2017 Long Term Catheter Reduction Project

Derek Taylor, RN

Quality Improvement / Community Education Coordinator

Topics

• Medical Director Participation

• Using the ESRD Forum toolkit

• Rapid Cycle Improvement- PDSA

• Patient Engagement – “Peer to Peer”

• CROWNWeb reporting

Long Term Catheter Reduction

Project

• CMS is requiring the Project Facility Medical Director to interact with the other nephrologists in their facilities for this project

• The goal is to assist the facility by have the Medical Director assist the facility by discussing options for lowering their catheter rates in a peer fashion, but with the authority and responsibility of being the Medical Director

Medical Director Engagement

Actions

• Per CMS facilities are instructed to compile list of catheter patients by MD and give it to the facility medical director so they can discuss with these nephrologists

• Facilities also asked to try and identify any barriers these patient’s have for placement to make discussion easier for the Medical Director

Medical Director Engagement

ESRD Forum Toolkit

Barriers

Barriers

Barriers

Other Tools

Other Tools

• The National Forum of ESRD Networks toolkit contains: PDSA worksheet, QAPI tool, tracking tools, referral letters, refusal form(maybe better as a tool)

• http://esrdnetworks.org/resources/toolkits/mac-toolkits-1/catheter-reduction-toolkit

Tools/Resources

Act What changes

are to be made? Next cycle?

Plan Objective, questions

and predictions (why) Plan to carry out the

cycle (who, what, where, when)

Study Complete the

analysis of the data Compare data to

predictions Summarize what

was learned

Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

The PDSA Cycle for

Learning and Improvement

Rapid Cycle Improvement

Begin a new PDSA Cycle!

PLAN: Plan a specific intervention(s).

Keep it simple and focused; do not over‐reach. Your initial project may be quite limited; you may learn more than you think. You can use what you learn to determine what the next project should be.

Designate personnel and resources for each intervention.

Consider whether to target a specific subgroup for initial intervention.

Determine a timeline; when and how will you collect your follow-up information?

PDSA

DO: Implement your intervention.

Each intervention should have a timeframe and designated personnel.

– Collect your follow‐up data at the planned timeline.

– Tabulate and/or graph your data, using numerators and denominators where appropriate. Calculate percent changes.

– Document your findings

PDSA

STUDY:

Examine your results and re‐evaluate with your team. Is the process working? If not, then why not?

What is working well? If necessary, re‐evaluate the root causes/barriers as well as your interventions.

– Document your progress and findings and revisions in goals and interventions as appropriate.

PDSA

ACT:

If you have not met your goals, begin again with your new plan.

If you met your goals, consider whether to expand to another aspect of the problem.

PDSA

• Every facility must elect a patient representative.

• This requires active involvement

• “Peer to Peer” Resources

Patient Engagement

Good examples:

• Patient representatives are in place and willing to discuss their access placements with catheter patients.

• One patient was identified as patient representative. VAM and CNM will sit with patient to provide resources that patient representative may need to help educate other patients

• Two patient representatives were identified by DON.VAM met with them and got their insights. One of them suggested to have family involved in education, hopefully to influence patients that are refusing.

• One patient identified as an advocate for the patients. She has called new patients and shared her experiences and positive outcome of having a fistula vs. catheter

Patient Engagement

These are not patient engagement but interventions or data

• 1 patient that have been refusing to have AVF use, finally agreed to start one to one stick as of this month of February 2 patients need revisions for access 2 catheters take out this month of February 1 patient transitioned to PD

• IDT team discuss with patients regarding go to vascular appointment, and help patient to set up transportation for appointment

• Continue to speak with patients on a daily basis.

Patient Engagement

Do you have a patient that is refusing to get an AVF?

• Encourage them to call a Peer Support Program. Patients have reported that getting to speak to another patient who understands what it’s like to be a dialysis patient is the most effective way to get information and education.

• Hotlines have ESRD patients trained and available to discuss topics such as getting an access to callers with concerns

• The Peer Supporter on the other end of the phone line can normalize fears, help debunk myths and provide tools that helped them get through a hard time in the past.

Referring Patients to Peer

Support

What to do:

• Refer any patient that is struggling with getting an access

– This resource should be used as a tool and not simply handed out to all your patients. Target the patients that need that extra push.

• Educate the patient on the resource.

– Let them know that they will get to speak to another patient.

– Let them know that the conversation will be totally confidential and nothing they say will be reported back to you.

– Highlight the convenience of being able to call from home at a time that works for them.

Referring Patients to Peer

Support

• Follow up – Ask the patient after a week if they used the resource.

• Do not inquire what they spoke about. – Encourage them to try it if they have not called yet.

• Track success using the enclosed tool. – How many patients did you refer? – How many patients reported calling? – How many of the patients who called made a change

Referring Patients to Peer

Support

Long Term Catheter Reduction

Patients to Peer Tracking and

Follow Up

• Some facilities are not entering their accesses correctly into CROWNWeb and have a higher rate than actual

• Facilities want to report in CROWNWeb monthly what their patients are actually using to dialyze with on the last day of the month

• When entering or updating access types in CROWNWeb please use the access definitions that are found here:

http://mycrownweb.org/help/glossary/

CROWNWeb Reporting

CROWNWeb Reporting

CROWNWeb Reporting

CROWNWeb Reporting

CROWNWeb Glossary

CROWNWeb Reporting

CROWNWeb Reporting

• Example 1: Patient has fistula/graft and a catheter and is using two 17 gauge needles to dialyze – then subtract patient from numerator

• Example 2: Patient has fistula/graft and a catheter and is using one 17 gauge needle and one limb of the catheter to dialyze – then keep patient in the numerator until using two needles solely for dialysis

Numerator = Access Counts

• Medical Director Involvement

• Peer to Peer and patient involvement

• Review your CROWNWeb

Expectations

Questions?

Derek Taylor DTaylor@nw16.esrd.net

206.923.0714

HealthInsight is a private, non-profit, community-based organization dedicated to improving health and health care, operating in nine western states: California, Alaska, Idaho, Montana, Oregon Washington, Nevada, New Mexico and Utah. The HealthInsight ESRD Alliance was formed in 2015 to bring together the strengths of all partners to further integrate quality efforts across the care continuum for patients at risk for kidney disease, those with chronic kidney disease, those on dialysis or receiving kidney transplant care.

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