Quest Demo - (Page 9) an AVF first where feasible and not otherwise medically contra-indicated. Not all patients will be considered suitable for an AVF, for any number of reasons other than anatomic limitations. The patient’s age, medical condition, life expectancy and other factors, along with anatomic issues, need to be considered. In a given patient, these considerations may actually make an AVG or CVC more suitable than an AVF. This is why the FFBI goal is 66% and not higher. A secondary goal of the FFBI, added in 2007, is to reduce catheter use. An FFBI multidisciplinary work group was assembled, along with task forces—working groups consisting of a cross-section of the ESRD community and the ESRD Networks—to address the development of the information base, as well as the tools and resources needed to implement recommendations and evidence-based guidelines at the local level in the ESRD community. The clinical “backbone” of Fistula First is the Change Package developed by the work group. The clinical Change Package consists of 11 specific behavioral or systems changes (the “Change Concepts”) considered crucial to improving AVF rates, and that have been identified in clinical practice as being successful in optimizing AVF outcomes (see Exhibit 1). In addition, best practices and the tools and resources needed to implement each of the concepts in this Change Package have been identified and developed, and can be found on the Fistula First website (fistulafirst.org). The day-to-day management and implementation of FF was assigned to the 18 ESRD Networks. Understanding that it takes a long period of time and great effort to provide education and to modify behavior and practice, the initial goal was established to achieve the original KDOQI benchmark of 40% prevalent use by 2006. This goal was reached in 2005, and as a result of this early success, the initiative was extended to 2009, with a “stretch” goal of 66% AVF use in prevalent patients—certainly still a conservative goal, considering the much higher prevalence achieved by other developed countries. This AVF stretch goal was also adopted by KDOQI in the updated 2006 Practice Guidelines. Exhibit 1 Fistula First Change Package Clinical and organizational recommendations based on best practices for increasing AV fistula use and improving hemodialysis patient outcomes: 1. Routine CQI review of vascular access 2. Timely referral to nephrologist 3. Early referral to surgeon for “AVF only” evaluation and timely placement 4. Surgeon selection based on best outcomes, willingness, and ability to provide access services 5. Full range of appropriate surgical approaches to AVF evaluation and placement 6. Secondary AVF placement in patients with AV grafts 7. AVF placement in patients with catheters where indicated 8. Cannulation training for AV fistulas 9. Monitoring and maintenance to ensure adequate access function 10. Education for caregivers and patients 11. Outcomes feedback to guide practice For more details on the Fistula First Change Package, visit http://www.fistulafirst.org/pdfs/ Change_Package_w-disclaimer.pdf. 9 http://fistulafirst.org http://www.fistulafirst.org/pdfs/Change_Package_w-disclaimer.pdf http://www.fistulafirst.org/pdfs/Change_Package_w-disclaimer.pdf
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