Making Dialysis Safer for Patients: Optimal Vascular Access

you hello and welcome to the tune in to face health care webinar series the attend today's presentation making dialysis safer for patients optimal vascular access hosted by the Centers for Disease Control and Prevention my name is Preeti Patel and I'm a medical officer in the division of healthcare quality promotion at CDC and the director of the making vows is safer for patients coalition's this webinar is a part of a series of infection control related webinars that CDC hosts along with a variety of external partners and experts we thank you for tuning in today world kidney day 2019 before we get started we have the following disclaimers to show and the following disclosure you this webinar is accredited for physicians nurses pharmacists certified health educators public health professionals and other health professions the next two slides show the accreditation for continuing education instructions for obtaining continuing education will be provided at the end of the webinar you you it is now my pleasure to introduce our main speaker for today's presentation dr. Dean of the Cova dr. kazakova is a health scientist in the division of healthcare quality promotion at CDC she completed her medical training in Russia obtained her master's degree in health services at Boston University School of Public Health and doctoral degree in health policy at Johns Hopkins Bloomberg School of Public Health her doctoral research was focused on access to primary care in the United States and its impact on individual health status she has previously worked at the agency for Healthcare Research and quality arts where she assisted with analyses of large Medicare databases doctor kazakova has also completed CDC's epidemic intelligence service or EIS training program during which time her investigations and other work were focused on healthcare associated infections I will now turn it over to dr. kazakova to present to you a study she led on infinite vascular access and risk of bloodstream infection among new ESRD patients receiving hemodialysis thank you so much for the opportunity to present to the analysis that were conducted by a group of epidemiologists and clinicians in the division of healthcare quality promotion of CDC according to the title the focus of the study was hemodialysis vascular access and more specifically incident access incident means or equals to being first it is the very first access used at dialysis initiation and during the presentation I will refer to incident catheter fistula and graph use in addition to incident access this study looked at prevalent access which is defined as vascular access continually used during a period of time and similarly to incident access I will refer to prevalence catheter fistula and grab shoes according to the most recent us renal data system report in 2016 there were over 700,000 and stage renal disease patients in the United States of those 63% were treated with hemodialysis which required reliable access to the bloodstream among the three types of accesses fistula is a first choice because of better and Java T and lowest rates of complications including infection grafts may also be the first choice particularly among children and patients with peripheral vascular disease catheters are important as well especially for patients requiring urgent dialysis or those whose permanent access field although catheters can be placed in a timely fashion they have been linked with severe complications such as bloodstream infections and therefore are not recommended for long-term use in recognition of the advantages of fistula in 2003 the National fistula first campaign was initiated to increase prevalent fistula use among end-stage renal disease patients on hemodialysis and in fact prevalent fistula use increased from 32 percent in 2003 to 63 percent in 2017 in this graph prevalence fistula used is represented by blue green line at the top and prevalent catheter used by brown and orange lines at the bottom as you can see the significant increase in prevalence is to use corresponded only when a small incremental decrease in prevalence catheter use when we look at vascular access use from the perspective of a new patient since 2005 about 80% of all incident patients have been initiating hemodialysis with catheter and this trend has not changed since 2005 this graph shows the relationship between incident and prevalent access where our outer portion of the circle shows the relative proportions of new and prevalent patients contributing to the prevalent access count as you can see the majority of prevalence catheter use count which is in blue comes from new patients confirming the importance of incident catheter use in addition to tracking incident access it is important to understand how initiating hemodialysis with one axis versus another another assess health outcomes today they have been several observational studies that examined incident access and found that initiating dialysis with fistula was associated with better survival lower rates of vascular access related hospitalizations and lower cost however every observational study can be subject to potential selection bias where healthier patients might be more likely to obtain fistula and those in need of urgent dialysis and ineligible for future look more likely to use catheters these highlights the importance of controlling for patient health status and other characteristics potentially linked with both vascular accidents and health outcomes under the study in light of the evidence and also its limitations we conducted a study with the goal to estimate the risk of acquiring bloodstream infection by vascular access