1. MARC – Network 5 5 Diamond Patient Safety Program
Decreasing Patient & Provider Conflict
Basics of Patient-Centered Care
2008

2. Basics of Patient – Centered Care
A Safe Environment
Jack Moore, MD, Washington Hospital Center, Network 5 Medical Review Board Chairman
A Working Access
Robert Lee, MD, Chung W. Lee, MD, PC
Yao-Foli Sekyema, MD, Danville Urologic Clinic
Jim Seymour, Dialysis Patient, MARC Patient Advisory Committee
Clean Hands
Valerie Riley, RN, Fresenius Medical Care

3. Patient Safety Issues & Activities in Network 5
May 2, 2003
Jack Moore, MD

4. Gathered Information in 2002 and 2003
Surveyed facility staff
22% overall response rate In
31% overall response rate
Questionnaire to each unit (via Adm.)
40% response rate
The focus on emergency preparedness has increased significantly since 9/11/2001, and most recently, Hurricane Katrina in August What did the dialysis community learn from Hurricane Katrina?
Almost all of the 2500 PD and HD patients dialyzing in 43 units in New Orleans were displaced to other U.S. cities, including Baton Rouge, Houston, and Atlanta. Some even ended up in Network 5 (about 8 patients)

5. Top 5 Safety Issues - Same in Both Years
Many of the patients who were displaced had been without dialysis for 1 week or longer before restarting.
In all, 94 facilities closed for at least 1 week (in Louisiana, Mississippi, and Alabama).
As of June 2007, 17 facilities remained closed (16 in Louisiana, 1 in Mississippi).
The majority of dialysis facilities had detailed patient evacuation plans, including dietary recommendations, medication supplies, and contact numbers.
Additional info:
USRDS data report that Louisiana and the surrounding region have the highest incidence of CKD and ESRD in the nation. A quarter of the population had household incomes below the federal poverty level.
In Louisiana, the number of patients who had ESRD and were receiving dialysis fell from 7557 patients on July 31, 2005 (before the storm), to 6213 on August 31, 2005, immediately after the storm (an 18% reduction). By December 31, 2005, the Louisiana ESRD population had grown to 6731 (89% of the pre-hurricane census).
Of the 5849 Gulf Coast dialysis patients who were affected by Hurricane Katrina (including those in Louisiana, Mississippi, Alabama, and northern Florida), 148 deaths occurred in the first month after the storm (mortality rate 2.5%; CMS claims data, provided by ESRD Network 13, 2005). However, morbidity and mortality related to Hurricane Katrina are difficult to establish for two reasons. First, patients with ESRD have high rates of morbidity and mortality, particularly from cardiovascular disease, for which mortality rates are 10- to 30-fold higher for dialysis patients compared with similarly aged patients from the general US population. Under these circumstances, identifying “storm-related” deaths may be difficult. Second, many patients remain permanently displaced after the hurricane and securing information on their health remains a challenge.

6. 2003 Patient Safety Issues Ranked
DCI – Tulane reopened on November 17, 2006 in a new location.

7. Response Rate by Discipline
Most patients were displaced to Baton Rouge…
All Baton Rouge facilities had generators.
Water was available thanks to Baton Rouge Water Company’s planning efforts after Hurricane Betsy in 1965.
Louisiana Dept. of Public Health set up surge hospital/triage center in athletic facilities at Louisiana State University.
Treatment was provided by US Public Health Services officers, medical emergency response teams from various states, and many volunteers.
In the 1st week post-Katrina, 700 ESRD patients who were evacuated from the New Orleans area received dialysis. This was in addition to the 1000 patients who concurrently received their regular treatments in the Baton Rouge area.

8. Top 3 Patient Safety Issues by Discipline
Limited early evacuation for vulnerable individuals, including dialysis and transplant and those with limited mobility.
Both landline and cell phone networks overwhelmed and functioned poorly.
Some patients delivered to out of area hospitals for dialysis, overwhelming the capacity of facilities to handle all patients, not set up to take dialysis patients. Not enough medical staff. Some needed PD supplies but did not have contracts with suppliers.
No designated shelter for dialysis patients, making them transient. Made tracking and transportation difficult.
Dialysis staff didn’t know where patients were and couldn’t contact them.
No easily accessible dialysis patient database available (no way to estimate number of patients coming).
Difficulty obtaining supplies because of transportation.

9. Patient Safety Activities Conducted by Network 5 Facilities

10. “Access Event” ? ? ? Top Patient Safety Issue  2 Years
For later discussion
How do you define an access-related event ?
Bad stick ? Infection ?
? ? ?
The purpose of this slide, aside from humor, is to drive home the point that emergencies are local. We cannot depend on the federal or state government to take care of us in an emergency.
Patients must take personal responsibility for their care through education and planning. Facility staff bear some responsibility for assisting patients in acquiring this education and planning for emergency events.
The goal of this training is to get participants thinking about what they can do in the facility and their home lives and that of their patients to prepare for and respond to emergency events. The key to a successful response is proper planning and preparation ahead of time!

