Developing a Quality Assurance Performance Improvement (QAPI) Program at Your Dialysis Center Rudolph P. Valentini, M.D. Associate Professor of Pediatrics Director of Dialysis Services Vice Chief of Staff Children s Hospital of Michigan rvalen@med.wayne.edu

Introduction Review CMS expectations for development of QAPI by dialysis facility Discuss strategies to initiate a QAPI program at your center Review outcomes of a Quality Initiative at our center as it relates to pediatric vascular access

494.110 Condition: Quality assessment & performance improvement (QAPI) V626: The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, driven, quality assessment and performance improvement program with participation p by the professional members of the interdisciplinary team.

494.110 Condition (Cont): Quality assessment & performance improvement (QAPI) The program must reflect the complexity of the dialysis facility s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.

QAPI Participants Interdisciplinary Team (IDT) Members Physician Registered nurse Masters-prepared social worker Registered dietician

QAPI Focus A Quality Process with: Data Analysis to Track Health Outcomes to Identify, Prevent, and Reduce Medical Errors, Morbidities and Mortality Accepted standards used for improvement targets: MAT (Measures Assessment Tool) CMS Clinical Performance Measures (CPMs)

Measures Assessment Tool: MAT Uses Standards and Reference values: [e.g. AAMI for water quality, KDOQI for patient assessment parameters] [CMS ESRD Interpretive Guidelines 2008]

MAT: Parameters to follow Dialysis adequacy Reuse Nutritional status Mineral metabolism/ Bone disease Anemia management Vascular access Medical injuries & Medical errors identification Patient satisfaction/ Grievance Infection control Vaccinations Physical and mental functioning Patient survival

Initiating QAPI at Your Center Where to Start? Answer: Get Organized and Follow the Data.

Considerations Prioritize improvement goals according to: Most prevalent problems vs The problems most likely to impact patient safety* Unsafe dialysate must be a higher priority than elevated phosphorus levels

Data Review Review Data Indicators with IDT Assess if Data Outcomes fall within set goals Data Outliers falling short of set goals = Identified Problem

Example As part of CQI or QAPI, the medical director and IDT set a goal that: > 85% of HD patients achieve KDOQI Adequacy goal [URR>65% & Kt/V >1.2] If after review with IDT, it is determined that only 75% of patients dialyzed at your center are achieving KDOQI goal for HD, then this identifies a PROBLEM.

Once Problem Identified-> Need to Conduct a Root Cause Analysis Need to review possible causes with IDT members Medical Patient Staff Psychosocial

Root Causes Identified -> Need to Identify Potential Barriers Example: Hgb concentrations are found to be < desired d goals; it is determined d that t cause is poor erythropoietin responsiveness (low reticulocyte t count despite adequate iron stores). Closer analysis reveals that patients with refractory anemia have marked elevated PTH Barrier: : optimal erythropoietin ti responsiveness cannot be achieved until PTH management improves

Barrier Identified-> Develop strategies to overcome barriers Example (Cont): To improve PTH control, the IDT determines that they will use more calcimimetic agents and aggressive use of vitamin D2 analogs while closely monitoring the calcium and phosphorus values of the patients.

Create a Plan Once plan is drafted, its feasibility should be discussed amongst IDT members. Plan should be written with data driven outcome measures.

Implement your Improvement Plan Then.. Track Outcomes Use a Data tracking tool Monitor Outcomes against Baseline with Periodic Reviews Review results and modify plan accordingly

CQI/QAPI at CHM Identifying the Problem(s) High incidence of positive blood cultures Frequent alarms on HD with suboptimal dialysis adequacy statistics

Root Cause Analysis Cause: Most problems linked to presence of central venous catheters (CVC)

Barriers to Reducing CVC Placement Rates [and Improving Placement Rates for Internal Vascular Access (AVF or AVG)] 1. Children have small vessels 2. Children do not want to be cannulated with painful needles 3. High primary failure rate of AVF in children 4. Children anticipating transplant need not undergo additional surgeries when CVC functioning

Central Venous Catheters: Predominant Access Type in Pediatrics Vascular access at initiation, by age Figure 8.25 (Volume 2) USRDS 2008 Report Currently, catheter use remains high (68-81%) Fistula use rates low (16-26%) Fistula use rates increasing in children < 13 yrs old Incident hemodialysis patients, 2001 2006; 2006; ESRD CPM data. Year represents incident year; access represents the access used at the time of data collection.

