Diversity is the Key: People, ideas, information.
Some of the key strategic goals of CANNT are to disseminate
educational materials to CANNT members; profile scientific research; and
to provide opportunities for nephrology colleagues to network.
CANNT's national conference, CANNT 2007, provides an excellent venue for accomplishing these goals of CANNT. However, only a portion of CANNT members are able to attend the national conference annually. Cognizant of this, CANNT is pleased to be printing this issue of the Journal as a special "CANNT 2007" issue, which includes the submitted abstracts being presented at this year's conference, both orally and in poster format.
The following abstracts celebrate the diversity of nephrology topics being investigated and discussed across Canada. It is our hope that CANNT members interested in pursuing a profiled topic will contact our national office at (705) 720-2819 or firstname.lastname@example.org to receive information regarding how to contact the author about the work.
We hope you will carefully review these abstracts!
|Publication:||Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2007 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136|
|Issue:||Date: July-Sept, 2007 Source Volume: 17 Source Issue: 3|
|Geographic:||Geographic Scope: Canada Geographic Code: 1CANA Canada|
Winnipeg Convention Centre Winnipeg, Manitoba
October 25-28, 2007
This conference, CANNT 2007, promises to be a stimulating forum where nephrology professionals ... nurses, technologists, administrators, researchers and pharmacists ... will be able to learn, share, network, discuss and socialize together.
Experience all that CANNT 2007 has to offer ...
* Share in the messages of top-rated professional speakers ...
* Choose from more than 40 concurrent sessions suited to all interests ... topics range from nutrition, transplantation, end-oflife issues, pediatrics, infection control and much, much more ...
* Peruse a record-breaking number of poster presentations (54), with contributing authors from one coast of Canada to the other--you'll be delighted in the diversity of nephrology topics being profiled this year!
* Interact with our corporate partners as they display their latest products and services, and share their expertise with delegates. With ample opportunities to network with corporate representatives, delegates should come prepared with questions and issues.
* Immerse yourself in this year's conference theme. Our social activities and the scientific program will inspire, educate, rejuvenate and motivate you for the everyday challenges of your professional and personal lives.
Register today! CANNT 2007 information is available as follows:
1) printed brochure available by calling: (519) 652-0364 (Innovative Conferences & Communications)
2) downloadable brochure on-line at www.cannt.ca
3) program, abstracts, on-line registration and secure payment on-line at www.cannt.ca
We're excited to welcome Canadian nephrology professionals to Winnipeg--to experience CANNT 2007.
Conference nationale annuelle de l'ACITN de 2007
Centre des congres de Winnipeg Winnipeg, Manitoba
October 25-28, 2007
LA DIVERSITE EST LA CLE PERSONNES, RENSEIGNEMENTS, PLANS
La Conference nationale annuelle de l'ACITN de 2007 promet d'etre un forum stimulant o les professionnels de la nephrologie--infirmieres, technologues, gestionnaires, chercheurs et pharmaciens--se donnent rendez-vous pour approfondir leurs connaissances, echanger leurs idees et opinions, reseauter, discuter et nouer des relations.
Venez vivre l'experience de la Conference nationale annuelle de l'ACITN de 2007 ...
* Venez ecouter nos conferenciers-invites, tous experts dans leur domaine.
* Choisissez parmi plus de 40 ateliers simultanes ceux qui repondent le plus a vos champs d'interet. Les sujets abordes vont de la nutrition, a la maitrise de l'infection, en passant par la transplantation, les questions liees a la fin de la vie et les enjeux d'ordre pediatrique. Et, beaucoup plus encore!
* Consultez le nombre record d'affiches scientifiques (54) auxquelles ont participe des auteurs d'un bout a l'autre du Canada--vous serez enchantes par la diversite des themes qui sont presentes cette annee sur la nephrologie!
* Venez rencontrer nos partenaires commerciaux. Ils vous feront part de leurs plus recents produits et services et partageront avec vous leur expertise. Comme nous vous offrons maintes occasions de reseauter avec les representants de l'industrie, nous vous conseillons de preparer les questions ou sujets de discussion que vous aimeriez aborder avec eux.
* Laissez-vous vous impregner du theme de la Conference de cette annee. Les activites sociales prevues et le programme visent notamment a vous inspirer, a parfaire vos connaissances, a vous regenerer et a vous motiver afin de relever les defis quotidiens qui jalonnent votre vie professionnelle, mais aussi votre vie personnelle.
Inscrivez-vous maintenant! Pour de plus amples renseignements sur la Conference nationale annuelle de l'ACITN de 2007, veuillez consulter les sources d'information suivantes :
1) brochure imprimee en appelant au 519-652-0364 (Innovative Conferences & Communications)
2) brochure en ligne a www.cannt.ca
3) programme et actes de la conference, inscription et paiement securise en ligne a www.cannt.ca
C'est donc un rendez-vous a Winnipeg pour tous les professionnels canadiens de la nephrologie--venez vivre l'experience de la Conference nationale annuelle de l'ACITN de 2007.
Actes de la conference
L'ACITN s'est donne comme objectifs strategiques cles de diffuser du materiel didactique a ses membres, d'etablir pour ses membres un profil des recherches scientifiques et d'offrir a ses membres et aux partenaires de l'industrie des occasions de reseauter.
La Conference nationale annuelle de l'ACITN de 2007 est une excellente vitrine pour accomplir ces objectifs, malgre qu'une portion seulement des membres de l'ACITN puissent y assister. Consciente de ce fait, l'ACITN est heureuse de publier une edition speciale de son Journal qui sera consacree aux actes de la Conference nationale annuelle de l'ACITN de 2007, incluant les textes des communications et les affiches scientifiques.
