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Fistula First Change Package
Quality Tool
Presented by:Katherine Astaneh, RN, BSN
Fistula First Change Concepts
To Nephrologist from Primary careTo a Surgeon for Evaluation and placement of an AVF / secondary AVF before failure of AVG
Based on:The best AVF outcomes (monitored)Continuous Learning and able to meetK/DOQI expectations
Focused care:Post-Operative Evaluation
To detect, refer, and remedial intervention as needed
• (Fistula first, 2009)
Improving patient hemodialysis outcomes & Use of Arterial Venous Fistulas (AVF)
Multi-Disciplinary vascular access Continuous Quality Improvement (CQI) review
Education to Dialysis Staff, care givers, and Multi Disciplinary CQI staff re: use/care of AVF
Feedback to provide needed changes for better outcomes (monthly)
(Kidney education, 2010, p. 68)
(Statereforum website, n.d., figure 1)
(Fichier, n.d., figure 1)
(Openstax cnx, 2010, figure 1)
Fistula First, 2009
Impact on Health Care
WHO is impacted Nephrologist
Nurses
Patients
Quality of Care is enhanced by: Nephrologist are given an earlier consult by the
Primary Care Physician (PCP) for CKD/ESRD
More education offered on equipment utilized at their center, Signs and Symptoms to monitor for during treatment, and how to educate patients on the importance of AVF access placement & use of clamps.
Educational seminars to assist in knowledge building of CKD/ESRD progression and their treatment options, strategies, and health coaching
Dialysis Centers(ESRD Network 18, n.d.)
(Fistula First, 2009)
Primary Care Physicians are given valuable educational seminars to enhance their ability to give a better understanding and education to their patients who are found to have renal insufficiency and require a Nephrologist consult.
A CKD action plan training module is given to assist in understanding of practice guidelines, kidney disease resources, and online CME.
A partnership is formed between Nephrologist and the Primary Care Physician to enhance patient care.
Patients who are in the early stages will be educated with treating options that will help delay the progressions of CKD.
Patients will benefit by gaining a chronological understanding of the events about to take place before the Nephrologist consult, be able to speak to their families about the future and what it may hold.
The patient will have the benefit of both primary care and nephrologist care due to the partnership formed.
Impact on Health CarePrimary Care
Physicians(PCP)A Partnership formed
(footage, n.d.)
(Chronic Kidney disease, 2007)
Answers: 1. The criteria a Nephrologist is looking for in a
surgeon is the willingness to participate on the Multi-disciplinary team, knowledge and judgment of this area, amount of successful placements and above all a caring attitude with time to commit.
2. AVF are less problematic than a graft. Usually the graft will be used until a malfunction occurs.
3. All patients are considered a candidate for an AVF that have a graft and should be evaluated early before the graft fails, allowing for a plan of action to be in place and avoid the placement of a catheter.
Impact on Health CareSurgeon
The Surgeon is impacted by seminars, training videos located online, and brochures that educate on needed information for frequently asked questions such as:
What criteria is used when a Nephrologist is choosing a surgeon for AVF placement?
What is the need for a secondary AVF when the graft is still accessible?
Why is evaluation of a patient completed for an AVF while a graft is in place?
(FistulaFirst, 2009, p.1 )(Overview of the vascular system, n.d.)
The interventionalist, radiologist and interventional nephrologist, will be impacted through educational seminars and videos assuring that: Pre-mapping strategies for
placement Identification & treatment of
Cephalic Vein Stenosis Major differences in AVF/AVG-
Why AVF is best.
Impact on Health CareInterventionalist
(Vein Mapping, n.d.)
(Complications: Cephalic Vein Stenosis, n.d.)(Vascular Access for Hemodialysis, 2010)
As an Advanced Nurse Practitioner utilizing the concept will assist in patient centered care, prompt attention to a dialysis need, and education for the patient can be given without hesitation.
Coordinate and assist on the Multi-Disciplinary Team
Collaboration between PCP and patient Chart Reviews for accuracy of
performance guidelines by all involved with patient care
Assessing AVF’s for functionability Education to patients Asking for patient opinion
Embracing the Fistula First ConceptIn Practice
Quality of Life Changes…
Through patient education of
Self management
Patient participation in
Health care
(NurseNews1, n.d.)
(Hospitalnews, 2013)
(What is Kidney Failure, n.d.)
(Vascular Access for Hemodialysis, 2010)
Monitoring for new admitted patients that may be at risk for kidney failure Acquiring proper labs Noting when nephrotoxicity will
increase the risk for further kidney failure
Monitoring any patient that undergoes placement of dyes for diagnostic workups
Patients Accurate information on the
procedure % of kidney failure after certain
procedure Education on kidney and
function when lab work is suspected to be showing kidney failure
HospitalsChange Concept 12 &13
AVF’s have: Lower rate of infection Lower rate of clotting Longer rate of patency Require less hospitalization Less patient morbidity Significant lower cost
AVG’s & other Catheters Increase rate of infection More visible Artificial material in body Does not last as long as AVF Require more hospitalizations
Clotting Replacement of catheters
every 90 days
In Comparrison
RT Internal Jugular Ash Catheter
Arterial Venous Fistula
Arterial VenousGraft
(Vascular Access for Hemodialysis, 2010)
(Vascular Access for Hemodialysis, 2013)
In Summary The emergent need in an adequate life line placement has become more
evident in the increasing hospital visits among dialysis patients In 2003 the Center for Medicaid and Medicare Services along with the
Institute for Healthcare Improvement began formatting the National Vascular Improvement Initiative (NVAII)
In 2005 the 40% goal achieved for prevalent AVF use in the U.S. and changed the name to Fistula First Breakthrough Initiative (Fistula First, n.d.)
In 2005 the intial 11 goals changed to 13 change concepts As of April 2012 the goal of 67.7% of fistulas placed in 381,051 patients
(Fistula First, 2012, graph 2) In 2013 the Fistula First Catheter Last quality tool was added to help
decrease the use of tunneled dialysis catheters
FISTULA FIRST CHANGE PACKAGE 1
Complications: Cephalic Vein Stenosis. (n.d.). www.intechopen.com
ESRD Network 18. (n.d.). www.esrdnetwork18.org
Fichier. (n.d.). www.fichier-pdf.fr
Fistula First . (2009). www.fistulafirst.org
Hospitalnews. (2013). www.hospitalnews.com
Kidney education. (2010). www.kidneyinenglish.com
NurseNews1. (n.d.). www.nursenews1.hubpages.com
Openstax cnx. (2010). www.cnx.org
Overview of the vascular system. (n.d.). www.hopkinsmedicine.org
Statereforum website. (n.d.). www.statereforum.org
Vascular Access for Hemodialysis. (2010). www.kidney.niddk.nih.gov
Vascular access for Hemodialysis. (2013). www.intechopen.com
Vein Mapping. (n.d.). www.aultman.org
What is Kidney Failure. (n.d.). www.ultracare-dialysis.com
footage. (n.d.). www.footage.shutterstock.com
kidney international. (n.d.). www.nature.com
References
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