11. A Working Access

12. K-DOQI Guidelines & MARC Goals
What They Say
Where We Are
and
What Activities Are Planned
Most of the emergencies impacting patients and providers will be natural disasters (hurricanes, flooding) but your facility’s disaster plan should be broad enough to address most types of internal and external events

13. At least 50% of all incident HD patients (adults  18) should have an A-V fistula.
25% in NW 5 per CPM data from 4th qtr (more recent data on incident patients not available)
Assist facilities in developing disaster plans.
MARC has a template available to assist facilities in developing a plan
webpages for emergency prep and pandemic flu
facility and patient emergency preparedness guides (English and Spanish)
presentations throughout Network 5 region (Back to School, American Kidney Fund, annual Council meetings)
2. Coordinate with providers, emergency workers, and other essential persons to ensure that the needs of individuals are being met and that patients have access to dialysis.
The Network has participated on all KCER Coalition calls as required, and the Director of Operations remains active with the Coalition’s Patient and Provider Tracking Workgroup.
In April 2006, a letter was sent to state and federal emergency management and health departments highlighting the needs of dialysis patients and requesting their inclusion (as well as that of dialysis facility workers) in the “high risk” priority group for vaccinations and/or anti-virals in the event of a pandemic flu.
Have worked closely with the Hampton Roads (Virginia) Planning District Commission to educate them on the special needs of dialysis patients.
3. Assist providers and patients in determining status of dialysis facilities.
MARC requires that facilities report their open/closed status to MARC ASAP, and then twice weekly post event.
“OPEN” = potable water, power from any source, and sufficient staff and supplies to provide dialysis; “CLOSED” = anything else
MARC will post facility status info to and MARC website if possible
If MARC is impacted by emergency event, patients and providers can call Kidney Community Emergency Response (KCER) Coalition toll-free Hotline ESRD ( ) to get contact information for the designated alternate Network which can assist them
4. Provide information to family members and treating facilities on where a patient previously/currently is receiving services to assist in the location of individuals and the exchange of critical medical information.
KCER Coalition has developed a Disaster Patient Activity Report (DPAR) to be used by facilities to report on the status of current and transient patients twice weekly post-event.
The KCER Coalition also developed a standardized emergency dataset (which has been approved by FMC, DaVita, and NRAA) with the recommendation that providers produce paper copies of the dataset in any form from their databases at least quarterly for each patient. Patients should be instructed to carry the dataset with them in the event of evacuation.

14. At least 40% of all prevalent HD patients (adults  18) should have an A-V fistula.
25% in NW 5 per CPM data from 4th quarter 2001
27% in NW 5 per CDC Survey from Dec (Comparative data from CDC Survey not yet available)

15. 100% of facilities must employ a prospective monitoring program for A-V accesses (grafts & fistula), which utilizes intra-access flow, and/or static venous pressures, and/or dynamic venous pressures.
44% in NW 5 per CPM data from 4th qtr (only patients with AVG included)
Minimum requirements for dialysis facilities,
More commonly know as “v-tags”, can be cited by State Survey Agency for non-compliance
There is an established written plan for dealing with fire and other emergencies
Should be developed in cooperation with fire and other expert personnel
Should have 4 components – prevention (when possible), preparation, response, and recovery
Should address emergency equipment, transportation, staffing, communications, evacuation, health records, and continuity of patient care
2. All personnel are trained as part of their orientation.
The written emergency preparedness plan provides for orientation, regular training, and periodic drills in all procedures; each person is able to promptly and correctly carry out his or her role in an emergency
3. There is fully equipped emergency tray available at all times.
To include emergency drugs, medical supplies, equipment
Staff should be trained on use
4. Staff are familiar with the use of all dialysis equipment and procedures to handle medical emergencies
5. Patients are trained to handle medical and non-medical emergencies (how to get off dialysis machine if they need to evacuate, etc.)
Should assist patients in developing individual emergency plans and review the plan regularly
Patients should know what to do, where to go, and whom to contact if an emergency occurs

16. Less than 10% of all prevalent HD patients (adults  18) should be maintained on catheters as their permanent chronic dialysis access.
28% in NW 5 per CPM data from 4th qtr. 2001
20%  90 days per CPM data from 4th qtr. 2001
26% per CDC Survey December 2002
Requires a written agreement or arrangement between facility and center (hospital) for provision of services.
Can also be between dialysis facilities
Preferably between facilities not located in the same geographic reason where both would not be simultaneously impacted by same event
b. Agreement provides that patients will be accepted and treated by the hospital/alternate facility in emergencies
Both facilities/facility and hospital should have documentation on file to the effect that patients will be accepted and treated in emergencies
*Agreement may also include a provision for sharing staff (e.g., in pandemic flu or post-disaster, could have staff shortages)

17. Patients Dialyzing via Catheter  90 Days Network 5 Compared to Other Networks & the US CPM Data from 4th Qtr. 2001
Even in an emergency situation, facilities are responsible for the safeguarding of medical record information!
Medical records are secured onsite with policies regarding storage, access, and retention
Where are records stored? How will you protect records from water damage? Fire?
Who is responsible for ensuring that records are not destroyed in emergency? Designate more than 1 person
Theft can constitute an emergency: Who has access to records? What security measures are in place to protect confidential information?

