2 BackgroundInadequate 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% QInadequate 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 dataFocus 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 patientsTo review importance of patient assessment and patient monitoringTo establish proper techniques for lab samplingUnderstand project requirementsFocus on areas identified as barriers
5 GoalsTo 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 patientsKnow your adequacy numbersURR > 65%, KT/V > 1.2Know what can have an effect on these numbersKnow when to interveneEarly intervention is key to successful outcomes
7 Educate Your PatientsTeach patients the importance of completing the prescribed RUN times.Teach patients the medical consequences of “underdialysis” at an appropriate grade level and culturally appropriate mannerEvery minute counts. Rapid blood flows exposed to large surface areas = a lot of clearance in 1 minute
8 Educate Your PatientsTeach 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 longerFewer infectionsDisadvantages of Central Venous CathetersHigher risk for InfectionsSlower blood flow ratesVessel damageDesigned for short term use only
10 Educate Your Staff Review patient issues: symptoms of uremia – Nausea, vomiting, poor appetite , yellow skin color, weakness, infections, bleedingAvoid hypotensive episodes that decrease dialysis deliveryAvoid 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 usageDocument 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 flowLimit 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 incorrectVerify dialysis prescription is followed each treatment.Correct dialyzerCorrect blood flowCorrect dialysate flowNotify 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 ratesChange dialyzer to increase surface areaIncrease treatment timeRefer patient for evaluation of access if neededEnsure that staff follows correct blood draw procedures.
15 Blood Draw TechniquesSingle pool variable volume model is recommended by K/DOQICalculates KT/V using pre and post BUN samplesPre & post dialysis BUN samples must be drawn correctly (on the same day) to ensure adequacy resultsPre – BUN sample:Should be drawn immediately prior to treatment initiationAvoid dilution of pre BUN sample with Heparin or salineTo avoid BUN sample dilution with Heparin from CVC line withdraw 10 ml of blood from arterial CVC port prior to taking the blood sampleRe-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 patientSlow flow samplingWith blood pump still running, draw post BUN sample from the arterial sample port closest to the patientDiscontinue treatment as usual.Have plastic cards that hang from the machines so that staff can refer to them on blood draw daysConduct random blood draw audits
18 Evaluate Vascular Access Promote AV fistula useDecrease venous catheter useAssess access status before each treatmentUtilize 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 careSchedule regular monthly Adequacy team QI meetings with dates and timesEvaluate your current process for improving adequacy your QI planIdentify barriers in your process that contribute to poor adequacy and their root causes.Team: Medical director
20 Adequacy TeamEvaluate the actions already implemented to improve adequacyWere they effective? Did they work? If not, why not?Implement new action steps and strategies to address root causesReview monthly Adequacy lab data, Identify patients not meeting Adequacy goals and reasons whyDevelop a patient specific care plan for all patients not meeting adequacy goals to address barriers and issues impacting their adequacy
21 Adequacy QI TeamReview this care plan with patients and the patient’s caregiversUpdate and evaluate your current adequacy QI plan as needed.
22 The Patient Care Team Can Determine Adequacy Patient Education is KEY to maintaining adequate treatmentTeach Your Patient About AdequacyIt’s About Quality of life !
23 Resources Free CEU: www.esrdnetwork6.org Visit continuing education website atClick on ESRD; Go to the course titledIMPROVING ADEQUACY OF HEMODIALYSISOther tools:Adequacy improvement flowchartHemodialysis Adequacy tracking toolHemodialysis Adequacy QAPI Tip sheet
24 2012 Data Collection1. 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, 20113. Send Adequacy QAPI (action plan) to the Network office via to by December 10, 20114. 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