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