Les actes de la conference mettent en valeur la diversite des sujets qui ont fait l'objet d'etudes et de discussions d'un bout a l'autre du Canada. Nous invitons les membres de l'ACITN qui desirent approfondir un sujet precis a communiquer avec le bureau national de l'ACITN au (705) 720-2819 ou a email@example.com afin de recevoir plus d'information sur la facon d'entrer en communication avec un auteur en particulier.
Nous esperons que les actes de la Conference nationale annuelle de l'ACITN de 2007 vous seront utiles. Bonne lecture!
Past the point of return: A case study of residual renal function recovery
Sylvia Zuidema, RN, MSc, and Renee Eggert, RN, CNeph(C) (Edmonton, Alberta)
A 54-year-old, 50 kg female with acute renal failure on hemodialysis (HD). Her history includes rheumatic heart disease since childhood with a mitral and/or aortic valve replacement in 1989, 1993, 1994, 1995 and 2004. In 2004, the mitral and aortic valve replacement surgery led to acute renal failure and stroke. She was then started on HD and her creatinine ranged from 106 to 248 mcmol/L. She then had a peritoneal dialysis (PD) catheter inserted and started PD in January 2006. Creatinine then ranged from 101 to 387 mcmol/L. The PD clinic focuses around a strong primary nursing and multidisciplinary team approach. In August 2006, at post-clinic rounds, it was noted that her creatinine had been in the normal range for four to six weeks. Residual renal function (RRF) showed glomerular filtration rate (GFR) of 14.50 mL/min in March of 2006. Blood work and RRF were monitored. Creatinine remained normal and RRF in August showed GFR of 33.38 mL/min. PD was held in October, weekly creatinine remained normal. Her renal function has been stable with a GFR of >30 mL/min for more than six months. She was on HD for two years and PD for almost one year, resulting in recovery and stopping dialysis ... amazing! Could routine RRF and multidisciplinary care rounds in HD have been beneficial? This case demonstrates how routine monitoring, primary nursing and the diversity of the multidisciplinary team are clearly valuable.
Development of a peritoneal dialysis support initiative for clients in the community
Susan MacNeil, BN Transition Coordinator, Provincial Renal Program
Many clients would benefit significantly from peritoneal dialysis, however; they are either not capable of performing it themselves, or they do not have family members capable of performing it for them. The Nova Scotia Continuing Care/Acute Care Peritoneal Dialysis Working Group was established to develop a framework for provision of community-based peritoneal dialysis services for this specific population. The working group has developed a report and recommendations for a Continuing Care Peritoneal Dialysis Program. The program will promote service delivery models that take peritoneal dialysis services to the client and promote a collaborative effort amongst home care, long-term care, acute care and service providers to better meet the needs of this specific patient population.
The Continuing Care Peritoneal Dialysis Program will provide education and supports required to provide peritoneal dialysis to clients, using six service delivery models: 1) Clients residing in their own home, where home care service provider performs peritoneal dialysis; 2) Clients residing in their own home, where home care service provider augments existing caregiver support by performing peritoneal dialysis; 3) Client residing in long-term care (LTC) facility, where client performs peritoneal dialysis independently, but under the supervision of the LTC facility staff; 4) Client residing in LTC facility, where home care service providers perform peritoneal dialysis; 5) Clients residing in LTC facility, where LTC facility staff perform peritoneal dialysis; and 6) Clients residing in acute care facility, where home care service provider performs peritoneal dialysis.
This presentation will outline the process, the program goals, the service delivery models, the home care and LTC pilot projects, the working group recommendations, policy changes required and progress to date.
Proposal for an enhanced Nova Scotia Satellite Dialysis Service
Susan MacNeil, BN Transition Coordinator, Provincial Renal Program
In collaboration with the four in-centre hemodialysis programs and the Department of Health, the Nova Scotia Provincial Dialysis Program is working towards an integrated approach to dialysis care that involves the implementation of a satellite dialysis "New Model of Care". As the result of the growing renal population, public demand for dialysis services closer to home, and the recommendations of a satellite program review, the group embarked on a project that would enhance local integration, coordination and provision of care, in collaboration with the specialty expertise provided by the in-centre dialysis program.
This New Model of Care will provide a balance of local resources with access to specialized expertise, which will be accomplished by travelling physician/nurse teams, regularly scheduled telecommunication links, and physician alliances with local physician groups. The local satellite staff will be integrated into the life and basic operations of their institution. The pilot project will create a new staffing model with the proper staff mix to provide appropriate renal care for an expanded patient population. The benefits of this new model of care include the integration of all satellite services provided within the local facility, the fiscal resources for infrastructure required to support the satellite program, the clinical and educational support from the in-centre program and the collaborative relationship with the provincial dialysis program to identify and plan for future needs.
This presentation will outline the satellite program as it currently exists; the issues or service gaps identified; the opportunities for resolution; the project purpose, scope and benefits; the "New Model of Care"; the pilot project; the evaluation component and next steps.
From small to tall and kids in between
Yvonne Rhoden, RN, CNeph(C) (Winnipeg, Manitoba)
This presentation will provide information for nurses in a pediatric unit or for those who provide care for young children in an adult unit. Information will include: a brief history of Manitoba's first and only pediatric hemodialysis unit including the area it serves and patient demographics, the top 10 reasons for causes of renal failure in children, how they compare with adults, the advantages to a pediatric hemodialysis unit, the differences in a child compared to an adult, including access, assessment, type of dialyzer, type of dialysis machine, length, frequency of treatment and growth and development. In conclusion, nurses will increase their knowledge in caring for the very young in an adult or a pediatric hemodialysis unit.