type a dialysis initiation during the first year of human Dallas's to address the selection bias we control for patient characteristics or confounders that could impact patients chance of obtaining fistula such as health status to achieve the study objective we used a retrospective cohort study design with a population of new and stage renal disease Medicare beneficiaries on hemodialysis as the only mode of renal replacement therapy who started hemodialysis between January 1st 2011 and December 31st 2012 and lastly we selected only patients where they continuous fee-for-service Medicare coverage for two years before and one year after the initiation of human dialysis or until time of death the study was completed by utilizing institutional and non-institutional claims from 2008 through 2013 for random 5% sample of Medicare beneficiaries our key exposures were incident and prevalent vascular accesses which were determined from monthly outpatient dialysis claims submitted during the first year of hemodialysis where vascular access was recorded in revenue Center codes b5 b6 and b7 for catheter graft and fistula respectively this information on vascular access was found to have an excellent level of agreement with that reported in the medical evidence form the outcome of interest was incident hospitalization with bloodstream infection during first year of human dialysis and was determined from inpatient claims using previously validated icd-9 codes for septicemia and bacteremia to address potential selection bias we adjusted our analysis for a number of patient characteristics available to us through insurance claim first we created a gagney core morbidities core for each patient which is a validated predictor of one year mortality and incorporates a number of current and past core mortgage conditions such as hemiplegia metastatic cancer and complicated diabetes it is constructed based on diagnostic codes from inpatient claims in the year prior to dialysis initiation we also controlled for a number of chronic conditions such as chronic heart failure stroke cancers chronic obstructive pulmonary disease just to name a few we used inpatient location of first hemodialysis is a marker of urgent start of hemodialysis and prai healthcare utilization as indirect measure of Health Prai health care utilization was measured by total Medicare reimbursement during baseline and was estimated using claims from across all healthcare settings such as inpatient outpatient home health skilled nursing facilities as well as physician and medical equipment claims and lastly we control for patient demographics such as age race and sex for analysis we use chi-square and students t-test for categorical and continuous variables respectively to compare incident vascular access groups we used survival analysis with kaplan-meier curves to compare event free times for each study group and we applied a novel method of survival analysis with multi variable extended Cox proportional hazards regression models that allowed us to estimate the risk of bloodstream infection by not only incident access but also by time dependence prevalent access and next I will present results of the analysis this graph describes how our study cohort was selected in brief from the 5% random sample of Medicare beneficiaries 15,000 583 had end stage renal disease in 2011 and 2012 of those 3,000 174 were new and stage renal disease patients with a complete Medicare fee for service coverage after excluding patients who change the mode of renal replacement therapy during the first year initiated peritoneal dialysis or obtain the renal transplant we had 2392 patients selected in the studying of those 1900 or 79 percent initiates hemodialysis with catheter 82 or 3% with grass and 410 or 17% with his Chauhan the next I will present a comparison of key patient characteristics by incident vascular access groups first I would like to highlight age among the 3 study groups the mean age was 78 and compared to catheter and graph starts patients starting with fistula were more likely to be white and male this table shows the distribution of patient characteristics such as deaths during follow-up initiation of dialysis in hospital a number of incident hospitalizations with bloodstream infection by incident access groups according to the results the proportion of patients who died during the first year was 38 percent among catheter starters compared to 13% among fistula starters 84 percent of patients starting with catheter obtained their first hemodialysis in the hospital compared with 44 percent of patients starting with system hospitalization with bloodstream infection was the main focus of this study and was assessed for every patient during the full log significant differences in frequency of incident bloodstream infection were identified among the study groups where 29 percent of patients in catheter start group had at least one hospitalization with bloodstream infection as compared with 10 percent of patients in the fistula start group the unadjusted rates per 1000 patient days for each incident access group or presented here according to the results the rate of blood stream infection was 1.5 among catheter starters which was significantly higher than the rate of 0.4 in patients starting with fistula the differences in bloodstream infection hospitalizations can also be seen in these kaplan-meier curves which show the probability of survival without the site during the follow-up survival times in our analysis were censored at time of death acquisition of BSI or and of study which was the end of the first year after dialysis initiation patients starting with fistula are represented by the shallow red line grass started by