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One
of the primary objectives of ESRD Networks is to improve the quality
of health care services for ESRD patients. Methods used to accomplish
this goal include Quality Improvement Projects. Network #15 is involved
in both national QI Projects and in Network-defined QI Projects.
QI
Form Template
The
following documents can be used as guidelines for deciding on and
implementing quality improvement projects.
Generic QI
Template
(pdf - 4 pgs)
 QI Project Examples, Root Cause Assessments, and Resources:
Overview
NVAII is the acronym for the National Vascular Access Improvement
Initiative and is a nationwide campaign to increase the use
of arterial venous fistulas (AVF). This project, also known as the
"Fistula First" initiative, was launched July 1, 2003
by CMS along with the 18 ESRD Networks and the Institute of Healthcare
Quality (IHI).
The
Fistula First mission is to make sure that every eligible ESRD patient
receives his/her optimal form of vascular access (in the majority
of cases AVF) and to avoid vascular access complications through
appropriate monitoring and intervention. The goal is to attain a prevalent AVF rate of 66% by June 2009.
Network
#15's strategy includes a variety of activities that target the
different needs of varied audiences. We will emphasize improved
communication between the nephrologist, the vascular surgeon, the
interventional radiologist, and dialysis staff.
| Tools
for Achieving Fistula First Goals |
| Project
Overview (pdf) |
| Fistula
First Change Package Overview (pdf) -
Lists 11 key strategies for increasing AV fistulas. |
| Video of Arteriovenous Fistula (AVF) Cannulation - This video can be viewed from the Fistula First Web site. |
| Example QI Project for Decreasing Central Venous Catheters / Increasing AVFs |
|
Change
#1:
Routine CQI Review of Vascular Access
•
Preventing
Central Venous Catheter Infections (pdf)
•
Vascular
Access Coordinator Role (pdf) |
Change
#2:
Timely Referral to Nephrologist
• Nephrologist
Letter to Primary Care Physician (MS
document)
• Pre-ESRD
Planning Algorithm (pdf) |
Change
#3:
Early Referral to Surgeon for "AVF Only" Evaluation
and Timely Placement
• KDOQI
Summary Guidelines - Management of Complications: When to Intervene
(pdf)
• Hemodialysis
Access Referral Form: New Access (pdf) |
Change
#4:
Surgeon Selection Based on Best Outcomes, Willingness, and
Ability to Provide Access Services
• KDOQI
Summary Guidelines - Patient Evaluation Prior to Access Placement
(pdf)
• Surgeon
Questionnaire (pdf)
• Universal
Vascular Access Diagram (pdf) |
|
Change
#5:
Full Range of Appropriate Surgical Approaches to AVF Evaluation
and Placement
•
Continuing Medical Education presentation "Creating
AV Fistulas in all Eligible Hemodialysis Patients"
- Follow this link to learn the fundamentals of placing AV
Fistulas and surgical strategies for successful placement.
• Vessel
Mapping Protocol (pdf)
• Autologous
AV Fistula Algorithm (pdf)
• Physical
Examination of Dialysis Vascular Access (pdf
- 20 pgs) - Developed by Network #14 in collaboration
with Gerald Beathard, MD.
• A
Practitioner's Resource Guide to Hemodialysis AVFs (pdf
- 21 pgs)
- Developed by Network #14 in collaboration with Gerald Beathard,
MD. |
Change
#6:
Secondary AVF Placement in Patients with AV Grafts
• Hemodialysis
Access Referral Form: Existing Access (pdf)
• Sleeves
Up Protocol (pdf) |
Change
#7:
AVF Placement in Patients with Catheters Where Indicated
• Management
of Patient with CVC Algorithm (pdf)
• Physician
Letter to Catheter Patient (pdf) |
Change
#8:
Cannulation Training for AV Fistulas
• Order
Form for Medisystems Cannulation Video (pdf)
• Ordering
Info for Dr. Twardowski's Buttonhole Method Video (pdf)
• Policy
and Procedure for Cannulating New Fistulas (pdf)
•
Self-Cannulation of Fistulas
Patient Policy and Procedure (pdf)
•
Self-Cannulation of Fistulas Staff Policy and Procedure
(pdf)
• Training
Checklist for Self-Cannulation (pdf) |
Change
#9:
Monitoring and Maintenance to Ensure Adequate Access Function
• KDOQI
Summary Guidelines Section II - Monitoring, Surveillance, and
Diagnostic Testing (pdf)
• Vascular
Access Referral Intervention Log (pdf)
• Vamp©
Vascular Access Monitoring & Surveillance
Flow Chart (pdf) |
|
Change
#10:
Education for Caregivers and Patients
• Conquering
Your Fistula Fear (pdf)
• Clamp
Usage Policy and Procedure (pdf)
• Have
More Control Over Your Dialysis and Health
•
FAQ
about Arterial Venous Fistula's (AVF)
• Fistula
Preservation, Development, and Maintenance (pdf)
• Patient
Resources List (pdf)
• Related
Articles for Vascular Access (pdf)
• Staff
Resources (pdf) |
Change
#11:
Outcomes Feedback to Guide Practice
• Networks are working with dialysis facilities to
provide specific outcomes feedback to all decision-makers, including
incident and prevalent rates of AVF, AVG, and catheter use.