Targets met:The challenge of retaining
Anne-Marie Sutherland, RN, CNeph(C), Cathy Baynham, RN, CNeph(C), Gale Burden, RN, CNeph(C), Heather Bouckley, RN, CNeph(C), Heather Scroder, RN, CNeph(C), Linda Nasso, RN, CNeph(C), and Emily Harrison, RN, BHScN, CNeph(C) (Toronto, Ontario)
Peritoneal dialysis (PD) prevalence within our program reached the Ministry of Health initiative target of 30% in July of 2006. Growth in the program was a result of many action items that were initiated to increase the recruitment of PD patients. PD patient numbers increased from 22% to more than 30% within two years. With the targets met, we now face the challenge of retaining our growth. With the goal of retention and possible further growth, some previous action items are being used, as well as the implementation of new strategies. Some of these include:
* Support from Community Care Access and Complex Continuing Care
* Use of Tidal 85% therapy with CCPD
* Decreased total volumes and longer dwell times with CCPD
* Increasing therapy with mid-day twin bag instead of increasing CCPD volumes
* Following current guidelines for hypertension, diabetes, anemia, and lipids
* Continued involvement in Ministry of Health PD initiative
* Increased staffing ratios
* Revised home visits protocol
* Peritonitis CQI
* Protection and monitoring of residual renal function
* Change of KDOQI/CSN targets
* Trail of hemodialysis with return to PD
* Weekly team meetings to capture parachuters to allow patients informed modality choice
Sharing our ideas, challenges and outcomes will provide others with information, strategies and encouragement to grow and retain PD prevalence. We have been able to retain our PD prevalence for more than a year with challenges ... but diverse ideas are the key to success.
A patient perspective on health care system navigation in the context of multi-morbidity: An interpretive description
Eleanor Ravenscroft, RN, MSN, PhD(c), CNeph(C) (Toronto, Ontario)
We know little about the phenomenon of health care system navigation from the patient perspective. My qualitative study, using an interpretive descriptive design, examined the point of view of patients dealing with multiple, co-existing chronic conditions. These people have a unique understanding of how health care delivery links across time, place, and settings because of the care they require for their multiple chronic conditions.
Primary data collection included audio-taped, face-to-face individual interviews with patients attending one of three urban chronic kidney disease (CKD) clinics. The participants were: (a) adults (19 years or older), with (b) diagnosed CKD, and (c) co-existing diagnosed diabetes mellitus and/or cardiovascular disease, and (d) able to communicate in English. Secondary contextual information sources included interview participants' clinic and/or hospital charts, organizational documents, and expert health care providers. Data collection and analysis were iterative. I used constant comparative data analysis methods to identify themes and patterns in the data.
My study findings add an important consumer perspective to what we know about health care system navigation. Enhanced understanding, from the consumer perspective, of what enables and hinders patients dealing with multi-morbidity to access and ensure the continuity of their care may improve care delivery for this population group. These findings are of relevance to clinicians who may use them to inform their assessment of patient needs and care planning for individual patients, and policy- and decision-makers who may use the findings to inform their decisions about ongoing health care system changes and reform.
Post-dialysis "pre-dialysis" care: The cart before the horse
Diane Watson, RN, MSc, CNeph(C), ACNP Nephrology (Toronto, Ontario)
University Health Network (UHN), as well as most nephrology programs, has a well-developed and successful multidisciplinary pre-dialysis clinic, which provides education and medical management for people with chronic kidney disease leading up to the need for dialysis or transplantation. Another large group of individuals, who have not had long-time renal failure, start dialysis on an emergency basis in hospital, often in ICUs with little or no preparation or education. Historically, a vast majority of this group of patients (87%) in our institution remained on in-centre hemodialysis, the most costly and nurse-intensive form of chronic dialysis. UHN Division of Nephrology developed a program by which a consulting Nurse Practitioner (cACNP) intervened with these individuals starting dialysis on an emergency basis, with the goal of encouraging home dialysis. In the first 21 months of this role, the percentage of patients who started dialysis acutely who stayed on in-centre HD number decreased from 87 to 33.8%, and the percentage who chose home dialysis increased from 13 to 66.2%. The cost savings to UHN in dialysis costs has been significant. There are additional advantages as well, such as appropriate use of nephrology hospital beds, fewer nephrology patients waiting in ER, and no wait times for outpatient hemodialysis spots. This presentation outlines the practice changes and the process for providing support and education to these individuals who start dialysis urgently.
"One appointment, two treatments!" Combining therapeutic plasma exchange and hemodialysis treatments for improved patient outcomes
Terry Gee, Renal Technician, BASc, PEng (Vancouver, British Columbia)
Why should a patient who requires both hemodialysis and therapeutic plasma exchange (TPE) treatments have to make two separate appointments? They don't!
This presentation describes how TPE and hemodialysis treatments can be combined so that the patient receives two treatments during one appointment: the what, why, who, when, where and how of combined TPE and conventional hemodialysis therapy. First, an explanation of what TPE is, when it is used and how it works will be reviewed. Then, a detailed description of the technical aspect of how these treatments are accomplished together will be provided. Lastly, outcomes of this combined approach in terms of improved quality of life for patients and more efficient use of health care resources will be highlighted.
Who might be interested in attending? If you are a hemodialysis practitioner, in particular one who works in a facility that also offers TPE or if you are simply intrigued by the idea, please join us at our presentation.
Twenty years at Lions Camp Dorset, or,What we dialysis nurses did on our summer holidays!
Evan Turner, RN, Kellie Clarke, Marilyn Bird, RN, Bernadette Reid, RN, Carol Rivers, RN, Cheryle Keys, RN, Ana Marticorena, RN, Rosa Marticorena, RN, Neil Groombridge, RN, Gail Shantz, RN, Sandy Taylor, RN, Diane Watson, RN, Mike Curtis, Dialysis Technologist, and Clarence Graansma, Dialysis Technologist (Huntsville, Ontario)
After 20 years of exhilarating service to our patients, the staff of Lions Camp Dorset is moving on. For each of us, the time spent at camp represents the epitome of what nursing is about. The provision of quality medical care, while at the same time meeting the psycho/social needs of our patients, is what every nurse aspires to.