green line and catheter started by bloom as evident from the graph and all from the log-rank test patients initiating with fistula were significantly more likely to survive without psi than the other two groups this table presents the distribution of some of the chronic conditions included in this study in general chronic conditions were more prevalent among catheter starters than among those initiated with graft or fistula with exception of anemia which was equally present among the three groups conditions that were particularly more prevalent among catheter starters were congestive heart failure ischemic heart disease and rheumatoid arthritis in addition to these conditions our analysis examined and controlled for diabetes depression stroke different types of cancers asthma and hyperthyroidism also gagney quorum ability score of 1 or greater indicating increased likelihood of death was significantly more prevalent among the catheter start group our assessment of transitions between vascular accesses during follow-up showed that half of patients starting dialysis with catheter never changed or transition to a permanent access among patients initiating dialysis with permanent access we found that 71% 81% of graft and fistula starters respectively use their initial access throughout the follow-up and never changed it among the patients that did did change their permanent access type during the follow-up the highest frequency of change occurred among graft starters where 29% of patients used a catheter at least once during the fall off to estimate the risk of acquiring BSI we seeded two multivariable regression models adjusting for age sex race chronic conditions location of first hemodialysis gagney comorbidities and baseline healthcare utilization model one included incident acts vascular access plus confounders and model 2 included time-dependent prevalent access and confounders according to the results of model 1 after adjustment the risk of hospitalization with bloodstream infection was 67% lower among fistula starters as compared with those initiating with catheter the incident use of grafts was not significantly different from the incident use of catheter in terms of the risk of BSI in model to the prevalent use of either graft of fistula was associated with significantly lower risk of BSI when compared with proof with prevalent catheter use results of these analysis should be interpreted in light of its strengths and limitations among the strengths are the studies use of a contemporary national cohort advanced stage renal disease patients and its ability to control for various potential confounders having healthcare utilization data from the entire spectrum of services delivered to this population we had the ability to center the follow-up at critical events such as changes in model of renal replacement therapy and death the use of a novel method of extended survival analysis allowed us to estimate the risk of ESI associated with time-dependent prevalent access and to compare the risks between incident and travel and accesses as a retrospective study using administrative insurance claims these analysis is a subject to potential miss classification bias in our exposure because dialysis providers in their monthly reports are required to report only the last access used during the month the actual incident access may be different from the one reported to the CMS prevalent access may also be affected by the inaccurate reporting however the miss classification is likely to occur at random affecting all access categories equally second although we controlled for a number of patient characteristics there is still a chance for potential residual confounding for example we did not have information on the on pre dialysis nephrology care which is by far the most important predictor of both early fistula use and better health outcomes and lastly because our study included a population of elderly patients there is a limited generalizability due to age in summary this study using a contemporary national cohort of new and stage renal disease patients on hemodialysis found that initiating with fistula was associated with significantly lower risk of acquiring VI in the first year as compared with catheter initiation initiating with graft was not associated with lower risk of BSI but prevalent use of either fistula or graft was associated with lower risk of BSI than the prevalent use of catheter and we determined the transition to another vascular access type among patients initiating with graft likely accounted for this difference in incident and the prevalent graph use associations in addition contrary to our expectation this analysis revealed that only 17% of Medicare beneficiaries with a two-year complete continuous pre dialysis fee-for-service Medicare coverage initiated hemodialysis with fistula and LA and lastly we found that 84% of catheter and 44% of fistula starters initiated hemodialysis in the hospital resulting in a higher resource use and cost to CMS in conclusion we would like to highlight several implications of this work first it demonstrated that reducing dialysis in placing systems in placing fistula as a permanent hemodialysis vascular access prior to initiation of dialysis could could prevent significant infection related morbidity and subsequently cost associated with preventable hospitalizations second persistently low use of fistula at hemodialysis initiation among Medicare patients with full coverage suggests that insurance is important but insufficient by itself to ensure optimal access and lastly we we would like to mention that there are additional recognized challenges for early fistula youth such as barriers to pre dialysis nephrology