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Fistula First Toolkits

Vascular Access The Fistula First Breakthrough Initiative (FFBI) has developed and adapted a suite of tools to help dialysis facilities and physicians accelerate their work to increase arteriovenous fistula (AVF) rates in hemodialysis patients. Healthcare Professionals - Fistula First website contains information on best practices and the tools and resources you can use to achieve them. In addition, other organizations and individuals have developed tools in the course of their improvement efforts — for example, successful protocols, order sets and forms, instructions and guidelines for implementing key changes — and are making them available on http://www.IHI.org for others to use or adapt in their own organizations. We invite you to submit tools you have found useful! Last updated 1/4/2010

TABLE OF CONTENT CHANGE CONCEPTS Routine CQI Review of Vascular Access Timely Referral to Neprhologist Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement Secondary AVF Placement in Patients with AV Grafts AVF Placement in Patients with Catheters Where Indicated Cannulation Training for AV Fistulas Monitoring and Maintenance to Ensure Adequate Access Function Education for Care Givers and Patients Outcomes Feedback to Guide Practice Modify hospital systems to detect CKD and promote AV fistula planning and placement Support patient efforts to live the best possible quality of life through self-management Get a copy of Data Collection Tools

CHANGE CONCEPTS

• Fistula First Change Package
• Introduction to Fistula First (PowerPoint by Lawrence Spergel, MD, FACS)

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1. Routine CQI Review of Vascular Access

• Overall Implementation Tracking Tool
• Referral / Intervention Tracking Log
• Baseline Vascular Access Monthly Tracking Tool Summary
• AVF Roadmap for Nephrologists
• Vascular Access Coordinator Role
• Role of the Dialysis Access Coordinator (PowerPoint Adapted by Carolyn Barclay, RN, CNN) (HANDOUT PDF VERSION )

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?

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2. Timely Referral to Nephrologist

• Draft Letter to PCP from Nephrologist
• Pre-ESRD Vascular Access / AVF Plan
• Fistula Preservation, Development and Maintenance Policy & Procedure - SAMPLE
• Fistulas for Dialysis: The Challenge of Preservation, Creation, Maturation, and Cannulation (PowerPoint by Leslie C. Dinwiddie, RN and William Marston, MD) (HANDOUT PDF VERSION)

Educational Materials Fistula First Web site:
Where should I begin if I am a Primary Care Provider?
Where should I begin if I am a Nephrologist?
Where should I begin if I work in a Hospital?

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3. Early Referral to Surgeon for "AVF Only"
Evaluation and Timely Placement

• Autologous AVF Algorithm
• Hemodialysis Access Referral Packet: New Access (Inclusive of fax diagram, patient consent)
• Request for Surgical Evaluation / Consultation – SAMPLE FOR REFERENCE
• AV Access Checklist - SAMPLE
• Universal Vascular Access Diagram (to be COMPLETED by Surgeon and Faxed to Facility)
• Commonly Used Permanent Vascular Access Codes (To be used for claims purposes)
• A Practitioner’s Resource Guide to Hemodialysis Arteriovenous Fistulas (Written by Gerald Bethard, MD)

• A Practitioner’s Resource Guide to Physical Examination of Dialysis Vascular Access (Written by Gerald Bethard, MD)

Educational Materials Fistula First Web site:
Where should I begin if I am a Nephrologist?
Where should I begin if I am an Interventionalist?

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4. Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services

• Local Surgeon Questionnaire – SAMPLE FOR REFERENCE
• National Surgeon Questionnaire – SAMPLE FOR REFERENCE

Educational Materials Fistula First Web site:
Where should I begin if I am a Nephrologist?

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5. Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement

• Duplex of Upper Extremity Vessels Prior to AVF Surgery (Provided by Olympic Vascular Lab Surgical Associates and Memorial Nephrology Associates, Olympia, WA) Information includes: 1) Venous template; 2) Arterial template; 3) Venous Map (example); and 4) Arterial Map (example)

• AV Fistulas in Most (All?) Patients (PowerPoint by William Jennings, MD, FACS)
• Wrist (Cimino and Brachial AVF’s (PowerPoint by William Jennings, MD, FACS)
• Exploiting the Proximal Radial Artery (PowerPoint by William Jennings, MD, FACS)
• Surgical Approaches to AVF Construction/Vein Transpositions (PowerPoint by Lawrence Spergel, MD, FACS)
• The Difficult Access Patient (PowerPoint by William Jennings, MD, FACS)
• CD/DVD Series: “Creating AV Fistulae in All Eligible Hemodialysis Patients”

Educational Materials Fistula First Web site:
Where should I begin if I am a Surgeon?

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6. Secondary AVF Placement in Patients with AV Grafts

• Secondary AV Fistulae in Patients with AVG’s – The “SLEEVES UP: PROTOCOL” (Provided by Lawrence Spergel, MD, FACS)
• Hemodialysis Access Referral: Existing Access (Inclusive of fax diagram)
• Surgical Approaches to AVF Construction: Secondary AVF’s (PowerPoint by Lawrence Spergel, MD, FACS)

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?
Where should I begin if I am a Nephrologist?
Where should I begin if I am a Surgeon?

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7. AVF Placement in Patients with Catheters Where Indicated

• Management of Patient with CVC Algorithm
• Checklist of Indications for Hemodialysis Catheter Use
• Monthly Catheter Tracking Tool for Facilities
• Root Cause Analysis for Patients with Continuing CVC’s
• Reducing CVC Infections

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?
Where should I begin if I am a Nephrologist?
Where should I begin if I am a Surgeon?

