Urgent-Start Peritoneal Dialysis Cathy Wilson-Bates, RN, CDN, CPDN

Objectives Define Urgent Start Peritoneal Dialysis (PD) What it is and what it’s not. Compare several centers and the outcomes they were able to achieve with Urgent Start PD - – Drop Out Rates – Peritonitis Rates – Adequacy Comparison of the benefits of PD to In center Hemodialysis (ICHD) and Home Hemodialysis (HHD)

Changes in PD Therapy First recorded date with studies on animals In FDA approved the use of polyvinyl bags In 1980’s - new systems were developed (Y Sets) In 1990’s - increased emphasis on adequacy, nutrition and individualized prescriptions Late 1990 to early Computer data collection via memory cards, lock mechanisms Present time – Buried and Pre-sternal catheter placement and Urgent start PD

Review - Advantages of PD Initial survival benefit Preservation of residual kidney function Lower risk of infections (bacteremia, hepatitis) Preservation of vascular access sites Improved quality of life – Patients feel in control of their life and schedule – More time at home with family – Less dietary restriction – Fewer medical interactions

Definition of Urgent Start PD

Urgent Start PD Any patient who has been without the benefit of planning for Chronic Kidney Disease (CKD) who will need therapy within two weeks of placement of the PD catheter. A structured initiation of PD therapy for identified “stable” CKD patients who are without a plan for initiating dialysis. Therapy is initiated with low fill volumes for a period of two weeks until the membrane is well healed. Patient position during initial two weeks of therapy is supine with any volume of dwell.

Urgent  Emergent Dialysis centers are not equipped to deal with acute patients who: – Are overtly uremic – Are severely volume overloaded (i.e. dyspnea) – Have severe metabolic disturbances – Have limited or no support system in place – Have multiple other co-morbid conditions that may require supplies and skill related to; – Wound Vacs, Trachs, Feeding Tubes Center specific criteria and supporting paperwork for Urgent Start PD should be established by the Core Team. Selecting the right patients is imperative to the overall success of the program.

Question to Consider How many have performed small volume exchanges on an adult or pediatric patient using a PD catheter that was less that two weeks old?

Benefits of Urgent-Start PD Avoids the placement and use of a central venous catheter (CVC) at all Allows for initiation of PD with an immature PD catheter (<2 weeks after PD catheter placement) Provided in the outpatient setting if patient is clinically stable Training is concurrent with dialysis Possibly limits the need for future medical leave and time off work

How is this Possible? TEAM- A group of people with different skills and tasks, who collaborate on a common project, service, or goal, with a blending of functions and mutual support. Together Everyone Achieves More

Core Team Dialysis venue will affect the members of team. Are you a stand alone, hospital based or training center? Core Team Includes: Patient and Family Medical Director Nephrologist Operator – Surgeon, Interventional Radiologist, Nephrologist Nurse, Dieticians & Social Workers Other Core Team Members: Transportation Primary Care MD’s, Hospitalists and Specialists Pastoral Care Nutrition Services

Nephrologist : Patient Nephrologist is first to evaluate if Urgent-Start PD is an appropriate modality for the patient. The Nephrologist: Establishes open communication and trust Objectively assesses suitability for home therapy Provides Medical/Psychosocial evaluations as needed Provide introduction of other disciplines Educator and resource for Operator - expertise varies, need to use catheter within days, potential for complications etc. Liaison to other disciplines in the healthcare continuum  Case Managers and Discharge Planners  Primary Care Providers, Specialists, Hospitalists, Emergency Room  Hospital Administration

Nephrologist : Operator Perhaps the most essential relationship of any Urgent Start PD program is between the Nephrologist and Operator. Vital to the success of the program is the general agreement upon procedures, practice and need for patient education related to: – Pre-op care – bowel prep, night before shower – Surgical – placement, titanium adapter, transfer sets, sutures – post-op care – parameters for first dressing change, first flush, when is it ok to shower, lifting and general things to avoid – Pain expectation, treatment and preventing complications

Nephrologist : Medical Director Criteria should dictate that all referrals must be reviewed by the Medical Director. Medical Director will either approve or deny the request. – Any denial will be verbally communicated with the referring nephrologist with reasons detailing the area(s) of concern

