between a native artery and vein with cannulation of the patient’s own blood vessel for dialysis access Fistula
  11. 11. Where Fistulas are Placed <ul><li>Wrist </li></ul><ul><li>Elbow </li></ul><ul><li>Elbow with vein transposed </li></ul><ul><li>Leg with vein transposed </li></ul>
  12. 12. Sites for Native Fistulas
  13. 13. Proximal radial artery AVF
  14. 14. Brachiobasilic transposition
  15. 15. A substance is interposed between an artery and a vein and used to connect them. This material is cannulated for dialysis. Usually the material used is polytetrafluoroethylene (PTFE), but other materials, artificial or organic, can be used. AV-Graft
  16. 16. Arm PTFE Grafts
  17. 17. Site of Loop Graft
  18. 18. Complications of AV Access <ul><li>Wound infection </li></ul><ul><ul><li>superficial or deep </li></ul></ul><ul><li>Prosthetic infection </li></ul><ul><li>Cellulitis </li></ul><ul><li>Seroma or hematoma </li></ul><ul><li>Chronic drainage </li></ul><ul><li>Wound dehiscence </li></ul><ul><li>Neuralgia or paresthesia </li></ul><ul><li>Vascular steal </li></ul>
  19. 19. There are several types of Catheters but all have in common the fact that the Catheter resides in a vein and there is a break in the skin to allow the catheter to enter . There in lies the main problem: prone to infection/thrombus Temporary Catheter
  20. 20. Hemodialysis Catheters
  21. 21. Internal Jugular Double-Lumen Tunneled Dialysis Catheter
  22. 22. What are the characteristics of an “Ideal Access”? <ul><li>Few complications during creation </li></ul><ul><li>Minimum time before being usable for dialysis </li></ul><ul><li>Comfortable to initiate dialysis </li></ul><ul><li>Quick to terminate treatment </li></ul><ul><li>Minimum of care required to maintain access </li></ul>Adapted from NKF-K/DOQI Guidelines: Vascular access: Introduction
  23. 23. Which is Closest to the Ideal Access? + = close to ideal, - = far from ideal
  24. 24. Why is the AVF rate low if it is the “gold standard”? <ul><li>50% of patients start dialysis emergently, thus catheters are inserted for a quick vascular access to initiate hemodialysis </li></ul><ul><li>Patients may resist changing to an AVF due to fear of needles </li></ul><ul><li>Reimbursement for an AV graft is higher </li></ul><ul><li>AV Grafts can be used sooner than an AV fistula </li></ul>
  25. 25. How Did the USA Compare to the Rest of the World Prior to 2003?
  26. 26. Where we were in 2003? 42 % Prevalent AVF New England
  27. 27. Have we made any progress? Source: March 2006 Network Provider Fistula First Reports Network of New England=47.5%
  28. 28. Rates across USA & Possessions End Stage Renal Disease Network Regional Map Prevalent AVF Percentage Rates in US 38.1% 48% 44.2% 46.3% 58.5% 37.6% 40.7% 38.8% 36.3% 34.6% 41.5% 37.5% 47.5% 48.9% 39.5% 35% 40.4% Date Source: FF Dash Board 100% of facilities may not of reported in each Network US US Rate =
  29. 29. How are the New England States Doing?
  30. 30. Where Do We Go From Here? <ul><li>CMS National Goal for 2009=66% </li></ul><ul><li>AV Fistulas </li></ul>
  31. 31. How are we going to get there? <ul><li>Need to educate healthcare professionals to be aware that CKD is becoming a major Public Health problem (Apr. 2006-CDC) </li></ul><ul><li>Primary Care Physicians must routinely screen for kidney function and refer patients to the nephrologists when the GFR decreases. It is estimated that 19.2 million Americans are living with CKD (11% of the adult population) </li></ul><ul><li>Nephrologists must refer sooner to the vascular surgeon for access evaluation for dialysis </li></ul>
  32. 32. Stages of Chronic Kidney Disease Renal replacement therapy: dialysis or kidney transplant <15 Kidney failure 5 Preparation for renal replacement therapy,vascular access 15-29 Severe drop in GFR 4 Evaluate & Treat complications. DM should start vascular access now 30-59 Moderate decrease in GFR 3 Estimate progression 60-90 Kidney damage with mild decrease in GFR 2 Diagnosis,treatment of co-morbid conditions, slow progression >90 Kidney damage with normal GFR 1 Action GFR(mL/min/1.73 Description Stage
  33. 33. Would Earlier Referrals Help?
  34. 34. What else needs to change? <ul><li>Hospital staff need education to consider vein preservation & reduce the use of PICC lines & lab draws in high risk pts. </li></ul><ul><li>The lab could automatically do a calculated GFR when a serum creatinine is 1.8(female) or 2.0(male) thus triggering nephrology consult </li></ul><ul><li>Diabetics, HTN & Cardiac patients should have routine screening for CKD </li></ul>
  35. 35. Can We Make Better Plans for Access During Hospitalizations? <ul><li>Acute care nurses can assist by asking if vein mapping has been ordered for AVF evaluation prior to discharge of a stage 3-4 CKD patient considering hemodialysis </li></ul><ul><li>Discharge planners need to be made aware that catheters are a bridge to a permanent access & appointments need to be made with the vascular surgeon prior to discharge </li></ul><ul><li>Patient education on the benefits of AVF & potential dangers of catheters needs to improve </li></ul>
  36. 36. And…. <ul><li>Vascular Access coordination needs to be part of d/c planning of both CKD & ESRD pts. </li></ul><ul><li>Hospitals as part of their QI program could track outcomes for fistula placement in patients with a GFR of 30ml or less who are d/c from their institution </li></ul><ul><li>To Reiterate: NO IVS, No PICC lines, no venipunctures in potential AVF arm (usually non dominant arm) </li></ul>
  37. 37. <ul><li>Fistula First </li></ul><ul><li>Data on access cost for grafts vs AV Fistulas </li></ul><ul><li>CPT Codes </li></ul><ul><li>AVF (36821) = $493.01 </li></ul><ul><li>Graft (36830) = $643.49 </li></ul>AV Fistulas ? $ Spent to encourage AVFs…… Payment for AVFs vs Grafts……
  38. 38. Strategies to Improve More <ul><li>The Networks and the QIOs are collaborating to get the Fistula First message out to the acute care hospitals nurses, discharge planners, quality managers and PCP office. </li></ul><ul><li>National Task force has been created with a multi-faceted approach with all stakeholders included to broaden the scope. </li></ul><ul><li>Encourage CMS to remove reimbursement barriers for the CKD patient & increase the reimbursement for AVF over AVG </li></ul>
  39. 39. As Hospital Caregivers What Can You Do? <ul><li>Collaborate with vascular surgery dept. & nephrologists to create QIP for CKD & ESRD pts. Vascular access placement </li></ul><ul><li>In-service hospital staff on vein preservation in high risk groups </li></ul><ul><li>Collaborate with discharge planners to assure vascular access planning is part of the d/c plan </li></ul><ul><li>Become Familiar with the KDOQI guidelines for CKD & ESRD ( For the KDOQI guidelines go to: NKF site http://www.kidney.org/professionals/) </li></ul>
  40. 40. Fistula First at the National & Local Level <ul><li>Visit the National Fistula First Project Website at: </li></ul><ul><li>http://www.fistulafirst.org </li></ul><ul><li>Visit the Network Website at: </li></ul><ul><li>http://www.networkofnewengland.org </li></ul><ul><li>Visit the MassPro website at: </li></ul><ul><li>http://www.masspro.org/ </li></ul>
  41. 41. AVF versus AVG

×