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

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% Q4 2010. 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).

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%.

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

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?

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

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

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

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

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? ?

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

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 pressure @ prescribed blood flow. Venous pressure should be < than ½ of blood flow rate, i.e. if Qb is 400, VP should be < 200

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

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.

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

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.

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

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

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

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

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

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 !

Resources Free CEU: www.esrdnetwork6.org Visit continuing education website at http://learning5.flqio.org/ 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 www.esrdnetwork6.org

2012 Data Collection 1. Submit Monthly Spreadsheet via email to info@nw6.esrd.net 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 info@nw6.esrd.net 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 info@nw6.esrd.net by December 15, 2011. 7. All resources and templates are available on the Network 6 website at http://www.esrdnetwork6.org/improving-care/

Data Collection Form Due 10th of each month

Adequacy QAPI Due December 10, 2011

Learning Session Summary – Due December 15, 0211

Final Documentation Verification of participation and post survey information http://www.surveymonkey.com/s/AdequacyWebinar by Friday, December 2, 2011 QUESTIONS?