Nephrologist : Nurse This relationship is the most fundamental to the overall success of the patient experience and outcomes related to Urgent Start PD. The role of a nurse is to provide quality care based on protocols, guidelines and current patient assessment concurrent to the role of liaison between all supportive core team members. California Board of Registered Nursing. (2011)

Other members of Core Team Dieticians and Social Workers have demanding yet varying roles – Social Worker: Crisis management related to lack of planning for life altering event Insurance and Education Transportation Services – Dietician: Frequent monitoring of labs given risk of hypokalemia & malnutrition Patient and family education on diet while in training and when they go home Intake and output – what should their intake be?

What’s Next? Infrastructure Considerations Whether you are a Hospital based, In Center – Stand Alone or Training Center, your infrastructure will determine your process and practice. Do you have more than one training room? Do you have chairs that have the capability of being flat? Do you have additional comfortable chairs for family? Do you have a call system in place? Do you have regularly scheduled clinics that require the use of all your training rooms? Do you have a bathroom in your training room?

Referral Process Policy to support the referral process Protocols that supports critical thinking Completed forms returned in a timely manner with applicable information: – ICD 9 codes, co-morbid conditions, past and current medical history, labs, medications, allergies etc. Without a paper or electronic process that starts the referral properly, you will have a chaotic start that could lead to an unpleasant patient and or staff experience.

Considerations Before scheduling a patient for Urgent Start PD consideration must be given to evaluate for the following: Staffing / census – consider not starting a patient on a Friday or a holiday Logistics – comfortable chair that will maintain supine position, communication, nourishment, medications, blanket and pillow. Plan for things to not always go as planned. Other commitments - MD clinics, PD or HHD training, Nurse clinic visits, home visits To accommodate Urgent Start PD, you may need to get creative with your staffing and real estate!

Ready to Start Initial Prescription for Urgent Start PD Solution: 1.5% dextrose, modify based upon nursing assessment for UF needs Fill volume: 500ml originally, now 1 L for two weeks # Exchanges: 4 – 6 (short dwells) Treatment time: hours 5 days per week No last fill – patient goes home dry Patient maintains supine position throughout therapy. It is imperative to drain the patient before sitting up

“The basis for urgent-start PD should always be patient centered and not enterprise driven” Arramreddy (2103) Patient Centered Care

WB Pre-op: Patient Education

WB Post-op: Patient Education

Bowel Care Guidelines

Expected Initial Prescription Results Likely poor clearance, but sufficient given the residual renal function (RRF) and imminent transition to higher volumes. However, move forward cautiously for those without RRF who may or may not be exhibiting signs of fluid overload.

Comparing Urgent Start PD Outcomes

Ghaffari 2012 Povlsen 2006 Lobbedez 2008 Casaretto 2012 Urgent-Start PD publications Koch 2012 Rioux Arramreddy 2013

Urgent-Start PD Outcomes Povlsen (NDT 2006) More mechanical complications among acute PD vs. planned PD starts No difference in technique survival No difference in infection rates Lobbedez (NDT 2008) No difference in peritonitis rates between acute and delayed PD starts Ghaffari (AJKD 2012) Similar outcomes (Kt/V, Hgb, Iron, Albumin) PD program grew 37.5% in first year of program

Comparison of Urgent-Start PD Regimens 34 GhaffariWellBound Standard protocolYes OperatorIRVariable GovernanceSingle groupVariable Starting volumes L0.5-1L Time5-8 hours5-7 hours Frequency3 x week3-5 x week Exclusion< 48 hours

Comparison of the benefits of PD to In-Center Hemodialysis (ICHD) and Home Hemodialysis (HHD)

PD vs. In Center HD Potential risk of infection More control over schedule, diet and lifestyle Ability to travel with limited preparation Care provided in the comfort of home Access protrudes Maintain RRF May see a decrease B/P meds IV meds during clinic visits Potential risk of infection In center with care providers Travel to and from center Less liberal diet and fluids Depressing atmosphere Potential for blood loss Access protrudes Limited control over schedule and time away from home IV meds Equal survival rates After effects of therapy

PD to HHD Training is 5-10 days Rarely nothing is seen as emergent in PD Closet full of supplies Machine smaller, less invasive of real estate Fluid removal more gradual Machine can be swapped out within 24 hours Green factor Data card Training ranges from 4 to 14 weeks or “as long as it takes” Constant risk of blood loss Supplies consume greater real estate than a closet Therapy consumes time of loved ones at home Results of UF seen immediately Higher costs with supplies, machines and training at initiation of therapy

“ If I have to do this, I would rather be at home.”