Cross sectional study:10 participating centers in MWPNC. Assessed CVL usage rates and relative complication rates in prevalent HD patients 61/83 (73%) HD patients t at participating i centers were dialyzed using a central venous line (CVL) CVL dysfunction (reduced blood flows, need for reversed e blood flow, or frequent intradialytic alarms) occurred in 46% in the prior month Treatment t for suspected clots occurred in 16 pts. Conclusion: Usage rates and complication rates were high in prevalent HD patients within the participating centers of MWPNC. Pediatric Nephrol. 2008; 23:291-5.

Catheters increase pediatric sepsis risk nearly 20 times AVF Dialysis access infectious events Figure 8.27 (Volume 2) USRDS 2008 Report incident hemodialysis patients age 0 19, in both the USRDS & ESRD CPM datasets & with Medicare as primary payor on January 1 of the year following incidence. Access obtained from CPM data; represents the current access as reported during October December of the incident year. Infection & sepsis from Medicare claims during the calendar year following incidence; infection refers to an infection of the vascular access/internal device.

Okay CVC s are bad, but How can we increase AVF/AVG rates in children?

Functional Assessment of Venous System [Malovrh M (AJKD 2002)] Emphasized the need to use duplex ultrasound to study the vein of interest Inflation of BP cuff to 50 mm Hg Patient examined to visualize cephalic vein Measure internal diameter of vein at baseline Remeasure vein after proximal venous compression (PVC) to assess ability of vein to dilate 80% primary patency rate for AVF Patent fistulae associated with 48% increase in vein diameter after PVC vs. only 11% increase after PVC in failed AVF Also arterial flow increased 83% in patent AVFs vs 41% Resistive indices decreased by 140% in patent AVFs vs 51% in failed AVFs

Volume Expansion may increase AVF Patency Malovrh M. [Nephrol Dial Transplant 2003] 44 patients with marginal vessels (arterial diameter approaching 1.6 mm or lower, high resistive indices on Doppler after release of clenched fist, and lower arterial blood flow) 22 patients were treated with a plasma expander during the surgical procedure and 22 were not Treated patients t had a patency rate of 86% Untreated patients had a patency rate of 27% Raises the question of intraoperative and perioperative management of ESRD patients seeking an AV fistula.

Barriers to Pediatric Vascular Access Children have smaller vessel caliber making achievement of permanent vascular access a challenge Surgical expertise is quite variable Pediatric surgeons, transplant surgeons, and vascular surgery perform vascular access surgery in pediatric nephrology

Access Data at CHM AV Fistulae: 29% AV Grafts: 14% CVC: 57% January 2006 Why so poor?..

CHM Vascular Access Goals Place more AV fistulae and Reduce catheter usage Aggressive Preop and Perioperative Aggressive Preop and Perioperative protocols put into effect March 2006

Early Planning Preserve vessels (especially in non- dominant arm) in Chronic Kidney Disease 3 (GFR < 60 cc/min/1.73 m2) Avoid phlebotomy, IVs and PICC lines Identify children with chronic kidney disease who are candidates for hemodialysis at least 6 months before anticipated dialysis date

Preoperative Planning Screen patients preoperatively with imaging of venous system in non-dominant arm Ultrasound preferred in CKD patients to avoid risk of IV contrast Venography required if prior central venous catheter Start patient on aspirin 81 mg daily (should ideally be on for 5-7 days minimum before surgery) Refer to vascular access surgeon for AVF

Surgical Planning Review imaging g study Assess non-dominant arm for quality of pulsations and forearm, antecubital, and upper arm scarring If patient s vessels are acceptable, schedule for placement of AVF and contact nephrology re: operative date Schedule e existing HD patients ts on Non-dialysis dayss days Pre-ESRD patients may require preop hydration if high urine output exists.