care and chronic disease management and initiating hemodialysis in a hospital these are all potential areas for improvement and this concludes my presentation thank you again for the opportunity to present and share these results and also for your attention thank you dr. kazakova for that presentation as you all heard previously and the director of CDC's making dialysis safer for patients coalition through this coalition we work together with a broad range of partner organizations to prevent bloodstream infections the topic of optimal vascular access and the findings from the study are extremely pertinent to what we aim to do within the coalition CDC has a list of what we call core interventions for dialysis bloodstream infection prevention this list the explanation of each intervention accompanying tools and other resources to sort support adoption of the intervention are available on CDC's dials with safety websites we encourage all dialysis facilities to utilize these interventions to prevent bloodstream infection the intervention I'd like to highlight today involves vascular access optimization and specifically catheter reduction facilities are asked to pursue efforts to reduce the prevalence and use of catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal there are many types of efforts that can be pursued to decrease catheter use today we are grateful to have several experts from the gaming community joining us to help discuss their experiences around vascular access and catheter reduction I'd like to introduce our discussions and facilitator leading the discussion is a colleague of mine dr. Ron ka patta dr. pata is a nephrologist in the division of healthcare quality promotion and CDC and an assistant professor of medicine at Emory University School of Medicine dr. o pata provides care to patients on the renal consult service at Grady Hospital in Atlanta Georgia she's a co-chair of the patient engagement workgroup for CDC's making valsa safer for patients coalition and a project committee member for a SMS nephrologist transforming dials and safety initiatives dr. Potter's dual roles as a public health professional and practicing nephrologists have given her unique and valuable perspective on dialysis patient safety our discussions today are dr. abundant and Iyer and dr. Tracy gemellus dr. buttman and ire is a professor of medicine in the division of Nephrology at emory university she completed her internal medicine residency training at the University of Louisville and her nephrology fellowship at Emory University dr. Nayar has been a member of the faculty at Emory University since 2006 dr. Neyers main clinical interests in areas of expertise are end-stage renal disease and management of vascular access in hemodialysis patients she is proficient in dialysis access procedures and in renal ultrasonography she's passionate about promoting multidisciplinary collaboration and vascular access research and education with the ultimate goal of optimizing access care and processes for dialysis patients dr. Tracy Janelle as' is a nephrologist and one of the core physician leaders at Kaiser Permanente inspired by the strength of people living with kidney conditions she has worked tirelessly toward creating one of the most respectful and high-quality kidney care programs she is passionate about patient centered care together with her team of Nephrology care providers she strives to create a culture and a system that delivers seamless care transitions between medical treatments surgery dialysis transplantation and supportive care services I thank each of our experts for joining us today and would like to turn it over to dr. Rapada to kick off the conversations with questions for our discussions Thank You dr. Patel I like to direct our first question to both dr. John Ellis and dr. Nayar dr. John Ellis in your experience what have you found to be the greatest challenge to reducing catheter greetings from San Francisco this is Tracy Jenelle is for a sound check am i okay coming across yes you're great dr. Patel and dr. Potter thank you for the introduction dr. kazakova I appreciate your in depth analysis it provides invaluable it provides valuable information confirming the benefits of fistula for hemodialysis initiation we have a lot of talent here in the audience audience in this audience we have a lot of talent so the strategies and the tools we discussed today are just meant to be ideas to spread and to scale up from the patient's perspective it is a terrifying experience to face end-stage renal disease as they walk through the journey from CKD to ESRD in our experience the greatest challenge and the greatest joy is to help patients navigate the complex step of CKD tes Rd care well coordinated care can positively affect patients perspective of living with CKD and ESRD reduce barriers to care these fear and anxiety move patients along appropriate pathways and provide a safety net to prevent fall through for example a proactive approach the goal of care discussion and life care planning shared decision-making including the choice of maximizing medical therapy without dialysis can provide better quality of care for those who choose dialysis education and empowerment for patients to choose a home modalities or prompt placement of a monitoring of hemodialysis exorcists can all lead the reduction of CDC therefore through seamless care coordination we can positively change the patient's outlook and lead to reduction of CDC to address the challenges challenges of coordinated care we have developed three tools on the left is a hemodialysis access playbook to map out the entire care process and to end from the time of primary care referral to the initiation of