Lions Camp Dorset provides the only opportunity that most dialysis patients in Ontario will ever have to enjoy a holiday. It is a fully provisioned resort, as well as a certified Independent Health Facility. The people who attend get to enjoy a week away with their friends and family while receiving the medical care they require.
The clinic at Camp Dorset houses a 16-station hemodialysis unit, the day-to-day running of which has been managed entirely by dialysis nurses. There are no onsite physicians or technicians. It is an understatement to say that performing up to 32 dialysis treatments per day--on an entirely transient clientele--in a facility located in the bush, 35 kilometres from the nearest hospital--presents its challenges.
Being a camp staff nurse requires a unique set of qualities. Dialysis must be second nature. One must be knowledgeable, flexible, dedicated and hard working. One must be resourceful, friendly and full of humour. Most importantly, one must be able to hold one's own in the midst of the most brutal of water fights, all the while ensuring the safety of one's patients.
In this presentation, members of Camp Dorset's nursing team will share their many experiences. Photos from over the years will provide a backdrop that will illustrate the many aspects of camp life. Everything from writing an entire policy and procedure manual in three days and nights, to doing drive-through SARS screening in a MASH-type army tent will be covered. All of us who have worked at the camp have been affected by the experience, and we look forward to sharing this with our peers.
You want me to do what? Supporting the professional development of TOH hemodialysis nurses in providing PD care for patients admitted to the Civic Campus
Cynthia Leroux, BN, RN, CNeph(C), Marilyn Kendall, RN, BScN, CCN(C), and Monique Benard, RN, CNeph(C) (Ottawa, Ontario)
The amalgamation of three hospitals into The Ottawa Hospital (TOH) in 2000 resulted in the merger of two previously independent nephrology programs (Civic and General) with various pieces spread over three campuses. Peritoneal dialysis was originally concentrated at the General Campus, which housed the home dialysis unit (HDU) and the single inpatient nephrology ward for the program (7NW). All patients with PD needs were to be admitted to 7NW but, as other TOH disciplines were consolidated to one geographic location, the need for PD (cycler) services at the Civic Campus grew. The decision was made to have the "PD experts" manage all PD patients within TOH, regardless of location. The 7NW staff travelled to the Civic Campus to assess the patient and set up the cycler each evening and the HDU nurse would see the patient each morning to disconnect. Fraught with challenges of managing supplies, maintaining skill competency and managing workload, a new coverage model was implemented from 2003 to 2005. The HDU (now located at the Riverside Campus) developed and supported an initiative to train nurses on the vascular surgery unit at the Civic to do their own PD cycler care. In 2006, the program experienced a huge increase in PD care after years of decreased PD activity and PD patients admitted to the Civic were not isolated to the vascular unit. Issues of nursing competency and, ultimately, patient safety forced a return to the original model while a sustainable solution was explored. It was time to do something different. Was it time to tap into the expertise of the nephrology nurses working in the Civic Hemodialysis Unit? Beginning in February 2007, that is exactly what was done.
This presentation will explore the successes and challenges in implementing a new model of PD care delivery, using hemodialysis nurse expertise with shared support from the home dialysis program.
Changing lives after dialysis: The over 80-year-old story
Gillian Brunier, RN, MScN, CNeph(C), Michelle Hladunewich, MD, BSc(Med), MSc, FRCP(C), and Sarbjit Vanita Jassal, MB, MD, FRCP(C) (Toronto, Ontario)
Background: One of the greatest challenges today for dialysis professionals is providing care to the increasing number of very elderly starting dialysis. The aim of our project was to estimate survival in a cohort of over 80-year-old patients starting chronic dialysis, to assess their burden of comorbidities, and to identify changes in their living situation after dialysis start.
Methods: Using a single-centre, retrospective cohort study design, we followed the progress of all patients aged 80 years and older who started chronic dialysis during the period 2000-2005.
Results: A total of 97 patients, 80 and older, started chronic dialysis over the five-year study period. Of these 97 patients: 50.5% were male; the mean age at dialysis start was 84.5[+ or -]3.3 years (range 80-96 years); 56% were started on hemodialysis and 44% on PD. Seventy-five per cent of patients had multiple comorbid conditions with a mean Modified Charlson score of 4.5[+ or -]1.9. One- and three-year survival was estimated at 72% and 51% respectively. No difference in survival was seen between those starting PD and those starting hemodialysis. At the time of the first outpatient dialysis, the proportion of patients who were still living independently had fallen from 78% to 46%. During the follow-up period, a further 17 patients on hemodialysis and 10 patients on PD transferred from their own home to a nursing home or retirement home. Also, nine patients on hemodialysis, but none of the patients on PD, underwent geriatric rehabilitation care.
Conclusions: Dialysis in this very elderly cohort of patients was associated with great loss of independence and modest survival. The option of treatment at a geriatric rehabilitation centre was not available for those on PD, but may have allowed more of these patients to remain at home.
Manitoba Renal Program's Renal Health Outreach: Shifting the paradigm
Jan Schneider, RN (Winnipeg, Manitoba)
Purpose: End stage renal disease (ESRD) is epidemic in Manitoba. Prevalent ESRD in Manitoba is 30% greater, and prevalent hemodialysis is 50% greater than the rest of Canada *. A major contributing factor is the large number of aboriginal patients in Manitoba living with diabetes. Of the 1,034 dialysis patients in Manitoba, 40% are aboriginal with 60% having diabetic nephropathy. The predicted prevalence of chronic kidney disease (CKD) in Manitoba is 9.4%, (6% for the rest of Canada) **. The purpose of this project is to describe the Renal Health Outreach (RHO) initiative of the Manitoba Renal Program (MRP).
