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Strategies For Improvement Debra Evans, RN, BSN Quality Improvement Nurse Specialist & Leighann Sauls RN, CDN Director, Quality Improvement 1.

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Presentation on theme: "Strategies For Improvement Debra Evans, RN, BSN Quality Improvement Nurse Specialist & Leighann Sauls RN, CDN Director, Quality Improvement 1."— Presentation transcript:

1 Strategies For Improvement Debra Evans, RN, BSN Quality Improvement Nurse Specialist & Leighann Sauls RN, CDN Director, Quality Improvement 1

2  Inadequate dialysis has long been identified as a contributor to increased mortality in hemodialysis patients.  The percent of patients being adequately dialyzed in the USA, as measured by urea reduction ratio (URR) in the Core Indicators Project and subsequently the Clinical Performance Measures Project, has increased from 43% in 1993 to 91.3% Q4 2010. 2

3  The 2010 Q4 Elab reports Network 6 URR of 90.7%  The Network 6 MRB reviewed facility specific data  Focus on facilities presenting the optimal opportunity for facility-specific improvement as well as overall Network improvement in hemodialysis adequacy.  Facilities were ranked from highest to lowest % of patients with URR <65%  Chose all facilities with >40 patients and 65%. 3

4  To develop strategies for improving adequacy  To promote ongoing education to staff and patients  To review importance of patient assessment and patient monitoring  To establish proper techniques for lab sampling  Understand project requirements 4

5  To improve the QOL and decrease mortality of ESRD patients by providing an adequate dose of dialysis every treatment.  90% of hemodialysis patients will have a URR of > 65% 5

6  Provide ongoing education to staff and patients  Know your adequacy numbers ◦ URR > 65%, KT/V > 1.2  Know what can have an effect on these numbers  Know when to intervene 6

7  Teach patients the importance of completing the prescribed RUN times.  Teach patients the medical consequences of “underdialysis” at an appropriate grade level and culturally appropriate manner 7

8  Teach each patient their prescribed blood flow rate and their prescribed dialysate flow rate.  Patients should understand the Importance of assessments: pre, during, post and home assessment. (check thrill, Signs & Symptoms to report) 8

9  Why fistulas are the best choice for access  last longer  Fewer infections  Disadvantages of Central Venous Catheters  Higher risk for Infections  Slower blood flow rates  Vessel damage  Designed for short term use only 9

10  Review patient issues: ◦ symptoms of uremia – Nausea, vomiting, poor appetite, yellow skin color, weakness, infections, bleeding ◦ Avoid hypotensive episodes that decrease dialysis delivery  Avoid excessive ultrafiltration-Does the patient gain more than 4.0 kgs between treatments?  Does the patient need a new estimated dry weight?  Does the staff actually watch the patients weigh pre and post treatment? 10

11  Review machine maintenance issues ◦ Are the machines kept up to date on all PM”s per manufacturer’s recommendations? ◦ Are the scales calibrated routinely?  Review Heparin usage ◦ Document condition of dialyzer to determine if heparin adjustment needed. ◦ Does staff wait 3-5 minutes after Heparin Bolus to initiate treatment? ◦ Do you conduct clinical audits to verify that Heparin policy is followed? 11

12  Do skills check and retraining for cannulation competency. (technique, needle placement)  Always verify direction of blood flow  Limit cannulation attempts. If unsuccessful on 2 nd attempt seek assist from “identified unit expert”  Monitor pressure @ prescribed blood flow. 12

13  Review lab results immediately upon receipt  Repeat adequacy lab draws, with Dr. order, If results appear incorrect  Verify dialysis prescription is followed each treatment. ◦ Correct dialyzer ◦ Correct blood flow ◦ Correct dialysate flow Notify physician if unable to follow dialysis prescription Every treatment until access problems are resolved. 13

14  Make treatment prescription changes to improve adequacy  Implement new physician treatment orders for next treatment. ◦ Increase blood and/or dialysate flow rates ◦ Change dialyzer to increase surface area ◦ Increase treatment time  Refer patient for evaluation of access if needed  Ensure that staff follows correct blood draw procedures. 14

15  Single pool variable volume model is recommended by K/DOQI  Calculates KT/V using pre and post BUN samples  Pre & post dialysis BUN samples must be drawn correctly (on the same day) to ensure adequacy results  Pre – BUN sample:  Should be drawn immediately prior to treatment initiation  Avoid dilution of pre BUN sample with Heparin or saline  To avoid BUN sample dilution with Heparin from CVC line withdraw 10 ml of blood from arterial CVC port prior to taking the blood sample 15

16  Drawing post BUN sample  Collect sample using the Slow flow or Stop pump technique to prevent dilution of post BUN sample with recirculating blood and minimize effects of urea rebound. 16

17  Stop flow sampling Stop the blood pump. Clamp arterial and venous blood lines. Clamp arterial needle tubing. Draw the post BUN sample from the arterial port closest to the patient  Slow flow sampling  With blood pump still running, draw post BUN sample from the arterial sample port closest to the patient  Discontinue treatment as usual. 17

18  Promote AV fistula use  Decrease venous catheter use  Assess access status before each treatment  Utilize the “ Sleeves up” protocol for converting AV grafts to AV fistulas 18

19  Include medical director, charge nurse, social worker, dietitian and other team members that impact care  Schedule regular monthly Adequacy team QI meetings with dates and times  Evaluate your current process for improving adequacy your QI plan  Identify barriers in your process that contribute to poor adequacy and their root causes. 19

20  Evaluate the actions already implemented to improve adequacy ◦ Were they effective? Did they work? If not, why not?  Implement new action steps and strategies to address root causes  Review monthly Adequacy lab data, Identify patients not meeting Adequacy goals and reasons why  Develop a patient specific care plan for all patients not meeting adequacy goals to address barriers and issues impacting their adequacy 20

21  Review this care plan with patients and the patient’s caregivers  Update and evaluate your current adequacy QI plan as needed. 21

22  Patient Education is KEY to maintaining adequate treatment  Teach Your Patient About Adequacy It’s About Quality of life ! 22

23  Free CEU: ◦ Visit continuing education website at ◦ Click on ESRD; Go to the course titled ◦ IMPROVING ADEQUACY OF HEMODIALYSIS Other tools: ◦ Adequacy improvement flowchart ◦ Hemodialysis Adequacy tracking tool ◦ Hemodialysis Adequacy QAPI Tip sheet  23

24 1. Submit Monthly Spreadsheet via email to by the 10th day of the month for information from the previous month. The monthly sheet will be emailed to you at the end of the month for submission. 2. Participate in an Adequacy Webinar on November 29, 2011 3. Send Adequacy QAPI (action plan) to the Network office via email to by December 10, 2011 4. Participate in facility-specific conference call(s) with Network staff to review QAPI information if requested. 5. Conduct an adequacy learning session for patients and staff at the facility. 6. Complete the learning session summary sheet and return to the Network office via email to by December 15, 2011. 7. All resources and templates are available on the Network 6 website at 24

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28  Verification of participation and post survey information  by Friday, December 2, 2011  QUESTIONS? 28

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