hemodialysis with examples of best practices across 21 medical centers the right upper picture is a weekly status report and catheter tally for each Medical Center as you can see there are patient information care team information information related to the procedures the ultrasound or vascular appointment or access procedures to status of patient for example on this is our RT status it could be CKD or it could be a hemodialysis the access type related to the modality and other information could be placed on the report as you can see fit based on this status report the care coordinators will be able to take appropriate actions for example if a patient is no-shows to rep two vascular surgery or or fistula is overdue ultrasound follow-up actions can be taken so this patient happens to be a PD patient with a PD catheter she's getting a fistula place in preparation of PD failure and under there are RT status say if this is a hemodialysis patient with access type of catheter the team can then review and take actions leading to catheter removal in 1796 two hundred years ago blossom the cow and the little boy phelps have no idea had no idea of their contribution to the world free of smallpox today imagine the world without hemodialysis CBC hopefully in less than 200 years so if we move our eyes lower to the right lower picture of a CKD dashboard this is a CKD dashboard that we took advantage of the Kaiser Permanente electronic medical records system to automatically pull information and cast a why safety net to enhance early CKD referral from primary care to nephrology if a patient meets certain criteria on the EMR his or her record will pop up on our CKD dashboard and this dashboard is managed by the nephrology group we have observed significant improvement in the outcome of the Kaiser Permanente's optimal starts program through this systematic approach and culture change in Kaiser Permanente in Northern California 33 percent of New Year's Rd patients start with home modalities in the higher performing medical centers home dialysis start reached 40 to 50% and fistula start for hemodialysis at high 60s percent thank you thank you navigating the healthcare system can be daunting for patients doctors and ire I would like to ask you the same question in your experience what have you found to be the greatest challenge to reducing catheters and how have you attempted to this challenge thank you and thank you dr. John Ellis for that elegant discussion on the challenges in the CKD population transitioning to dialysis I'll now focus on those patients that we see in the dialysis unit those who are already died lysing with central venous catheters the biggest challenge here is getting timely appointments and interventions not just for placement but also successful use of permanent accesses so that once the patient has transitioned we may be able to remove the catheter in a timely manner at Emory we've tried to address this issue by coming at it from multiple perspectives the patient is at the core of this process it's critical to educate and involve the patient and get their buy-in because unless the patient is vested in this process it will be difficult to get the results we need and it's essential to start early at our dialysis unit we make it a point that every new patient died lysing with the CDC get a surgical consult and a vascular mapping appointment within the first two weeks of starting dialysis the other thing we've done at Emory is to organize a vascular access team we have two vascular access coordinators who are experienced in the ins and outs of vascular access who spearhead this process and really they're the backbone of this process we do weekly rounds on all our catheter patients where we discuss every one of them in details we discuss their comorbidities look at their upper port and climb the next steps and record everything on an Excel spreadsheet that we update on these weekly rounds in addition to that we also do focused access rounds on a rotating basis where we go around our dialysis units we have for dialysis units with around 600 hemodialysis patients spread all over the city and we examine and evaluate the accesses at the chair side we're also fortunate here at Emory to have great working relationships with our vascular surgeons and interventionists in order to expedite care we were able to convince our surgeons to give our patients multiple appointments across the time line so when the patient gets the surgery appointment at the same time they also get a two week and a six week follow-up appointment from the day of surgery at the 60 appointment the access is evaluated if it looks like it's maturing and we'll be ready for you that's fine but if it needs an intervention it's scheduled right away and acted upon on our end in the dialysis unit we also backup this process and continuously follow and examine the access the six weeks post-op date is marked on the calendar and the access is reevaluated around that time until we have a functional access and once the access is ready we have an understanding with our surgeons that we in the dialysis unit can decide when to cannulate instead of having to send the patient back to the surgeons to get an okay to cannulate and that saves our patients at least a couple more weeks of further catheter dependency all of these measures and our team approach allow us to get functional permanent accesses in a timely manner and help us to reduce our catheters thank you this was very helpful both of you have demonstrated the multifaceted approach needed to decrease catheter use and it's great to see your efforts have shown positive results moving to the next question dr. Nayar can you describe one aspect of your vascular