Description: RHO provides education by a specialized interdisciplinary renal team (nephrologist, nurse, dietitian, aboriginal liaison social worker, pharmacist, exercise specialist, occupational therapist) for health care providers, the public and schools throughout Manitoba. The focus of RHO is renal health promotion and disease prevention. Under the umbrella of RHO are Renal Health Clinics (RHCs) that encompass the continuum of CKD from early identification, prevention, attenuation of progression and preparation of renal replacement therapy. This is achieved through education and clinical care from the interdisciplinary renal team.
Evaluation: Since the inception of RHO/RHCs, the number of acute dialysis starts (within three months from referral) has decreased from 45% to 35%.
Implications for nephrology practice: Public and health care provider awareness/education of renal disease in Manitoba, emphasizing prevention with a focus on high-risk reserves.
Early identification of high-risk patients to prevent progressive renal disease.
Timely referral for assessment and treatment to interdisciplinary renal care.
* Canadian Organ Replacement Registry
** Adapted from Levin, CMAJ, June 2003
Work environment, health outcomes and magnet hospital traits in the Canadian nephrology nursing scene
Jane Ridley, RN, MScN, CNeph(C), Barbara Wilson, RN, MScN, CNeph(C), and Lori Harwood, RN, MSc, CNeph(C) (London, Ontario)
Nephrology, like other areas of health care, is confronting a nursing shortage. The American Nephrology Nurses' Association contends that patients will be negatively impacted unless decisive action is taken to address both current and future nursing shortages.
Previous research on magnet hospitals--organizations that successfully attract and retain nurses--has demonstrated that work environments that promote empowerment, autonomy, responsibility, control over the work environment, and collaborative working relationships contribute to nurses' job satisfaction. Nephrology nurses view their role as being unique and different from their nursing colleagues. There is, however, little literature specific to nephrology nursing work environments. One recent Canadian study reported that implementation of a renal nursing professional practice model promoted a positive and empowering environment for hemodialysis nurses.
This descriptive study examined whether magnet hospital traits, empowerment, and organizational support contributed to Canadian nephrology nurses' job satisfaction, health outcomes, and perceived quality of patient care. A randomized convenience sample of 300 nurse members of CANNT was asked to complete a survey consisting of four instruments: the Nursing Work Index, Conditions of Work Effectiveness Questionnaire II, Maslach Burnout Inventory, and the Pressure Management Indicator. Data collection was in the process at the time of abstract submission.
Information garnered from this study may assist managers in identifying characteristics of practice environments that appeal to the type of nurses attracted to nephrology. This information is necessary in generating recruitment and retention strategies to ensure an adequate nephrology nursing workforce in the future.
A comprehensive glucose program for renal patients--A collaboration between the diabetes education centre and the renal unit
Julie Paterson, RN, BScN, CNeph(C), CDE, and Ursula Betker, RN (Mississauga, Ontario)
There were several challenges that we faced in the ongoing monitoring and care of our outpatient diabetic renal patients. The collaborative effort of a dedicated team from the diabetes education centre and the renal unit has been successful in improving patient outcomes through some simple, but consistent care strategies.
Some of the challenges were the use of old meters that displayed measurements in non SI units. Some patients recorded inaccurate measurements due to poor vision. Diabetic education prior to pre-renal clinic involvement was rarely provided by the family physician.
The use of consistent meters, software for download and, checking compliance has facilitated accurate measurements of blood glucose and has optimized care. Education is ongoing for all patients. An endocrinologist reviews appropriate referrals in a timely manner. The endocrinologist often sees the patient during dialysis. The benefit of this program is seen in the outcome. We have seen better control of blood glucose in several patients. Some patients no longer take insulin.
This presentation will outline the challenges, the strategies, the improvements, the outcomes and the lessons learned during the implementation of this program in our diabetic renal population.
Oh patient--Where art thou? Development of a process to address missed hemodialysis treatments
Jane Ridley, RN, MSN, CNeph(C), Karen Peters, RN, Gail Barbour, RN, CNeph(C), Mike Berta, RN, BScN, BScB, Andrew House, MD, MSc, FRCPC, Marlene Rees-Newton, MSW, RSW, Catherine Smith, MSW, RSW, and Dennis Smith, RN(EC), MN (London, Ontario)
Patients missing treatments: It's inevitable. Sometimes weather or other circumstances prevent patients from making it in for their treatments; sometimes they simply choose to not come to dialysis. Rescheduling the treatment is not always an option, particularly when the dialysis census is high.
This begs the question: What is the best way to address missed treatment/off-schedule hemodialysis patients?
This question was being examined by both in-centre and satellite teams within a regional renal program. The two groups united to address the issue from the program perspective. The goal was to develop a consistent approach in handling missed treatments, be it for patients who occasionally miss treatments or for patients who routinely miss treatments.
A multi-disciplinary committee was formed. A representative from the risk management department was asked to join the team.
The issue was examined from various perspectives: Patient (physical and psychosocial), nursing, medical, and legal. Key elements addressed included: assessing stability, notifying and briefing appropriate care team members, rendering a treatment decision, and follow-up.
Benchmarking was done to identify how other programs manage this issue. An analysis of the pros and cons of different methods of management was done. Issues surrounding professional responsibility and liability as well as patient responsibility and accountability were researched.
The process has been reviewed and revised. Strategies for staff and patient education were generated and integrated into the process. An evaluation strategy was developed. An algorithm was created and reviewed by stakeholders for potential program-wide adoption.
Redefining peritoneal dialysis adequacy
Linda Kloosterman, RN, BScN, CNeph(C) (Peterborough, Ontario)
What does it mean to be adequate? What formed your beliefs? The purpose of this presentation is to explore the history of adequacy in peritoneal dialysis and to examine the current literature internationally to dispel common myths. Based on this research, I will demonstrate that adequacy today is well-defined and easy to achieve.