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8. Cannulation Training for AVFs

• Cannulation Camp Basic Needle Cannulation Training for Dialysis Staff (Written by Deborah Brouwer, RN, CNN)

• Improving Arteriovenous Fistula Cannulation Skills (Written by Lynda Ball, BS, BSN, RN, CNN)
• Cannulation of New Fistula Policy and Procedure - SAMPLE FOR REFERENCE
• Determining Maturity of New Arteriovenous Fistulae (Written by Lynda Ball, BS, BSN, RN, CNN)
• What You “KNOW” about the “FLOW” is Really Important with Reverse Flow AVF’s such as Proximal Radial Artery Fistulas (Written by William Jennings, MD, FACS; Lynda Ball, BS, BSN, RN, CNN; and Linda Duval, RN, BSN)
• Flow Diagram for Surgeon Completion / Facility Utilization
• Clamp Usage Policy and Procedure – SAMPLE FOR REFERENCE
• Dialysis Facility Guidelines for Rating & Improving Staff Cannulation Competency – SAMPLE FOR REFERENCE
• AV Fistula Cannulation Resources for Staff
• BUTTONHOLE SECTION
• The Buttonhole Technique for Arteriovenous Fistula Cannulation (Written by Lynda Ball, BS, BSN, RN, CNN)
• Buttonhole Technique for AV Fistulae Only (education and tracking log)
• Buttonhole Technique Fact Sheet
• Buttonhole Method of Needle Insertion into Arteriovenous Fistulas (Written by Zbylut Twardowski, MD and George Harper)
• Dynamic Duo: The Chairside Perspective of the Buttonhole Method and Self-Cannulation (Written by Cate Lewis, RN, BSN, CNN)
• SELF CANNULATION SECTION
• Self Cannulation of Vascular Access Procedure – SAMPLE FOR REFERENCE
• Self Cannulation of Hemodialysis Vascular Access (PowerPoint by Lynda Ball, BS, BSN, RN, CNN)

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?

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9. Monitoring and Maintenance to Ensure
adequate Access Function

• Vascular Access Monitoring & Surveillance Flow Chart (VAMP) – SAMPLE FOR REFERENCE Provided by Lawrence Spergel, MD, FACS

• Permanent Vascular Access Algorithm Surveillance/Intervention – SAMPLE FOR REFERENCE
• Monthly Vascular Access Surveillance Tools – SAMPLES FOR REFERENCE
• Access Tracking Tools - SAMPLES FOR REFERENCE
• Vascular Access Clotting Fishbone – SAMPLE FOR REFERENCE
• Dynamic Venous Pressure (DVP) Monitoring – SAMPLE FOR REFERENCE
• Infection Tracking Tool – SAMPLE FOR REFERENCE

A. REFERENCE LITERATURE

• Early Arteriovenous Fistula Failure: A Logical Proposal for When and How to Intervene (Written by Asif, Roy-Chaudhury, Beathard)
• Vascular Access Surveillance Reduces Vascular Access Thrombosis Rates (VATR) (Written by Zasuwa, Frinak, Besarab, Yee)
• Vascular Access Thrombosis Prophylaxis (Written by Choudhury)
• Endovascular Preservation of Immature and Dysfunctional AVF’s (PowerPoint by W. Perry Arnold, MD)
• Management of Steal Syndrome (PowerPoint by Lawrence Spergel, MD, FACS)
• Endovascular Recanalization of Thrombosed AVFs (PowerPoint by W. Perry Arnold, MD)

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?
Where should I begin if I am a Nephrologist?
Where should I begin if I am a Surgeon?
Where should I begin if I am an Interventionalist?

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10. Education for Care Givers and Patients

• STAFF RESOURCES
• Best Access Procedures from the Dialysis Units’ Viewpoint (PowerPoint by Lesley Dinwiddie, MSN, RN, FNP, CNN) (HANDOUT PDF VERSION )
• General References and Resources
• Staff Resources Spreadsheet / Grid

• PATIENT RESOURCES
• Patient Resources Spreadsheet / Grid
• FFBI Web site for Links to Patient Education Tools
• Doppler Studies and Vessel Mapping Patient Brochure
• Buttonhole Technique Patient Brochure

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?
Where should I begin if I am a Nephrologist?
Where should I begin if I am an Interventionalist?

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11. Outcomes Feedback to Guide Practice

• WHAT PROFESSIONALS CAN DO TO MAXIMIZE AVF’S

Educational Materials Fistula First Web site:
Where should I begin if I work at a Dialysis Facility?
Where should I begin if I am a Nephrologist?
Where should I begin if I am a Surgeon?
Where should I begin if I am an Interventionalist?

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12. Modify Hospital Systems to Detect CKD
and Promote AV Fistula Planning and Placement

• Hospitals develop a comprehensive plan for early identification1 of patients with kidney disease to allow for interdepartmental coordination for protective measures programs to prevent nephrotoxicity or other causes of further kidney damage, to allow for vessel preservation, for patient and family support, and vascular access planning and/or placement.
  1 Patients with eGFR <30 - 44 (CKD Stage 3B)

Fistula First Web site:
Where should I begin if I work in a Hospital?
Where should I begin if I am a Primary Care Provider?

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13. Support Patient Efforts to Live the Best Possible
Quality of Life Through Self-Management

• Patient achieves optimum treatment outcomes and health status through collaborative knowledge-building related to CKD progression and treatment and through effective application of self-management interventions, such as self-monitoring and decision-making.
• Health care clinicians utilize techniques and strategies for the education of those who participate in vascular access education and management that are designed to encourage, enhance, and support patient self-management. This includes motivational interviewing, health coaching, and other patient empowerment strategies and techniques.

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Data Collection Tools

• Data Collection Tools (Excel)
• Data Collection Tools Instruction (PDF)