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FFCL Change Packet

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The FFCL Change Package includes 13 Change Concepts that provide a roadmap for implementation of the K/DOQI vascular access recommendations. Click here for an overview.


Change Concept 1: Routine CQI Review of Vascular Access

Dialysis facilities should incorporate vascular access into their continuous quality improvement (CQI) processes. Planning and care for vascular access spans many disciplines and settings; breakdowns in communication put patients at risk for sub-optimal treatment. In order to identify patients who...

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Change Concept 2: Timely Referral to Nephrologist

Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria. Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists. Establish meaningful criteria for PCPs who may not perform GFR or...

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Change Concept 3: Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement

When possible, coordinate chronic kidney disease patient care so that patients will be referred early to surgeons specifically for AV fistula evaluation, including vein mapping where indicated, allowing sufficient lead-time for AV fistula maturation. Studies show that mapping vessels can...

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Change Concept 4: Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services

Collect data on the surgeons in your community to find out who has the skills and interest in placing fistulae. Choose surgeons who are willing and able to do AV fistula construction. Nephrologist/skilled nurse performs appropriate evaluation and physical exam prior to surgery...

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Change Concept 5: Full Range of Surgical Approaches to AV Fistula Evaluation and Placement

Surgeons who are skilled in vein transposition techniques are able to create successful AV fistulae in a substantially greater number of patients. These options require vein mapping and a surgeon’s willingness to put in the additional time and effort. Make sure surgeons understand the logistics of...

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Change Concept 6: Secondary AV Fistula Placement in Patients with AV Grafts

Evaluate graft patients for placement of a secondary AV fistula. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when...

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Change Concept 7: AV Fistula Placement in Patients with Catheters Where Indicated

Higher catheter use is associated with increased infection, morbidity, mortality, and hospitalization. Evaluation and mapping of catheter patients is crucial to facilitate the placement of AV fistulae. While catheters are necessary in some circumstances (e.g., while an AV fistula matures), the...

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Change Concept 8: AV Fistula Cannulation Training

Prevent fistulae from being destroyed by inexperienced staff. Discuss the basics of needle cannulation with all staff. Facility uses best cannulators and best teaching tools (e.g., videos) to teach AVF cannulation to all appropriate dialysis staff. Dialysis staff use specific protocols for initial...

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Change Concept 9: Monitoring and Maintenance to Ensure Adequate Access Function

The health care team should establish a process for monitoring and maintenance of AV fistulae to ensure adequate access function. It is extremely important to catch problems with fistulae early. Problems must be caught within 24 hours or the fistula will fail and be irreparable. There is a 20 to 30...

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Change Concept 10: Education for Caregivers and Patients

To make good decisions about their care, dialysis patients and their caregivers need support and resources, including information about the value of fistulae over other access types, protecting their veins, and advocating for themselves with their health care team. Routine facility staff...

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Change Concept 11: Outcomes Feedback to Guide Practice

Facilities can start by measuring performance on a monthly basis by access type – catheter, AV graft, and AV fistula – since access type is the major determinant of outcomes and directly affects dialysis delivery and adequacy. It is also important to focus specifically on native AV fistula...

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Change Concept 12: Modify Hospital Systems to Detect CKD and Promote AV Fisutla Planning and Placement

Early identification, early education, timely referral to nephrology, and coordination with discharge planning will provide patient and family support in making decisions related to renal replacement therapy and vascular access. Hospital stays provide an additional opportunity for early diagnosis...

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

Patient self-management support will increase patients’ skills and confidence in managing their health problems, including goal setting, regular assessment of progress and problems, and problem-solving support. Patient achieves optimum treatment outcomes and health status through...

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Implementing the Concept Changes and Change Package

Some change concepts may involve clinical approaches that are not currently common practice or about which there is a range of opinion. Local clinical guidance is critical to selecting and implementing appropriate strategies. Practitioners and Networks must take into consideration the availability...

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