AV Join Transformation Venture: Rundown and Lessons Learned.

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Nephrologist alludes to specialist for assessment/situation of optional AV fistula before ... Restorative Director to cooperate with different nephrologists and vascular specialists as required ...
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AV Graft Conversion Project: Summary and Lessons Learned Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 July 23, 2009

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"Fistula First" Goal is to augment autogenous AVF development & achievement rate… .. To accomplish in the shorter term (2006) the underlying K/DOQI least benchmark of AVF use in 40% of predominant patients… . Furthermore, in the long haul (2009), a 66% AVF rate in common patients Additional Goal: Reduce Catheter Use!

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Fistula First Goals (AVF Rates) CMS objective – 66% AVF Yearly Network 18 objective – 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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Routine CQI Review of vascular get to Timely referral to nephrologist Early referral to specialist for "AVF Only" Surgeon Selection Full scope of suitable surgical methodologies Secondary AVFs in AFG patients AVF assessment/position in catheter pts Cannulation preparing Monitoring and upkeep Continuing Education Outcomes criticism Tools & Best Practices: Fistula First Change Concepts

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Inclusion Criteria for Participating Facilities AVF rate < half (April SIMS information) Highest rate and number of AV Grafts Patients evaluation > 50 patients Administrative bolster: All intercession offices have a steady initiative

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Exclusion Criteria Patient statistics < 50 patients Facilities effectively incorporated into another QIWP venture with the Network

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Project Timelines Oct. 2008 – Environmental sweep and WebEx Nov. 2008 – RCA and PDSA (steps 1-3) Dec. 2008 – 1 st follow-up Jan-Feb. 2009 – 2 nd follow-up March-Apr. 2009 – 3 rd follow up May 2009 – last catch up June 2009 – Project rundown and conclusion

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Network Role During the Project: Project Leader Supplied the layouts for RCA & PDSA Supplied offices with apparatuses and information Periodically observed and gave input Conducted telephone meetings to acquire office particular information Chased you for information & documentation  Assisted your office to stay in consistence with the QAPI program prerequisites

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V626 QAPI Condition Statement The dialysis office must create, execute, keep up and assess a successful, information driven, quality evaluation and execution change program with cooperation by the expert individuals from the interdisciplinary group... … The dialysis office must keep up and exhibit confirmation of its quality change and execution change program for survey by CMS

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Project Summary

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Change Concept # 6: Secondary AVF Placement in Patients with AV Grafts Nephrologists assess each AV unite quiet for conceivable auxiliary AV fistula, including mapping as demonstrated, and report arrangement in patient\'s record. Dialysis office staff and/or adjusting nephrologists look at outpouring vein of all lower arm unite patients ("sleeves-up") amid dialysis medicines (least recurrence = month to month) to distinguish patients

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Change Concept # 6: Secondary AVF Placement in Patients with AV Grafts (proceeded with) Nephrologist alludes to specialist for assessment/situation of optional AV fistula before disappointment of AV joining. Fistula First considers an AVG that has coagulated in any event once a FAILING GRAFT.

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Summary of Facility QAPI Strategies Patients and Families: Educate patients and their families about the benefits of an AV fistula (staff and nephrologists) Patient-to-patient showing Post publications and have presents accessible in the entryway in regards to sorts of vascular gets to and vascular access care

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Summary of Facility QAPI Strategies (proceeded with) Facility and Staff: Designate a Vascular Access Coordinator/Manager to administer the office\'s vascular access program Inform nephrologists and specialists about the AV Graft Conversion Project Inform nephrologists and specialists about the office\'s desires as to vascular access

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Summary of Facility QAPI Strategies (proceeded with) Facility give the Fistula First surgical video to specialists to survey Medical Director to communicate with different nephrologists and vascular specialists as required Have nephrologists begin growing their vascular access specialist pool in the territory Nephrologists will recognize fruitful specialists outside the neighborhood Summary of Facility QAPI Strategies (proceeded with) Educate staff and nephrologists on the best way to perform a "Sleeves Up" appraisal – use video Initiate/actualize the "Sleeves Up" evaluation to distinguish patients (staff and nephrologists) Staff and nephrologists teach the patients Have nephrologists allude patients to specialists

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Summary of Facility QAPI Strategies (proceeded with) Schedule vein mapping of AVG patients that have thickened in any event once if not already done Obtain a duplicate of the vein mapping results and keep in the patient\'s outline Assist patient and families in booking vascular access related arrangements Conduct stenosis checking and reconnaissance

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Summary of Facility QAPI Strategies (proceeded with) Document issues and perceptions and report to the Nephrologist Refer patients for fistulogram after clench hand indication of union disappointment Maintain a month to month vascular access following log – kind of access, occasions, and status of the entrance

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Summary of Facility QAPI Strategies (proceeded with) Review vascular access reports amid QAPI gatherings (URR, Kt/V, stenosis observation reports, dialysis solution, and so on.) Discuss the task and the office\'s advancement amid QAPI gatherings and conceptualize different thoughts for expanding the office\'s AVF rate Document all occasions that happen with the patient\'s AVG and submit to the insurance agency expressing explanations behind patient needing an AVF assessment and position

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Activities that backing effective change: Consider an AV unite with no less than one coagulating scene to be a falling flat join The nephrologist ought to have the patient assessed for a conceivable auxiliary AV fistula, including vein mapping as demonstrated

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Series of exercises that backing effective transformation: (proceeded with) 3. An auxiliary AVF arrangement ought to be examined with the patient, family, staff, nephrologist and specialist in foresight of an AVF creation at the most punctual proof of union disappointment and the arrangement ought to be recorded in the patient\'s diagram 4. The office ought to have an arrangement of consideration set up to keep away from the requirement for a catheter when the union comes up short and there is earnestness for a prompt usable access

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Series of exercises that backing effective change: (proceeded with) 5. A "Sleeves-Up" exam ought to be performed month to month to recognize patients who can be possibility for a joining to fistula transformation 6. At the indication of a second obstructing AVG disappointment, the patient ought to be sent for an AV fistula transformation

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Next Steps Ensure that all AVG patients are assessed for optional AVF position Have a procedure set up for an auxiliary AV fistula situation for lower arm AVG patients Educate the patients, families, nephrologists and specialists about the idea of an optional AV fistula arrangement Refer to the Fistula First site for assets in regards to this Change Concept. www.fistulafirst.org

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Next Steps Have a procedure set up to guarantee that the recently made AV fistula creates to development Perform physical appraisal of the entrance with each treatment Send the patient for a 4 week follow-up with the specialist/vascular access focus to assess the development procedure If the entrance is not developing, the specialist can then reconsider or actualize mediations to rescue the access.

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Svetlana (Lana) Kacherova, QI Director skacherova@nw18.esrd.net Lisle Mukai, QI Coordinator lmukai@nw18.esrd.net 6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028 (323) 962-2020  (323) 962-2891/Fax  www.esrdnetwork18.org

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