Historically, there have been several studies that have had significant impact on our perceptions of adequacy. I will examine the perceptions from the CANUSA (1996) study, HEMO trial (2002), ADEMEX study (2002) and Hong Kong study by Lo et al. (2003) and how they have influenced peritoneal dialysis (PD) patient care.
Adequacy today is well-defined. There is international consensus from Australia, Europe, United Kingdom and United States of America. The International Society of Peritoneal Dialysis (ISPD) developed guidelines based on research and discussion with representatives from Hong Kong, USA, India, Canada, Finland, etc. All are in agreement!
Adequacy is easy to achieve. A patient-focused approach is possible through prescription tailoring to meet individual patient needs. The flexibility of therapy options meets patients' diverse requirements. Examples of innovative techniques/prescription tailoring will be discussed.
Implications for nephrology care include a re-evaluation of peritoneal dialysis adequacy, as well as a return to patient-focused care.
Reasons for high-prevalence of central venous catheter (CVC) use in a Canadian hemodialysis (HD) program
Janet Graham, RN, BHScN, CNeph(C), Swapril Hiremath, MD, Greg Knoll, MD, FRCPC, Peter Magner, MD, FRCPC, FRACP, and Kevin Burns, MD, FRCPC (Ottawa, Ontario)
Background: In many Canadian hemodialysis (HD) units AV fistula (AVF) use remains low despite clinical practice guidelines recommending its use. Despite having a dedicated vascular access (VA) coordinator, dedicated OR time, and five vascular surgeons committed to access creation, our centre has been unable to achieve an AVF rate> 60%.
Purpose: To determine factors associated with the choice of HD access and to identify if the attitudes of the nephrologists at the Ottawa Hospital (TOH) might be influencing the selection of types of VA being used.
Methods: Data collection (type of access, rationale for access type, demographics, co-morbidities) of prevalent HD patients (n=594) receiving treatment on Nov. 1, 2006. Questionnaire distributed to 17 TOH nephrologists.
Results: Access types: AVF, n=294 (49.4%); AV grafts (AVG), n=16 (2.7%); CVC, n=284 (47.8%). Of the 284 patients with a CVC, reasons for CVC use: 116 (40.8%) vessels unsuitable for AVF; 51 (18%) medically unsuitable; 34 (12%) AVF awaiting maturation; 33 (11.6%) not on long-term HD; 27 (9.5%) refused AVF; 19 (6.7%) awaiting AV access surgery.
Survey: (n=17, 100%) unanimous agreement-optimal HD access is an AVF, nearly uniform agreement-referral for access is appropriate for patients with previous failed access and patients with co-morbidities, 76% of nephrologists did not consider increasing age alone to be a barrier for AVF creation.
Conclusion: Relatively high use of CVC for HD at TOH is mainly due to patient-specific factors rather than system factors or physician beliefs. With the aging HD population, optimistic targets for AVF use might need to be revisited.
Matchmaking for dialysis access
Anita Salmon, RN, BSc, MA, CNeph(C), and Rick Luscombe, RN, BSN, CNeph(C) (Vancouver, British Columbia)
It has been recognized in the hemodialysis (HD) community (1) that fistulas and grafts vary in the ease with which they can be cannulated, and (2) that there is a range of cannulation skills among HD nurses. Despite recommendations in the literature and in many national guidelines to match the degree of difficulty of an access to cannulate with the skill level of the cannulator, few (if any) programs exist to ensure this match.
In British Columbia in 2006, the Provincial Vascular Access Services Team (PVAST) developed a provincial guideline for cannulation of arteriovenous (AV) fistulas and grafts. One of the recommendations in the guideline is to formally match the degree of difficulty of an access to cannulate with the skill level of the cannulator. Objective assessment criteria for both cannulator and access have been delineated.
The Provincial Vascular Access Educators Group (PVAEG) has been charged with the responsibility of implementing this recommendation. The presentation will present the objective assessment criteria for accesses and for cannulators and will describe the progress made in implementation.
This innovative approach holds promise for improving cannulation outcomes for the dialysis population.
The effects of buttonhole needling in a hemodialysis unit: The patient and staff experience
Valerie Ludlow, RN, MN, and Koren Snow, RN, BN, NP (Paradise, Newfoundland)
A progressive cohort research project was developed and initiated in February 2007 in five hemodialysis (HD) units in Newfoundland to assess the effects of the buttonhole (BH) needling technique in terms of confidence levels of the patients and staff in relation to the use of the BH procedure, complications experienced by the patients, and the overall experience of both groups. Input from patients and staff was requested at four separate times throughout the study: at the start, after the first four weeks and then eight weeks of the study, and then at the end of the study period (three months).
Additionally, we plan to review the financial consequences of the BH needling technique at the unit and the corporate level. Expenses being reviewed at the unit level include the cost of the more expensive blunt needles versus the extra nursing time required to address patients' pain levels, hematomas, reneedling of accesses, and extended bleeding times post needle removal. On the corporation level, we hope to assess whether or not there has been a decrease in the procedures required to repair fistula injury or failure (e.g., hospitalizations, x-ray procedures, central venous catheters, and surgical repairs) in the year prior to and the year immediately post-use of BH needling technique. The review of all these outcomes will allow us to assess whether or not the use of the BH needling procedure is financially viable as well as effective in improving the quality of life of our HD patients.
Using long-distance education to achieve program goals
Sharon White, RN, BScN, MBA, Sandra Bartlett, RN, and Rebecca Thomas, BHScN, RN (London, Ontario)
Purpose: To increase the number of patients receiving chronic kidney disease (CKD) education, which will result in more patients choosing home therapies.
The large geography of London Health Sciences Centre (LHSC) catchment has become a barrier for patient attendance at the CKD education classes. The drive one way into London can be up to five hours. As a result, only 40% of eligible patients have been attending these education classes.