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| Web sites
with Fistula First Resources |
American
Society of Diagnostic and Interventional Nephrology (ASDIN)
-
A principal goal of the society is to increase fistula use and
this site includes online training videos as well as links to
hands-on training programs for diagnostic interventional Nephrology.
|
| FistulaFirst.org
- This web site provides comprehensive information and tools
about the Fistula First project. It also has a link to the video
training program developed by Dr. William Jennings and Dr. Lawrence
Spergel for surgeons and interventionalists. 10.5 AMA/PRA Category
1 credits are available upon completion of this training program. |
| VascularWeb
- See the Society for Vascular Surgery's endorsement of the Fistula
First project. |
| Vascular
Access Society - This web site has detailed guidelines for
vascular access which include diagrams for placement and management
of AV Fistulas, as well as a vascular access forum. |
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Increasing
Arteriovenous Fistulas (AVF) Within Network #15
The primary objective of this project was to increase the placement
of AVF within the adult, in-center hemodialysis population in Network
#15. In accordance with the NKF-K/DOQI Vascular Access Workgroup
recommendations, facilities, surgeons, and nephrologists were encouraged
to achieve a 50% or higher fistula placement rate in incident (new)
patients, and a 40% or higher fistula placement rate in prevalent
(existing) patients. Patients at facilities within and outside Network
#15 have matched and greatly exceeded these rates, so we knew the
goal was attainable.
Key
features of this project included:
- Visiting
key nephrologists and surgeons in the community, educating them
about the importance of fistulas, sharing information about the
project, and promoting a team effort.
- Sharing surgeon-specific
data on access placements, allowing surgeons to see how their
practices compared to their peers.
- Organizing
educational events with nephrologists, surgeons, and nurse educators
to present different perspectives on fistula placement.
- Presenting
"Change Packets" that contain resource materials for
surgeons, nephrologists, facility staff, and patients.
- Developing
a simple vascular access tracking system that allows facilities
to track surgeon-specific information (if they wished to continuing
generating surgeon-specific information at the end of the project).
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Chronic Kidney Disease (CKD)
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Safe
and Timely Immunization Coalition (STIC)
A national coalition comprised of healthcare professionals
and patients with End Stage Renal Disease was formed in 2005 at
the request of CMS to increase the rate of Hepatitis B, Influenza,
and Pneumococcal immunizations in patients and staff in the dialysis
setting. The following educational resources can be used to help
achieve this goal.
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MIMI (Multiple Immunization Monitoring Instrument)
MIMI is an Excel-based tracking tool designed to assist dialysis clinics with monitoring vaccination information and in getting all needed vaccinations provided in a timely way. MIMI will let you quickly see each patient’s current vaccination status, and can generate lists of patients needing a given vaccination. With chart generation to show you your overall rates, tracking of “refused” vaccinations, monitoring of “no information available” patients, and even an automatic reporting feature (for future STIC collections performed by the Network), MIMI will help address your vaccination tracking needs in one easy-to-learn and use interface.
MIMI Instructions - (pdf) - (Please read these BEFORE dowloading MIMI) - A guide that will help you to download MIMI and to learn all of MIMI’s features. While every attempt has been made to make MIMI intuitive to learn and use, these instructions will assure that you get full use of MIMI’s tracking and monitoring.
Download MIMI Here (MS Excel) - System requirements: Windows computers only! Must be running Excel 5.0 or later – and security settings must be such that the operation of macros is allowed. (See instructions above.)
Bug report FaxBack (pdf) - Network #15 is always looking for ways to better support the ongoing QI efforts our clinics are making, and we hope that MIMI – and perhaps other tools like it – will make these QI tasks easier to complete effectively. Your feedback about this tool and the sort of experience you had using MIMI will help us refine and enhance the tool for future versions. We encourage you to report any difficulties you may experience using this resource (as well as any positive experiences, or your general feedback) to Network #15 using the one-page feedback form available at this link.
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Ongoing
Quality Initiative - Improving Albumin Levels
Results from
annual CPM collections indicate that Network #15 has an opportunity
to improve albumin rates for adult, in-center hemodialysis patients.
