Change Package
Vascular Access for Hemodialysis
Increasing the Incidence and Prevalence of AV Fistulas

Introduction

As part of the ESRD Network Scope of Work beginning July 2003, CMS, the ESRD Networks and key provider representatives jointly recommended adoption of a National Vascular Access Improvement Initiative (NVAII). The principal goal of the initiative is to increase the appropriate use of AV fistulas for hemodialysis access, reaching or exceeding the CPM and K/DOQI guidelines for AVF incidence and prevalence.

The pages that follow describe a set of change concepts for increasing AV fistula use among hemodialysis patients in the United States. Input to these change concepts was provided by a multi-disciplinary working group with representation from the following groups: ESRD Network Executive Directors and Quality Improvement Directors, corporate and independent dialysis providers, nephrologists (including interventional nephrologists), nephrology nurses, vascular surgeons, interventional radiologists, patients, CMS project leaders and quality improvement staff, and the Institute for Healthcare Improvement. Lawrence Spergel, MD, a vascular access surgeon with substantial experience in clinical and quality improvement issues, chaired the working group.

The working group identified two main approaches to increasing AV fistula use—
• Clinical and organizational changes that can be adapted and applied locally to improve AVF prevalence and success. These changes can be undertaken immediately.
• System changes that must be implemented at a national level. These will require national leadership from CMS and should be expected to take longer to accomplish.

Many within the ESRD community have pointed out the need for system-level policy changes to encourage more AV fistula placement. These include reimbursing AVFs at a higher rate than AV grafts or catheters. Similarly, reimbursing venous mapping in limited and specific cases, for example. evaluation for a first AVF, would encourage AVF placement and improve the likelihood of success. CMS has stated its commitment to examining these issues carefully and considering appropriate changes.

National Vascular Access Improvement Initiative

The focus of the NVAII is on the first issue stated above—to address clinical and organizational improvements that will lead to more successful use of AV fistulas. ESRD Networks, dialysis providers, medical specialists, hospitals, and clinics, all share the responsibility for improving dialysis care by increasing appropriate and successful AVF placement. The ESRD Networks have a major role in catalyzing change, creating efficient ways to share knowledge and resources, and building strong alliances with the facilities and medical professionals in their regions. This document focuses on changes that can be made immediately to give all hemodialysis patients a better chance to receive an AV fistula.

Change Package Overview

Change concepts are ideas that have been used successfully, at least in some settings. They are presented to the ESRD Networks as a starting point in addressing the upcoming National Vascular Access Improvement Initiative. Network leaders and Quality Improvement staff in each region will need to develop their own strategies for implementation, addressing the opportunities and issues in their own regions.

The change package comprises two parts. The first provides a summary of the proposed change concepts. The second offers a list of resources including published references and available tools to support implementation.

Implementing the Change Package

Throughout the implementation process, the ESRD networks will function as leaders of the overall effort, establishing strategy, convening key stakeholders, providing education, disseminating practical tools and resources, and ensuring an open flow of information and feedback.

Regarding the clinical recommendations contained in the change package, Networks must draw upon the experience and expertise of their Medical Review Boards and medical experts in their community. Some change concepts may involve clinical approaches that are not currently common practice or about which there is a range of opinion. Local clinical guidance is critical to selecting and implementing appropriate strategies. Similarly, Networks must take into consideration the availability of local clinical resources and expertise in developing their own strategies.

Together, the ESRD Networks, dialysis providers and medical specialists comprise a complex and sophisticated system for serving hemodialysis patients. By working together within a common framework, professionals in the field of hemodialysis can be certain that their efforts will lead to better care and better outcomes for the most important group of stakeholders—ESRD patients.

Here are 11 key clinical and organizational changes for increasing AV fistula use and improving hemodialysis patient outcomes:

