ESRD Network #17 - Fistula First

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. This project was launched July 1, 2003 by CMS along with the 18 ESRD Networks and the Institute of Healthcare Quality (IHI). The goal is to attain a prevalent AVF rate of 66% by June 2009.

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.

Fistula First Overview and Change Concepts

Project Overview (pdf)

Fistula First Change Package Overview - (pdf) - Lists 11 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 - 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 (pdf)
• FAQ about Arterial Venous Fistula's (AVF) (pdf)
• Fistula Preservation, Development, and Maintenance (pdf)
• Patient Education Resources Notebook (pdf - 6 pgs)
• 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.