Perioperative Management Immediate Preoperative Intraoperative Postoperative ti

Immediate Preoperative Care Patient advised to hold AM BP medications NPO IV hydration initiated at maintenance* *Patients with CKD and high urine output usually admitted on the night prior to surgery with fluid prescription tailored to UOP (usually 1.5-2 x maintenance)

Intraoperative Management Prepare OR with 5% albumin and dopamine on hand (no need to spike) Monitor BP per protocol Aim for BP at 90-95 th percentile for age, height, and gender Support BP with: Crystalloid (saline) at 10 cc/kg x 2 if needed Colloid using 5% albumin at 5-10 cc/kg Inotropic support with dopamine (5-10 mcg/kg/min) Surgeon to confirm flow thru AVF in OR

Postop Management Recovery Room Maintain BP at 90-95 th percentile as defined Confirm bruit with light pressure on stethescope Floor (6 west) Monitor BP closely Continue to hold home BP meds, can use low dose hd hydralazine IV or lbtll labetalol Monitor bruit thru AVF q 15 min x 4, q 30 min x 2, then q hour Educate family re: fistula care-avoid compression and exercises to support; Schedule follow up with vasc access surgeon- 2 weeks

Is Hypotension and AVF viability important? Berger and Rosenberg presented 2 patients who thrombosed their AVF in the setting of hypotension (Am Surg 1983) Thomsen et al (Acta Chir Scand 1983) reported in adults that early AVF failure was associated with diabetes, peroperative BP < 110 mm Hg (53% vs 24%), and small caliber veins

What evidence is there that developing a dedicated, di d coordinated d vascular access program of nephrologists, nephrology nurses, surgery, anesthesia, and interventional radiology has made a Difference in Patient t Care Outcomes at CHM?

Changing HD Access Practices at CHM 2007 2008 Permanent HD Catheters Placed: 6 Permanent HD Catheters Placed: 4 Internal accesses Internal accesses (AVF/AVG) Placed: 5 (AVF/AVG) Placed: 8

HD Vascular Access at CHM 100% 90% 80% 70% 60% 50% CVC AVG 40% AVF 30% 20% 10% 0% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Jan 2006 thru Sept 2008

Current HD population at CHM AVF AVG Number of pts 7 5 Mean age at 14.5 years 7.3 years placement (10.1-16.4) (3.7-11.8) Mean weight at 53.3 kg 21.1 kg placement (29-105.4) (14.3-28.4) Site/Type 5 Forearm; 4 thigh; 2 upper arm 1 upper arm Maturation time 6.7 months 28.6 days (2.3-23 months) (21-35)

CVC Avoidance: From CKD to AVF

Radiocephalic Fistula in Non-Dominant Arm Radiocephalic AVF

Summary Developing a Quality Assurance and Performance Improvement (QAPI) program at your program is achievable Using IDT with an organized process of data review will identify problems Set goals to resolve problems and aim for preset targets t such as MAT or CMS Clinical Performance Measures

Summary II Prioritize improvement goals QAPI process involves: Root Cause Analysis Identifying barriers leading to cause of problem Developing strategies to overcome these barriers Establishing, implementing, and reassessing results of improvement plan

Summary III An organized and dedicated, multidisciplinary team approach can result in improved outcomes even when the goals appear difficult to achieve.

Acknowledgements Dialysis Staff at Children s Hospital of Michigan Vascular access team (Surgery and Int Radiology) Quality Staff at CHM Network 11 collaborators: Jan Deane and Chris Singer Network 9/10: Bridget Carson and Dr. Deepa Chand

Questions?