Ideally, at least half of dialysis patients should have a mean serum
albumin > 4.0 gm/dl BCG, or > 3.7 gm/dl BCP. This goal is
currently being met in 20% of Network #15's facilities so we know
this is an achievable target. The challenge is for every facility
to hit that mark!
The resources
below (previously mailed to all facilities) may be helpful
in achieving higher albumin levels:
Albumin Magnets
Network
#15 recently mailed a supply of albumin refrigerator magnets to dietitians for distribution
to current dialysis patients. The magnet shows which foods are high in protein
and how to measure the protein in these foods. Network #15 only has a few magnets left, so if you would like more (minimum order 500) you may purchase magnets directly from:
Karen
Amack @ Images Everything
797 Shadowstone Drive
Highlands Ranch, Colorado 80129-1841
Phone: 303-683-9594
Fax: 303-683-7119
To
copy the info from the magnet click on the image to the
right which can be downloaded for printing.  |
|
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National
Clinical Performance Measures
The ESRD Clinical Performance Measures (CPM) Project is a national
effort to assist dialysis providers in improving patient care and
outcomes. Since 1994 the project has documented continued improvements,
specifically in the areas of adequacy of dialysis and anemia management.
However, the opportunities to improve care for dialysis patients
in these areas and in the area of vascular access continue.
CPM 2007 Annual Report (pdf 106 pgs) - This year the CPM Annual Report will NOT be mailed out by Network #15, so it must be downloaded here or from the CMS Web site.
For more information about the CPM project
you may go to the CMS
web site.
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Network
#15 Adequacy/Access Project
The
primary long-term goal of this project was and continues to be to
increase and sustain the adequacy of hemodialysis (HD) in the Network
#15 patient population.
The Network
#15 goal is to have at least 80% of adult in-center HD patients
achieve a delivered dose of dialysis (65% as measured by the Urea
Reduction Ratio). As a group, Network #15 facilities continue to
achieve this goal. However, in both preliminary and follow-up data,
patients with catheters showed a higher likelihood of not receiving
adequate dialysis. For this reason, Network #15 facilities are encouraged
to focus on improving adequacy for this sub-group of patients. Facilities
should strive to achieve the goal of having less than 10% of patients
maintained on catheters as their permanent access. For those patients
who must continue to have a catheter as their primary access KDOQI
recommends URRs of > 65% and Kt/Vs of > 1.2.
This project
began in January 2001. The final data collection occurred in January
2002 and the final report was approved by CMS in October 2002.
Results
of the Adequacy/Access Project:
Hemodialysis
Adequacy and Catheter Use (PDF - 1 pg)
Adequacy by Access Type (PDF
- 1 pg)
Prescribed vs. Delivered Dialysis, and
Type & Location of Catheter (PDF - 1 pg)
Reasons for Long-term Catheters and Access
Conversion Rates (PDF - 1 pg)
Final Report - Improving Hemodialysis
Adequacy by Decreasing the Percent of Patients for Whom Vascular
Access is a Long-term Catheter (PDF - 10 pgs)
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Anemia Management
Anemia
contributes to a persistent poor quality of life if left untreated
in ESRD patients. The CMS/K/DOQI targets for anemia management are
to attain/maintain a Hgb of >11gm/dL for at least 70%
of all patients. However, the Network #15 Medical Review Board has
set a stretch goal of attaining/maintaining these levels for 85%
of all patients. The following Power Point Presentation covering anemia management was given in December of 2006 - Management of Patients with Sub-11 Hemoglobin.
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Quality
Improvement Tools
Fistula
First Project
Increasing
Arteriovenous Fistulas
Improving Adequacy/Access
Increasing Albumin
Improving Immunization Rates
Chronic Kidney Disease
Quality Improvement Form Template
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WebEx Recordings
Medical/FDA
Alerts
For updated
medical/drug alerts we recommend you visit the MedWatch
web site which is maintained by the FDA.
Guidelines
for Environmental Infection Control in Healthcare Facilities is
now available in its entirety at the CDC
web site.
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Intermountain
End-Stage Renal Disease Network, Inc.
1301 Pennsylvania St #750, Denver, CO 80203-5012
Phone: 303-831-8818 Fax: 303-860-8392
Toll free for patients only: 1-800-783-8818 or 1-888-777-0105
For Network #15 Patients
| For
Network #15 Providers |
About Network #15
| Contact
Us
Supported by
Centers for Medicare and Medicaid Services (CMS) Contract HHSM-500-2006-NW015C.
The content of this web site does not necessarily reflect the views
or policies of CMS or the Department of Health and Human Services;
nor does mention of trade names, commercial products, or organizations
imply endorsement by the U.S. Government. Network #15 assumes full
responsibility for the accuracy and completeness of this web site. |