We have found that patients attending the classes not only benefit from the content, but the process as well. They realize they are not alone in their disease and learn from other patients. Hence, the need for LHSC to maintain a "real time" education process that can then be followed up by videos, 1:1 teaching, etc.
We invited our regional partners (where we have existing hemodialysis satellite units) to participate in providing long-distance education via Ontario Telemedicine Network. Five of the eight partners now provide local room and technology connectivity to London. Another satellite will be joining this initiative in April. At this point, we have provided five classes with 25 patients participating and had overwhelming positive feedback of patients.
This presentation will describe in more detail the problem statement, planning, implementation and evaluation of this education service.
Helping patients who are acute hemodialysis starts cope with the psychosocial impact of living with kidney disease
Emily Harrison, RN, BHScN, CNeph(C), Sue Bonnetta, RN, CNeph(C), Patti Elliott, RN, Lise Vardy, RN, and Anne Goerz, RN (Toronto, Ontario)
Patients who start hemodialysis acutely in the hospital setting are overwhelmed by the diagnosis and the psychosocial impacts of living with kidney disease. Most often, these patients have received no pre-dialysis education and are unaware of the education and supports available to them.
Within our program, we have developed a strong multidisciplinary team and primary nursing model to help these patients develop self-management skills necessary to cope with this new diagnosis and to select a renal replacement therapy of their choice.
While in hospital, all new patients must be seen by a dietitian, social worker, pharmacist and ACNP to start this process. This process is continued in the out-patient setting and includes: facts about their disease, how to cope with the illness, diet changes, medications and other tests, how the illness may affect their family life, and education regarding renal replacement options.
Once discharged, the hemodialysis nurse is the central person for the patient within the team, providing basic education and consulting other team members to ensure they have received the support they require. This team not only includes members within the program, but also our community partners; the family doctor, community pharmacist, community access to care centres, and The Kidney Foundation.
Through sharing of this process, we hope to provide other programs with ideas and strategies that will help with the smooth positive transition for patients starting dialysis acutely to living with chronic kidney disease.
Meeting the challenges of a diverse CKD population in Southern Alberta: Redesigning the care delivery system through multidisciplinary innovation projects
Suzanne Searle, BA, RN, CCRN, and Veronica Chang, RN, BA, CN, CNeph(C) (Calgary, Alberta)
The Southern Alberta Renal Program originally launched the CKD (pre-renal) program in Calgary, Alberta, in 1996. It has evolved over the years to a highly specialized and very functional clinic. There are currently 1,200 patients enrolled in this clinic. In the past two years, many new innovations have been implemented to meet the CKD program goals and objectives, which focus on the following broad components: education, prevention, early detection and treatment, patient empowerment, and timely referral to appropriate adjunct clinics.
This poster presentation will identify and delineate the innovative programs that now exist to serve the growing patient population. A multidisciplinary approach has improved the clinical outcomes of CKD patients and successfully managed the co-morbidities in the CKD patient group.
Projects and care delivery now includes:
* Triage role for a CKD nurse for all referrals
* New GN clinic specifically for early glomerulonephritis patients
* New CKD clinic for patients with MDRD GFR > 30
* Continued central CKD micro case management clinic for MDRD GFR < 30
* Additional new CKD clinic in NE Calgary to accommodate the growing CKD patient population with MDRD GFR < 30
* New research-based project for aboriginal diabetic/renal patients to screen and treat (managed by a nurse practitioner)
* Diabetic/renal nurse educator three days/week
* Medically trained interpreters for all non-English speaking patients
* Renal replacement therapy group teaching classes
* Early group nutrition classes
* Individually prescribed exercise program for CKD patients (research-based)
* Advanced care planning training for all CKD nurses and social workers
* Patient empowerment and personal growth training for all CKD staff ("Falling Awake" course)
We've got a plan! Tracking the progress and outcomes of education in CKD
Jan Baker, RN, BN, CNeph(C) (Oakville, Ontario)
How do you keep track of 600 patients in a chronic kidney disease clinic? How do you ensure that education is delivered to each patient? How do you mandate that the education is appropriate to the stage of renal disease? How do you keep track of treatment decisions and what actions are required?
This was the dilemma faced in our clinic. With burgeoning numbers, it was becoming difficult to ensure that the delivered education was patient-focused, relevant to the stage of renal disease and delivered in a timely manner. Once education had been delivered, the next dilemma was knowing that the appropriate steps were being taken to ensure that patients had a safe transition to their chosen modality.
An education record was developed to assist in providing consistent patient-focused care. The record begins at the first visit with an expected curriculum that follows through the next five visits. Once education has been provided, the focus of the record then becomes a tracking tool to ensure that steps are taken to prepare patients for their chosen modality. Those steps include fistula creation, PD catheter insertion or referral to transplant centre. This record is an ever-evolving method of tracking the progress and outcomes of education whilst providing patient-focused care.
A specialized clinic for patients with poor renal allograft function leads to improved survival
Mimi Cheng, RN, BScN(Hons), John Johnson, MD, FRCPC, Ramesh Prasad, MBBS, MSc, FRCPC, FACP, Janice Richie- Carrabau, BScN, CNeph(C), MScN(c), and Fernanda Shamy, RN, CNeph(C) (Toronto, Ontario)
Background: All renal transplant recipients (RTR) will eventually experience either graft failure or death with graft function. Graft failure is usually preceded by a period of chronic kidney disease (CKD). We hypothesized that a specialized clinic targeted to RTR with advanced CKD improves outcomes.