Potential Benefits of Urgent-Start PD Avoids use of CVC in selected patients Reduces obligatory discharge with CVC to in-center HD Reduces risk related to responsibility of care for CVC Reduces number of RN order entries requiring MD signature Reduces duration of exposure to CVC Reduces hospitalization days for acute PD starts Increases PD incidence and prevalence Reduces overall healthcare costs related to hospitalizations for access placement 43

Barriers to Urgent-Start PD Overall inexperience Lack of appropriate infrastructure – Integrated system involving nephrologist, operator, hospital, provider and patient Lack of common goal and buy in amongst the core team Lack of policies and procedures that define the common goal and purpose of urgent start Myth that there is a 2-4 week waiting period before the PD catheter can be used Hesitance to treat patients that are severely uremic, volume overloaded or have severe electrolyte disturbances with PD – Would require in-patient Urgent-Start PD

Frequent Question to Wellbound Why not offer Urgent-Start PD at all home centers? Answer: – Every center has its own set of challenges and barriers, making standardization technically difficult. – We need more data on quality metrics from centers participating in Urgent-Start PD pilots to determine feasibility, outcomes, technique survival.

What have we learned? 1.Urgent-Start PD programs require clear communication and agreement of care plan by all stakeholders. 2. Barriers to success may vary by region but can be minimized with a strong infrastructure and education.

The people we serve are just like us. They are someone’s Mother, Father, Sister or Brother, they have responsibilities, challenges, dreams and desires in addition to managing to live with kidney disease. Never underestimate how the education we provide and care we deliver adds to their ability to live more productive lives.

Role of Nurse The Standards of Competent Performance, California Code of Regulations, Title 16, section speaks to the role of nurses and how we demonstrate the ability to transfer scientific knowledge and apply that knowledge to our nursing process. This practice is demonstrated by our actions when we “act as a client’s advocate, as circumstances require by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client, the opportunity to make informed decisions about health care before it is delivered.” (California Board of Registered Nursing website, 2011)

Acknowledgements Dr. Rohini Arramreddy graciously provided her time, unique perspective and consultation as well as the structure and supportive documents for this presentation. Sheree Piccinini - Clinical Manager of WellBound of Modesto provided her time, insight and wisdom to make this presentation a reflection of what Urgent-Start PD looks like in real life. Satellite Healthcare for their continued vision and innovation while delivering effective and compassionate care to those in need.

Contact Us Please any questions/comments to Dr. Rohini Arramreddy Cathy Wilson-Bates, RN

There’s No Place Like Home I am blessed to be a part of a wonderful organization that supports a “One size does not fit all philosophy.” Thank you for being here today and taking part in this presentation. Thank you for all you do to help those we serve.

References Povlsen, J. (2006) How to start the late referred ESRD patient urgently on chronic apd. Nephrology Dialysis Transplantation, 21, [Suppl 2] ii56-ii59. Lobbedez, T. (2008) Is rapid initiation of peritoneal dialysis feasible in unplanned dialysis patients? A single-center experience. Nephrology Dialysis Transplantation, 23, Rioux, J.P. (2011) Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent- start dialysis. Clinical Journal American Society Nephrology, Apr. 6(4),

References Arramreddy-, R., (2013). Urgent start peritoneal dialysis: a chance for a new beginning. American Journal Kidney Disease 2013 Casaretto, A., (2012) Urgent start peritoneal dialysis: report from a u. s. private nephrology practice. Advances in Peritoneal Dialysis, Vol. 28, 2012 Ghaffari, A. (2012). Urgent start peritoneal dialysis: A quality improvement report, American Journal Kidney Disease, 59(3), Koch, M. (2011) - Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis. Nephrology Dialysis Transplantation 0, 1–6