Fistula First Change

Package

Quality Tool
Presented by:
Katherine Astaneh, RN, BSN
Fistula First Change Concepts


To Nephrologist from Primary care
To 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 meet
K/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
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


(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.
(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.

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.


(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 AVFs for functionability
Education to patients
Asking for patient opinion


(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

AVFs have:
Lower rate of infection
Lower rate of clotting
Longer rate of patency
Require less hospitalization
Less patient morbidity
Significant lower cost
AVGs & 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


RT Internal Jugular Ash Catheter
Arterial
Venous Fistula
Arterial Venous
Graft
(Vascular Access for Hemodialysis, 2010)
(Vascular Access for Hemodialysis, 2013)
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