access program that you feel has been particularly effective sure so as I mentioned earlier one aspect of minimizing catheters is not just placing new permanent accesses but also maintaining an access that's already in place and minimizing infiltration and infiltration is the bruising of the access that occurs if it's not being cannulated properly a unique aspect of our vascular access probe is ultrasound guidance for cannulation and we have modified our cannulation protocols to reflect this change we have now trained our vascular access coordinators in the use of basic ultrasound and they mark all new AV fistula and difficult AV grafts with ultrasound and provide a visual map for cannulation each dialysis unit has also identified cannulation experts who function closely together as a team and only members of these previously identified cannulation teams can calculate the accesses anecdotally we have seen our infiltration rates drop and we are now collecting data prospectively to look at the effects of our policy in the long term thank you do you know how widespread the practice of using ultrasound guided cannulation is is it likely to go overtime I think we are one of the few units using ultrasound guidance for cannulation but I'm sure it will grow over time as we are able to prove a decrease in the infiltration rate and thus decreasing the catheter prevalence time Thank You dr. John Ellis can you describe one aspects of your vascular access program that you feel has been particularly effective absolutely so thank you dr. Nayak you called out the crucial steps in the preservation of fistulas it is great that we can share ideas and experience from two different care environments with one common theme putting the patient front and center here in Kaiser Permanente we took advantage of our integrated care system and created a one-stop shop nephrology vascular surgery ultrasound Joint Clinic to monitor the newly placed permanent accesses particularly for the pre ESRD patients in this joint clinic patients are evaluated by neurologist vascular surgery care coordinators and get their ultrasound all at the same visits patients appreciate multidisciplinary team approach when they hear the same message from all their providers they feel confident in their care in return the care team finds joy and meaning in practice marginal fish gos matured with prompt intervention and close follow-up and some of the fish Jewelers that initially looked great were found to have serious problems and were savaged pride prior to dialysis in initiation and this is one of the crucial steps in terms of preventing fistula failure which could be rather common in some of the other practices setting and we hope to share this experience and to share this the results of this experience it has spread to many other medical centers within Northern California Kaiser Permanente and we have reported initial findings as an ASN abstract in 2018 thank you the one-stop shop sounds great in helping streamline the process for patients and improving communication between the frolla gist and vascular surgeons how have nephrologist and surgeons responded to this strategy how do they like it they love it initially was a little bit of a slow start and we play a we book less appointments and so seeing less patients but as time passed by everybody other Kings are working out and we can pretty much see about 20 to 22 patients in about two to three hours we are actually running the clinic as of today this morning it's no problem it's a little bit of coordination for the providers to come together but the results and the satisfaction from the patients really gives very positive feedback to the care team and we felt we fell great every after each connected you know a great feeling that the patient's get that good care that's great thank you dr. John Ellis what educational strategies or resources have you found to be most effective when talking to patients about having official or a graph place right so we went through a bit of a combination and trying to really find what's the key and most effective components of all the CKD or an ESR the education that we have done through the past many years and what we found is one picture is worth a thousand words visual aids are very effective in educating patients regarding the risk of CVC complications including infection from BOCES and late their noses it helps to promote placement of fistula we also use visual aids to promote peritoneal dialysis for example by showing a PD Casta in a model tummy it helps to convert CVC to PD capita we use Kaiser Permanente CKD education material make for adult learning we provide life education either in small groups or one-to-one we also use online videos for those who cannot attend in person peer-to-peer or patient the patient education and share experience is also very effective if there is a willing patient with a fistula shows and tells his or her story other patients are more receptive to fistula placement Kaiser Permanente in Northern California ESRD patients are spread to over 100 hemodialysis clinics strategically KP nephrologists function as medical directors in some of the larger contracted dialysis clinics to enhance that KP culture of high quality care thank you thank you I agree visual aids can be effective in patient education I also show pictures of fishless to patients initiating dialysis with a catheter in the hospital it helps to improve awareness and education on the importance of being evaluated for official graft I will start training pictures of catheters and its proximity to the heart to underscore the education on the risk of catheter use particularly sections such as endocarditis dr. Nayar I would like to ask you