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| Fistula First/NVAII Project |  Increasing AVF | Immunizations (STIC)CAHPS | Chronic Kidney Disease (CKD) |  Improving Albumin  |  Clinical Performance Measures (CPM)  | Adequacy/Access Project |
| Anemia Management | QI ToolsMedical Alerts
| WebEx Recordings |

Quality ImprovementQuality Improvement

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 document can be used as a guideline for deciding on and implementing quality improvement projects.

QI Template (pdf - 4 pgs)

Fistula First - NVAII Project  

Overview
Tools
Web site Links
Network #15 Reports

This link will take you to the national  Fistula First website.

new Video of Arteriovenous Fistula (AVF) Cannulation - This video resides on the Fistula First Web site.

Patient Education Resources Notebook (pdf - 6 pgs) - This pdf document contains links to a variety of resources regarding vascular accesses and AV fistulas that can be downloaded and provided to patients.

Patient Education Resource Evaluation - Click here to take an online questionnaire about your use of the resources contained in the Patient Education Resources Notebook (see above link).

Continuing Medical Education presentation "Creating AV Fistulas in all Eligible Hemodialysis Patients" can be viewed by following this link. Learn the fundamentals of placing AV Fistulas and surgical strategies for successful placement.

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.
new Video of Arteriovenous Fistula (AVF) Cannulation - This video can be viewed from the Fistula First Web site.

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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Network #15 Fistula First (FF) Reports
Instructions for Interpreting Facility-specific FF Reports (pdf - 1 pg)
Step-by Step Guide to Analyzing AVF Data (pdf - 2 pgs)
FF Summary Report (pdf - 6 pgs) Comparative AFV rates for most recent quarter in Network #15

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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).
Tools for Increasing Arteriovenous Fistulas
Executive Summary (PDF - 2 pgs)
Patient Handout - Caring for Your Fistula (PDF - 2 pgs)
Patient Handout - Caring for Your Fistula (Spanish language) (PDF - 2 pgs)
Patient Handout - Fistula Exercises (PDF - 10 pgs) This handout can be made into a booklet by converting these single-sided pages to double-sided pages (using a copier) and folding.
Chart for Identifying Root Causes of Low AVF Rates (PDF - 1 pg)
Summary of NKF-K/DOQI Vascular Access Guidelines -2000 Update (PDF - 2 pgs)
Billing Rules for Non Invasive Vascular Studies - (PDF - 3 pgs)
Vein Mapping Procedure from Olympic Vascular Lab (PDF - 4 pgs)
Sample Letter to PCPs and/or Insurance Companies (PDF - 1 pg)
Job Description for Vascular Access Nurse Coordinator/Case Manager (PDF - 2 pgs)
Final Report on Increasing AVF Within Network #15 (PDF - 10 pgs)

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Chronic Kidney Disease (CKD)

CKD Resources
Diagnosis Codes and Billing for CKD (pdf - 1 pg)
Patient Self-Assessment for Kidney Disease (pdf - 1 pg)
Provider CKD Information Tool (pdf - 1 pg)
Screening for Occult Renal Disease (SCORED) (pdf - 8 pgs)

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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.

Immunization Resources

Adult Immunizations - Info on the CMS Web site for both providers/caretakers and patients.

Guidelines for Vaccinating Kidney Dialysis Patients ... (pdf - 8 pgs)
Immunization Education Resource Book - (pdf -285 pgs ) This resource book is very large so may take considerable time to download. It contains a variety of materials including: a step-by-step guide to adult immunizations, immunization record sheets, posters, handouts, brochures, newsletters, fact sheets, and more.
National Immunization Program - This is a portion of the CDC Web site that is specifically geared to healthcare professionals and has a plethora of immunization resources.

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Consumer Assessment of Healthcare Providers and Systems (CAHPS)

CAHPS overview
In-Center Hemodialysis Survey and Reporting Kit

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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:

Patient/Family Educational Materials for Increasing Albumin
Albumin: Why is it Important? (PDF - 1 pg)
In Control Newsletter - Protein: An Important Part of Your Dialysis Diet (pdf 4 pgs) Reprinted with permission from Life Options.
Live Longer with a Higher Albumin (PDF - 1 pg)
Promoting Protein (PDF - 2 pgs)
Protein Packed Snacks (PDF - 3 pgs)
Increasing Your Protein Intake isn't as Hard as you Think (PDF - 10 pgs)
new Protein Calendar - 30 Ways to Increase Your Protein (PDF - 1 pg)
new Kid and Kidney-Friendly Foods (PDF - 2 pgs)

Staff Resources for Increasing Albumin
2000 NKF-KDOQI Nutrition Guidelines (highlights) (PDF - 1 pg)
Improving Albumin Levels Among Hemodialysis Patients: A Community-Based Randomized Controlled Trial (pdf - 9 pgs)
In Control - Dialysis Patients' Need for Protein (pdf - 4pgs) Reprinted with permission from Life Options.
Barriers to Adequate Albumin Checklist (pdf - 2 pgs)
Albumin Facts (PDF - 1 pg)
kidneytools.com - This site requires users to go through a very short registration process before entering. Please go to "Nutrition A to Z" and be sure to see the "Nutrition Assessment" section. This contains the Subjective Global Assessment (SGA) as well as other assessment forms that can help determine a patient's nutrition status.

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. arrow

click here to download protein magnet image

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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, or to view previous years' annual reports 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)

Adequacy/Access Tools
Permanent Vascular Access Surveillance/Intervention Flowchart (PDF - 2 pgs)
Temporary Access Surveillance (PDF - 2 pgs)
Accesses in Your Facility Are in Trouble if . . . (PDF - 1 pg)
Access History Forms (PDF - 2 pgs)
Monthly Vascular Access Surveillance Record (PDF - 1 pg)
Vascular Access Referral Summary (PDF - 1 pg)

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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
Quality Improvement Form Template

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WebEx Recordings

  • Introduction to Fault Tree Analysis (WebEx recording) - This 50-minute WebEx session was presented on February 14, 2006 by Mike Silver of Healthsight, in collaboration with ESRD Network #15. Fault tree analysis is a QI tool that can be used to help identify and evaluate the potential weaknesses in your healthcare system which might be contributing to poor patient outcomes.

 

Medical/FDA Alerts

Guidelines for Environmental Infection Control in Healthcare Facilities is now available in its entirety at the CDC web site.

For updated medical/drug alerts we recommend you visit the MedWatch web site which is maintained by the FDA.

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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

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