18. Catheter Reduction Project
47 facilities were required to participate
Goal was to reduce catheter use by 50%
Baseline data from July 2002
Re-Measurement data from December 2002
Interventions included
Educational workshop
Clinical algorithms
Tools to use
All can be downloaded from MARC website

19. Preliminary Results At re-measurement, facilities that . . .
Used a written access plan on all patients
Conducted staff education sessions and/or used a catheter referral algorithm
Preparedness is more than knowing whether you are located in a hurricane zone
. . . made larger reductions in the overall percent of patients dialyzing via catheter

20. Preliminary Results, continued
Process Indicators
Catheter patients assessed for alternative access using the intervention tools
Improved from 14.6% to 74.8%
60.2% absolute change in rate
Statistically p < level
Long-term catheter patients referred to a surgeon for alternative access placement
Decreased from 81.9% to 80.6%, but not statistically significant change at remains high
2. How ready is your facility? To minimize damage:
a. Secure facility to prevent injuries during disaster:
Ceiling TVs secured
Machines and chair wheels locked
Oxygen tanks secured
Water treatment components secured
Storeroom shelves secure, heavy items are on bottom shelves
Emergency exits well marked and pathways clear
Label utility shutoff valves
Keep trees trimmed and away from power lines
b. Keep patient and business records secure
Keep data backed up with copies in a secure location
Make paper copies of your patients’ orders and medication lists on a periodic basis (at least quarterly or if changed)
Distribute copies to your patients
All facilities should maintain off-site copies of
-comprehensive list of all pts
-2728 forms
-dialysis prescription
-care plan for each pt
-DNR or Advance Directives
Should also keep copies onsite in secure water and/or fire proof box; keep in secure location and where it is easily accessible in event of evacuation; update regularly
Facility medical and financial records should be backed up regularly and stored in secure off-site location
c. Have a back up utility plan
Power: If you do not have an onsite generator you should have a written contract with someone who will agree to provide one if needed. Have a known supply of fuel
Water: Make a back up plan. You may need to have an adapter made.
Phone: Telephone networks are generally designed to provide 15% capacity, assuming that most subscribers will not be using their phones at the same time. In emergency, phone lines likely to be overwhelmed
Consider redundant methods of communication: satellite phone, landline, Blackberry, even amateur radio

21. Preliminary Results, continued
Outcome Indicators
% patients dialyzing via catheter
Improved from 37.1% to 33.6%
Statistically p < 0.01 level
% patients dialyzing via catheter  90 days
Improved from 28.4% to 26.2%
Almost statistically p < 0.05 level
3. Prepare staff
a. Identify the disaster organizational structure you will use in the event of a disaster.
Who is the person in charge?
Who will account for all patients and staff?
Who will contact your patients?
Who will grab the emergency evacuation box?
Who will call the utilities?
b. Develop a communications plan:
How will you keep in contact with each other, patients and local disaster response teams?
Give patients a number to contact you with (designate at least 2 “disaster contacts” and the Network requires 2 disaster contacts with a work phone number and 2 alternate means of communication)
Run PSAs on tv, radio; update website if possible
Have an “out of area” contact number (facility you have agreement with?)
c. Educate key personnel in their roles during a disaster.
Hold periodic disaster drills (at least quarterly)
Include your patients in the drills
Evaluate and modify your plans based on how the drill goes

22. Future Activities Focused on Vascular Access
National QIP to increase AVFs
All Networks, CMS & IHI (Institute for Healthcare Improvement)
Collaborative Project - Partners Recruited
Key Role for Med. Directors, Nephrologists, Vascular Surgeons, & Facility Staff
Likely a multi-year project
d. Have a back up facility agreement with a facility that can take your patients
Nearby facility because this simplifies transportation issues, but if event is regional should have back-up in a noncontiguous geographical area as it is less likely to be affected.
e. Know in advance whom to contact for assistance and information
Your ESRD Network (Required to report open/closed status to Network "Open" facilities are defined as facilities that have potable water, electricity from any source, and supplies and staff sufficient to provide dialysis, and that are performing dialysis. Anything less than this is considered "closed." Required to submit DPAR 5 days post event and then semiweekly until return to normal operations)
City, County and State Emergency Response Teams
American Red Cross Chapter
Security Company

23. More Activities . . . NW 5 Vascular Access Committee
Develop interactive website for vascular access case studies to demonstrate patient safety issues
Identify vascular surgeons used by NW 5 renal community for partnering opportunities
Educational opportunities
Develop model for training & spread

24. Facility Vascular Access Program . . .
Surgical Aspects
Robert Lee, MD, Chung W. Lee, MD, PC
Patient Perspective
Jim Seymour, Dialysis Patient, Patient Advisory Committee
Facility Vascular Access Program
Yao-Foli Sekyema, MD, Danville Urologic Clinic
Clean Hands & CDC’s Campaign
Valerie Riley, RN, Fresenius Medical Care
Define “access event”
Jack Moore, MD, Washington Hospital Center, MRB Chair