the same question what educational strategies or resources have you found to be most effective when talking to patients about having official graph placed I agree with Tracy patient education is the key to inform decision making at Emory we have made a dialysis options video that is freely available on YouTube it's not just limited to our patients and the URL is up on the screen we show this video to our CKD patients in the clinic to help them know more about all the different options available to replace their kidney function transplant peritoneal dialysis and hemodialysis and within hemodialysis the differences between fistula grafts and catheters we also offer a monthly in-person class at one of our dialysis units where patients can discuss their options in detail and they have the opportunity to ask questions and actually see the in-center dialysis patients in all of these educational options we emphasize peer interactions and patient to patient discussion with patients describing their own perspectives as that is so much more meaningful than a provider talking to the patient making an educational video for patients that's accessible and free to patients is definitely commendable how has the video been received by patients and have you received any feedback so far I just check that yesterday there are around 450 views on the YouTube site I do know anecdotally from the patients that have started dialysis that they felt that the video helped them to be more educated not just about the different modes but also the different things like home dialysis nocturnal dialysis and peritoneal dialysis so a lot of our patients have really come back with being very appreciative of that video that's great thank you so doctor and I are thinking to the future what innovations or ideas are needed to assist with early up to vascular access placements to me the number one most important thing is a team approach once we place the patient at the core of our processes and all of us nephrologists surgeons interventionist nurses and technicians acknowledge that we are all part of the same team and work together collaboratively we can achieve the optimal access for each patient the upcoming revision of the kado key guidelines are also built on this foundation making sure that we have the right access for the right patient at the right time and for the right reasons an innovation that I'm really excited about is the endovascular AV fistula option there are two new devices that allow for a patient to get AV fistula without open surgery and both of them have just been recently approved by the FDA one works with magnets and the other is a thermal device at this point we only have preliminary data for both of them and not the long-term effects but they both seem very attractive options for those subsets of patients who would be a candidate for these procedures their advantage over open surgery is that they are minimally invasive and the procedure can be done as an outpatient even more importantly the endovascular fistula overall require less time to mature in the initial studies most of them have been cannulated relatively early after placement so that that would again help to minimize catheter time there are certain limitations as well including the need for secondary procedures and their overall lower blood flows but this again emphasizes the importance of a team approach towards these accesses thank you doctor journalist thinking to the future what innovations or ideas are needed to assist with early optimal vascular access placement thank you doctor night doc night astutely pointed out two of the most important aspects of vascular access care team approach and technological event sment the magic and the solution lie within our patients we will have to continue the culture of patients in the care adding and patient voice to improve the experience and value of ESRD care thank you thank you both for highlighting the importance of a team and coordinated approach in vascular access placement and maintenance and sharing your efforts and innovative ways to make the process easier for patients such as the one-stop shop combined vascular surgery and nephrology Clinic patient visual aides and videos pair two pair education and ultrasound-guided can you lations of fistulas patients form relationships and trust with different members of the team such as dialysis techs nurses dietitians social workers and nephrologist so we all have a role to play in achieving optimal vascular access thank you both for your time and expertise and a special thank you to the coalition team for organizing this webinar I would also like to thank everyone for tuning in today world Kitty Day 2019 if you're interested in learning more about CDC and the making dialysis safer for patients coalition work to protect dialysis patients and reduce infections please email us or check out our website and last to obtain continuing education for this presentation you will need to visit the tceo website at WWDC gov for slash gets EEE if not previously registered you will need to complete a short registration process once logged in you will then utilize the search courses tab and type in WC 2720 – 0 3 1 4 1 9 choose the option for making douses safer for patients optimal vascular access and in order to receive continuing education you need to complete the evaluation and post-test scoring at least 80% you can then go to the transcripts and certification tab to download your paper certificate if needed there are no fees for this continuing education thank you for joining us and have a great afternoon

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  1. Your good people.

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