FFBI Tools and Catheter Wipeout in DaVita Facilities

1. FFBI Tools and Catheter Wipeout in DaVita Facilities Svetlana (Lana) Kacherova, RN, MPH, CPHQ QI Director, ESRD Network 18 April 2008

2. Fistula First – started as NVAII • Nationwide Quality Improvement Project whose goal is to improve fistula placement consistent with K-DOQI Guidelines • Incorporates partnership principle in development and implementation • Relies on spread strategy that leverages success • Conducted over sufficient time (3+ years) to truly intervene and measure improvement

3. “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!

4. Fistula First Goals (AVF Rates) • CMS goal – 66% by June 30, 2009 • Yearly Network 18 goal – 53.4% by March 31, 2008 • Yearly Network Stretch Goal – 55.0% by March 31, 2008 • Feb. 2008 AVF rates: NW 18 – 52.4% US – 48.8%

5. Routine CQI Review of vascular access Timely referral to nephrologist Early referral to surgeon for “AVF Only” Surgeon Selection Full range of appropriate surgical approaches Secondary AVFs in AFG patients AVF evaluation/placement in catheter pts Cannulation training Monitoring and maintenance Continuing Education Outcomes feedback Tools & Best Practices:Fistula First Change Concepts

6. Improvement in Prevalent AVF Rates by ESRD Network FFBI AVF goal- 66% Increased to 45.4% (1-07) Original K/DOQI Goal- 40% (1-06) FF Start Point- 32% (1-03)

9. AV Fistula First: Accomplishments • Website (fistulafirst.org): Revised site launched 10/1/07! • Re-imbursement code for AVF vessel mapping (G-0365) • Country-wide workshop for surgeons / Cannulation Workshops • DVD & website streaming of surgeon & Interv. education program • Formation of Interventional Work Group (Call 12/10/07) • Cannulation education/training program on DVD (& Website) • Consultation with experts via website contact (Speaker Bureau)

10. AV Fistula First: New projects • Catheter reduction guidelines and white paper • Extension of FF into CKD arena • Evaluation of selected clinical issues, i.e. “buttonhole” technique • Focus on education re: early recognition & treatment of failure-to-mature & dysfunctional AVFs • Engage nephrologist community as catalysts for change • Hospital-based initiatives (Networks and QIOs) • Education/Training video re: proper vessel mapping protocol • Collaboration with other groups: KDOQI, DOQ-IT, NKDEP

11. Targets of Planned Outreach • ER departments • OR departments • Community-based imaging/radiology • MD offices • Laboratory/phlebotomy • Infusion Nurses Society • AA Diabetes Educators • Others

12. Vascular Access Use

13. ESRD Network 18 – Vascular Access Trends 1995-2006

15. Network 18 Fistula Rates by County

19. Catheter Rates since launch of FF: FFBI Dashboard Data Note: Since FF in 2003: AVFs 50% (p=.003) vs. Caths unchanged (p=.202) L. Spergel MD, FFBI, 10-30-07

20. Statistical Analysis of Dashboard Cath vs. AVF data J. Sayre, 2007

21. 2006 CPM: Access Types 21% 6%

22. Is the prevalence of Catheters too high?YES! Do we need to do something about this? YES! Is the FFBI effort causing an increase in catheters ? Based on the evidence to date, the answer is NO.

23. DaVita Group Rate as of January 2008

24. AVF Breakdown by Teams

25. AVG Breakdown by Teams

26. Long-term Catheter Breakdown by Teams

27. Identified Roadblocks:

28. System Roadblocks Identified by Facilities • Patients without medical insurance • Med-Cal only patients • Restricted Medi-Cal • HMO (ex. RMC, PMD) that requires authorization • No good surgeons • Not all surgeons accept Med-Cal and those who accept require long waiting time

29. Patient Roadblocks Identified by Facilities: • Afraid of needles • Comfortable with catheter • Exhausted sites • Language barriers • Forgetting follow-ups and missing appointments • Lack of education

30. More Roadblocks: • Lack of knowledge and effort from the PCP offices • Communication between dialysis unit and surgeon’s office • Problems with the newly placed AVF (does not mature or clots)

31. Possible Solutions: • Educate patients • Vessel mapping for everyone • Establish “Sleeves-up” Monday and Tuesday • Utilize Outpatient Vascular Access Center • Establish relationship with surgeon’s office • Establish relationship with HMO contacts • Early follow-up on newly placed AVFs (as early as 4 weeks) • Address every single catheter • Documentation is the key!

32. Possible Solutions (cont): • Visit fistulafirst.org website • Utilize FFBI tools and tools that are already available in DaVita • Recognize issues and address them early • Empower your staff by delegating roles • Share successes and approach vascular access as one community • Call your Network for help

33. DaVita Vascular Access Tracking Tools • Patient Report • Facility Report • Catheter Tracking tool • Vascular Access Event Log

38. Very important: Report VA Data Correctly & Update Regularly!:

39. Race starts today ! • Three Teams (Carl, Rosemarie, & Sue) • Timeline: April 1, 2008 – June 30, 2008 • Baseline: February 28, 2008 data (SIMS database – for all vascular access types) • The Network will do random validation comparing SIMS report to your facility-specific reports • The goal: AVF, AVG and catheters • The winners will be recognized!

40. Conclusions: • We are all partners • We are on the right track • Utilize available recourses and still shamelessly • Visit the FFBI website for more resources • Call your Network for help • Share successes • It CAN be done!

41. How Can We Help You?

42. Svetlana (Lana) Kacherova, RN, MPH, CPHQ Quality Improvement Director ESRD Network 18 323-962-2020 phone 323-962-2891 fax skacherova@nw18.esrd.net