Serving: AS, Guam, HI, Mariana Islands, and Northern CA as ESRD Network #17   

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Vascular Access

Fistula First - NVAII Project 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. 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. Network #17'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.

National AV Fistula Rate = 60.4%, Network #17 AV Fistula Rate = 62.8% for January 2012

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"I'm an Essential Piece"

Network #17 is proud to announce the official roll-out of the new and exciting Fistula First Achievement Project, “I’m an Essential Piece”. Network #17 has always maintained a high standing on the Fistula First Initiative comparative dashboard. Although Network #17 has and is maintaining its AVF goals, Quality Improvement staff felt it was important to revitalize the Fistula First Initiative throughout the Network by developing a plan that would give all facilities the opportunity to improve. The Network has developed the “I’m an Essential Piece” fistula achievement project to increase the awareness, importance and revitalization of the Fistula First Initiative. 

Network #17 facilities were sent an “I’m an Essential Piece” poster to place in their facility where both patients and staff can monitor their Fistula First progress. “I’m an Essential Piece” lapel pins were sent along with the posters as gifts for every patient who is currently utilizing an AV Fistula for their dialysis. We hope the lapel pin will inspire other patients to inquire about AV Fistula and the advantages of having one placed. 

Please join your Network in the “I’m an Essential Piece” Fistula First Achievement Project to improve our patient care and AV Fistula rates. We are all pieces of this most important puzzle and will work together to complete it.

Vascular Access Coordinator Resources
Arteriovenous Graft (AVG)
• Sleeves Up Brochure (pdf)
• Sleeves Up Checklist (pdf)
• Sleeves Up Information (pdf)
Vascular Access Coordinator
• Patient Vascular Access History (MS Excel)
• Vascular Access Coordinator Job Description (pdf)
Vascular Access Infection
• Access Infection Flow Sheet (MS Word)
• Access Infection Flow Sheet (MS Excel)
• CDC Guidelines - Catheter Related Infections (pdf)

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Thirteen Change Concepts for Increasing AV Fistulas
Fistula First Change Package Overview - (pdf) - Lists 13 key strategies for increasing AV fistulas.
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 (Micorsoft doc)
• 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) - Developed by Network #14 in collaboration with Gerald Beathard, MD.
• A Practitioner's Resource Guide to Hemodialysis AVFs (pdf) -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)
• Patient Assessment Video - Lawrence Spergel, MD
Change #7: AVF Placement in Patients with Catheters Where Indicated
• Management of Patient with CVC Algorithm (pdf)
• Physician Letter to Catheter Patient (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.
• Monthly Performance Tracking Tool (Excel)
• Developed 11/11: Tushar Vachharanjani, MD, FACP, FASN, Dialysis Access Group of Wake Forest University School of Medicine, North Carolina. These animated videos will instruct the user to perform complete and proper physical exams of an arteriovenous fistula.
Physical Examination of AVF 
Continuous Circuit
Arm Elevation Test
Augmentation Test
Outflow Stenosis
Accessory Vein

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Fistula First Resources
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.

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NETWORK #17 Fistula First Reports

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Network #17 Fistula First Newsletters

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The Gold Standard - Fistula First Breakthrough Initiative Newletters

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