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

2. Background
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% Q
Inadequate dialysis has long been identified as a contributor to increased mortality in hemodialysis patients. Since the early nineties, hemodialysis adequacy, initially measured only by urea reduction ratio (URR), and then more commonly by various methods of urea kinetic modeling (Kt/V), has been a clinical focus of KDOQI, CMS and the ESRD Networks. KDOQI recommends that delivered dialysis be at least 65% (URR) or 1.2 (single pool Kt/V).

3. Selection Criteria 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 < than 80% of the patients with a URR>65%.

4. Objectives 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
Focus on areas identified as barriers

5. Goals
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%
? Why facilities were chosen. Place on slide 2?

6. How Do We Reach Our Goal?
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
Early intervention is key to successful outcomes

7. Educate Your Patients
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
Every minute counts. Rapid blood flows exposed to large surface areas = a lot of clearance in 1 minute

8. Educate Your Patients
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)
Every minute counts. Rapid blood flows exposed to large surface areas = a lot of clearance in 1 minute

9. Educate your Patients 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

10. Educate Your Staff 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? ?

11. Educate Your Staff 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?
Machine accurately calibrated? Clocks synchronized? Blood & dialysate pumps routinely calibrated

12. Educate Your Dialysis Team
Do skills check and retraining for cannulation competency. (technique, needle placement)
Always verify direction of blood flow
Limit cannulation attempts. If unsuccessful on 2nd attempt seek assist from “identified unit expert”
Monitor prescribed blood flow.
Venous pressure should be < than ½ of blood flow rate, i.e. if Qb is 400, VP should be < 200

13. Educate Staff 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.
Conduct treatment sheet audits for prescription adherence

14. Educate Staff 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.

15. Blood Draw Techniques
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
Re-infusion of withdrawn blood per unit policy

16. Blood Draw Techniques 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.

17. Blood Draw Techniques Stop flow sampling Slow 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 .
Have plastic cards that hang from the machines so that staff can refer to them on blood draw days
Conduct random blood draw audits

18. Evaluate Vascular Access
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

19. Form an Adequacy QI Team
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.
Team: Medical director

20. Adequacy Team
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

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

22. The Patient Care Team Can Determine Adequacy
Patient Education is KEY to maintaining adequate treatment
Teach Your Patient About Adequacy
It’s About Quality of life !

23. Resources Free CEU: www.esrdnetwork6.org
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

24. 2012 Data Collection
1. Submit Monthly Spreadsheet via to by the 10th day of the month for information from the previous month. The monthly sheet will be ed 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 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 to by December 15, 2011.
7. All resources and templates are available on the Network 6 website at

25. Data Collection Form
Due 10th of each month

26. Adequacy QAPI
Due December 10, 2011

27. Learning Session Summary – Due December 15, 0211

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