Michigan Dialysis Research and Education (MiDRE), is a 501 c3 Federal tax-exempt non-profit organization formed to improve the care of dialysis patients in Michigan. MiDRE advances practical initiatives derived from real-world experience in this areana which are designed to improve patient care, reduce overall costs, and which deserve to be supported from industry, government, the public and the charitable world.
Introduction
As a very busy, dedicated vascular access surgeon wrestling with the problems of dialysis patients over the last decade, I worked in an underserved and misunderstood field solving individual patient problems one by one, twenty to thirty cases a week.
Doing that, I frequently came face to face with problems outside of the limits of what a single surgeon in private practice could usually address – problems that existed for patients once they were released by the surgeon to use their dialysis accesss and then ran into trouble. There were so many problems beyond the operating room, there was only so much time, and there was no support for these extra efforts. Yet, something had to be done about improving the delivery of services for dialysis patients.
We formed Michigan Dialysis Research and Education (MiDRE), LLC, a Michigan non-profit and Federal tax-exempt organization, to provide local grass-roots educational services to local providers. It is our intent and our goal to work with patients, local providers, and national organizations to bring all helpful messages to each and every dialysis unit and provider in our region. It is also our intent to become a model of how to achieve quality improvement and cost reduction through local action.
MiDRE has a number of existing programs (see below) which have been tested and validated. Most of these programs are oriented toward improving patient management in the dialysis unit.
Initiative one – the Ultrasound Assisted digital photo diagram
Presentations by Dr. Webb – overview
We have restarted our series of monthly talks for dialysis professionals this year with a talk called “Vascular Access in 2012 – Vascular access planning and execution”, covering issues of central venous catheters, central venous stenosis, statistics from our own practice on the success rates of fistula creation, and time to usability, the indications for a graft, and directions for quality improvement. It was first given at Children’s Hospital in November of 2011. We have had five talks since, and have several more in the works. This talk has gotten very strong positive feedback, and booked up venues.
The talk is presented by Dr. Webb, typically during a dinner meeting for up to 50 people, and is approximately one hour long. The evening is typically 2 ½ to three hours, and held in a private dining room of a local restaurant. Michigan Vascular Access (MVA) and MiDRE staffs are present to arrange seating, take names, answer questions, and host their tables. Sponsors are invited to give a brief prologue talk, a short sponsor’s PowerPoint presentation may be shown, and then the talk by Dr. Webb, with plenty of opportunity for questions during and after the talk. Informational handouts are made available at the door on the way out at the end. Written feedback is requested of all participants. CEUs or CMEs may be made available to participants depending on circumstances.
Introduction to Correct Cannulation
We have been very concerned about difficult or problematic cannulation of dialysis accesses, and want to move beyond the usual finger pointing and character assassination that occurs when things don’t go right. Typically the surgeon is trying to do a good job for the patient, and the dialysis techs definitely want things to go smoothly, so we should be working together to solve the problems.
As part of the MiDRE project, we have assigned a staff member, Ramsis Georgi, to serve as an Access Ambassador for our practice (MVA), and as a Correct Cannulation educator for MiDRE. After 18 years as a dialysis technician, and after a year in my office seeing the surgical perspective, he is uniquely positioned to liaison with the units. Ramsis has visited 20 units in the last three months, helping with difficult cases, orienting the unit personnel to new products we think are helpful (e.g., the early-cannulation Flixene and Acuseal grafts) and giving in-services on access problems. Ramsis can bring a portable ultrasound to the unit to show the techs what we are able to see in a patient’s access, and hopefully give them a better understanding of problem accesses.
Unit visit reports from Ramsis and feedback letters from the dialysis personnel are kept in the MiDRE office, and are available for ongoing review.
Education for dialysis unit professionals, students and industry representatives
Fourth, as a part of our educational mission, MVA and MiDRE offer qualified personnel (nurses, dialysis technicians, and dialysis tech students and industry representatives) a comprehensive exposure to the world of a busy vascular access surgeon.
The office experience – qualified personnel can sign up for a four hour experience in the MVA office during one of our half day clinics. Between 17 and 25 patients are seen each session – four or five new patients being evaluated for their options, four or five old patients with new problems needing to be clarified and a treatment planned, and a dozen post-surgical patients being re-evaluated for their progress and possible release to use their new fistula. Mapping and diagnostic ultrasounds are performed, the practice electronic medical record system (Turbo Doc) is demonstrated, and our teaching protocol for patients also demonstrated. Several new fistulas are diagramed and released each clinic day. When time permits, Dr. Webb goes through part of his talk on dialysis access creation. Nurses can earn CEU units through our cooperation with St. Mary Mercy Hospital.
The operative experience – this experience offered to qualified personnel consists of attending surgery with Dr. Webb at one of several participating hospitals, seeing creation of fistulas, placements of grafts, and endovascular maintenance or rescue procedures. At Saint Mary Mercy Hospital, the experience also includes exposure to the SMMH interventional radiology department, where access cases may be going on at that time.
The MVA office/SMMH experience, with CEUs for nurses, is arranged by calling Holly Favero, at 734-655-2700. The MVA office and Southeast Surgical Hospital or Oakland Regional Hospital experiences can be arranged by calling Ronda Seley at 248-355-1330.
A six session program to prepare dialysis unit personnel to serve as dialysis access resource people is an outgrowth of this program, and is in the pilot stages.
Research projects
MiDRE is also designed to support research efforts. I presented our results for transposed basilic fistulas (466 patients – a very big series, if not the biggest ever reported) and covered stents (125 patients – also the largest series ever reported) at the Vascular Access Society of the Americas meeting in May 2012 in Orlando. Our MVA database is large, with approximately 3500 patients and 14,000 procedures over the last decade and a half.
We are seeking support for studies on the use of covered stents in dialysis access (with nearly 1500 stents deployed in the last 8 years), an update on previously reported statistics on our series of fistulas (over 1700 fistulas in the last 8 years), as well as other clinical outcome research efforts. We plan to be present at the VASA, CIDA and ASDIN meetings on a regular basis, and to present our results as often as possible.
Support for MiDRE
Michigan Dialysis Research and Education (MiDRE), is a 501 c3 Federal tax-exempt non-profit organization formed to improve the care of dialysis patients in Michigan. MiDRE advances practical initiatives derived from real-world experience in this areana which are designed to improve patient care, reduce overall costs, and which deserve to be supported from industry, government, the public and the charitable world.