1. Routine CQI review of vascular access
   • Designate staff member in dialysis facility (RN if feasible) responsible for vascular access CQI.
   • Assemble multi-disciplinary vascular access CQI team in facility or hospital.
     • Minimally: Medical Director and RN (VA CQI Coordinator).
     • Ideally: Representatives of all key disciplines including access surgeons and interventionalists.
   • Investigate and track all non-AVF access placements, and AVF failures.
2. Timely referral to nephrologist
• Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.
  • Establish meaningful criteria for PCPs who may not perform GFR or creatinine clearance testing.
• Nephrologist documents AVF plan for all patients expected to require renal replacement therapy.
• Designated nephrology staff person educates patient and family to protect vessels, when possible using bracelet as reminder.
3. Early referral to surgeon for “AVF only” evaluation and timely placement
   • Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery referral.
   • Nephrologist refers for vessel mapping where feasible, prior to surgery referral.
   • Nephrologist refers patients to surgeons for “AVF only” evaluation, no later than Stage 4 CKD (GFR<30). Surgery scheduled with sufficient lead-time for AVF maturation.
   • Nephrologist defines AVF expectations to surgeon, including vessel mapping (if not already performed).
   • If timely placement of AVF does not occur, nephrologist ensures that patient receives AVF evaluation and placement at the time of initial hospitalization for temporary access (e.g. catheter).
4. Surgeon selection based on best outcomes, willingness, and ability to provide access services
• Nephrologists communicate standards and expectations to surgeons performing access, e.g., K/DOQI minimal standards for AVF placement, and training in current techniques for AVFs.
• Nephrologists refer to surgeons willing and able to meet the standards and expectations.
• Surgeons are continuously evaluated on frequency, quality and patency of access placements. Data collection ideally is initiated and reported at the dialysis center as part of ongoing CQI process, and can be aggregated at the Network level.
5. Full range of appropriate surgical approaches to AVF evaluation and placement
• Surgeons utilize current techniques for AVF placement including vein transposition.
• Surgeons ensure mapping is performed for any patient not clearly suitable for AVF based only on physical exam.
• Surgeons work with nephrologists to plan for and place secondary AVFs in suitable AV graft patients.
6. Secondary AVF placement in patients with AV grafts
   • Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion, including mapping as indicated, and document the plan in the patient’s record.
• Dialysis facility staff and/or rounding nephrologists examine outflow vein of all graft patients (“sleeves up”) during dialysis treatments (minimum frequency, monthly). Identify patients who may be suitable for elective secondary AVF conversion in upper arm and inform nephrologist of suitable outflow vein.
• Nephrologists refer to surgeon for placement of secondary AVF before failure of AVG.
7. AVF placement in patients with catheters where indicated
• Regardless of prior access (e.g. AV graft), nephrologists and surgeons evaluate all catheter patients as soon as possible for AVF, including mapping as indicated.
• Facility implements protocol to track all catheter patients for early removal of catheter.
8. Cannulation training for AV fistulas
• Facility uses best cannulators and best teaching tools (e.g., videos) to teach AVF cannulation to all appropriate dialysis staff.
• Dialysis staff use specific protocols for initial dialysis treatments with new AVFs and assign the most skilled staff to such patients.
• Facility offers option of self-cannulation to patients who are interested and able.
9. Monitoring and maintenance to ensure adequate access function
• Nephrologists and surgeons conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure and refer for intervention as indicated.
• Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF.
• Nephrologists, interventional radiologists, and surgeons adopt standard criteria, and a plan for each patient, to determine the appropriate extent of intervention on an existing access before considering placing a new access.
10. Education for caregivers and patients
• Routine facility staff in-servicing and education program in vascular access.
• Continuing education for all caregivers to include periodic in-services by nephrologists, surgeons, and interventionalists.
• Facilities educate patients to improve quality of care and outcomes (e.g., prepping puncture sites, applying pressure at needle sites, etc.).
11. Outcomes feedback to guide practice
• Networks work with dialysis providers to give specific feedback to all decision-makers on incident and prevalent rates of AVF, AVG, and catheter use.
• Review data monthly or quarterly in facility staff meetings. Present and evaluate data trended over time for incident and prevalent rates of AVF, AVG, and catheter use.

Vascular Access Working Group Members

Chair
Larry Spergel, MD, Dialysis Management Medical Group (Vascular Access Surgeon)

Network/Forum Members
Jeanette Cain, QI Director, Network 9/10
Janet Crow, MBA, Administrator, Forum of ESRD Networks
Jennie Kitsen, Executive Director, ESRD Network 1
Doug Marsh, Executive Director, ESRD Network 18 (Network Coordinating Center)

Provider Representatives
Maureen Herget, RN, VP CQM, Fresenius Medical Care (designated by Michael Lazarus, MD)
John Sadler, MD, Pres. & CEO, Independent Dialysis Foundation

Patient Representative
Mike Zecca, ESRD Patient

Clinicians
Deborah Brouwer, RN, Allegheny General Hospital (Nephrology Nurse)
Richard Gray, MD, Medstar Health (Interventional Radiologist)
Vo D. Nguyen, MD, Renal Care Group of the Northwest (Nephrologist)
Jack Work, MD, Emory University (Interventional Nephrologist)
Bessie Young, MD, MPH, VA Puget Sound Health Care (Nephrologist)

CMS
Jefferson Rowland, Government Task Leader
David Hunt, MD, Medical Officer, Quality Improvement Group

Institute for Healthcare Improvement
Carol Beasley, Project Director
Kevin Nolan, Improvement Advisor
Rebecca Steinfield, Project Manager