Methods: The Progressive Renal Diseases Clinic (PRDC) for RTR was established in 2000. The PRDC team includes a transplant nephrologist, but the CKD nurse, pharmacist, dietician and social worker have dialysis rather than transplant expertise. Patients are referred when they have serum creatinine [greater than or equal to] 200 [micro]mol/l, with biopsy-proven CAN, polyoma virus nephropathy or recurrent GN. Data on all RTR followed in this clinic were collected by chart review and compared to similar RTR who elected to be followed in the regular transplant clinic. Biochemical parameters among RTR with [greater than or equal to] 6 months follow-up were compared. Similar comparisons were made to patients with failing native kidneys also followed in the PRDC by K-DOQI guidelines. Student t-tests and chi-square analysis were used as appropriate. Graft survival was compared by Kaplan-Meier methodology and the log-rank test.
Results: Seventy-four RTR enrolled in the PRDC between July 2000 and October 2006. Twenty RTR were offered transfer, but elected to be followed in the regular transplant clinic. Eighty-eight per cent of PRDC patients started their RRT modality of choice. PRDC patients demonstrated improved graft survival (p=0.05). There were also improvements in renal function (p<0.05), hemoglobin, Ca, PO4, total CO2, and albumin in the PRDC group while there was decline in these parameters in the regular transplant clinic group. Eight RTR started either PD or received pre-emptive transplants, compared to none in the non- PRDC group (p<0.05). Fewer failing transplant patients, however, attained K-DOQI targets for Ca-PO4 product, PTH, and hemoglobin than those with failing native kidneys.
Conclusions: A specialized clinic for RTR with failing kidney transplants is a viable entity that requires both transplant and CKD expertise. Enrolling such patients with CKD leads to improved graft function and survival. K-DOQI-based outcomes remain inferior to those with failing native kidneys, likely due to cumulative uremic burden. Further analyses such as QOL measures and cost analyses need to be performed in the future.
Thoracic outlet compression syndrome (TOCS):An unrecognized cause of reduced vascular access flow in hemodialysis patients with arteriovenous fistulas and grafts
Clifford Chan-Yan, MD, FRCPC, Anthony Chiu, MD, FRCPC, Ognjenka Djurdjev, Mercedeh Kiaii, MD, FRCPC, Beverly Jung, MD, FRCPC, and Rick Luscombe, RN, BSN, CNeph(C) (Vancouver, British Columbia)
Subclavian vessels and nerves exit the thorax through the thoracic outlet. We hypothesize, during shoulder girdle movement, subclinical TOCS causes compression of the subclavian vessels, with resultant reduction of vascular access (VA) flow (Qa).
During VA monitoring, we compared the results for five shoulder postures: Usual and opposite positions (sitting and lying), and during provocative shoulder postures, including hyperabduction (hand high); Roos ("stick em up") and Adson's test ("military posture").
Qa data were available for 49 patients. Recorded demographic characteristics were representative of hemodialysis patients.
Qa, venous and arterial pressure measurements varied among all five positions (p values < 0.001) (Table One). Qas in all four "non-usual" positions differed from the Qa in the usual position (p values < 0.01). Furthermore, percentages of Qa change in TOCS provocative positions were different than the percentage of change from usual to opposite positions (p values < 0.02).
In a number of patients (Table Two), Qa decreased by [greater than or equal to] 50% during provocative postures and in these, arterial negative pressures increased (with hyperabduction).
Comparison of patients who decreased Qa [greater than or equal to] 50% in provocative positions versus patients with Qa decrease of < 50 %.
TOCS shoulder postures resulted in significant reductions in Qa, associated with changes in arterial and venous pressures. Implications include the need for: awareness of posture effect on Qa, standardization of posture during access monitoring and avoidance of certain shoulder postures, in consideration of TOCS being potentially contributory to subclavian vein stenosis. This is the first study demonstrating dynamic blood flow changes during TOCS testing.
Raising the practice bar: Meeting guidelines for central venous catheter exit site care
Emily Harrison, RN, BHScN, CNeph(C), and Lori Mehew, RN, CNeph(C) (Toronto, Ontario)
Previous to December 2004, the practice within the hemodialysis (HD) unit was to change the dressing on all central venous catheters once per week using a bio-occlusive dressing. The dressing was only changed every HD treatment if the exit site had drainage, redness or pain.
Our infection rate for catheter-associated bloodstream infection (CABSI) was 0.92 episodes per 1,000 line days. The recommended standard of year 1.4 episodes per 1,000 line days or 0.5 episodes per patient year at risk set by the Canadian Society of Nephrology (CSN). Although we had less CABSI than the standard, there was an opportunity to improve our infection rate.
The recommended guideline for exit site care from the CSN (1999 & 2006) is to "change the dressing at each hemodialysis treatment using a dry gauze dressing". The decision was made to change exit site dressings every HD treatment in December 2004. To reinforce the practice change, the dressing material was also changed to gauze-type dressing only.
After one month, in January 2005 our CABSI rates dropped to 0.32 episodes per 1,000 line days and have continued at this low level over the last two years.
Careful monitoring of infection rates and implementing change to meet best practice guidelines can improve clinical outcomes for our patients.
Group modality training for pre-dialysis patients
Heather Jones, RN, BN, Braden Manns, MD, FRCPC, Lianne Barnieh, MSc, and Brenda Poo le, BN (Calgary, Alberta)
Purpose: Based on the success of an educational intervention study published in 2005 by Dr. Braden Manns, the Southern Alberta Renal Program started group modality teaching sessions for pre-dialysis clients to help increase the proportion of patients who choose a self-care modality.
Description of the project: Since November 2005, pre-dialysis patients who are suitable for group modality are provided with teaching booklets and a 20-minute video to view prior to attending the group session. A nephrologist and a nurse clinician conduct the two-hour interactive small-group session. Patients brainstorm the advantages and disadvantages of self-care treatment options, work through case studies, and are provided with the opportunity to ask a peer presenter about his/her experience on dialysis.
Evaluation/outcomes: Results of the May 2006 group modality evaluation were: 42% felt their desire to do self-care changed, 97% agreed or strongly agreed they gained a better understanding about dialysis, 100% agreed or strongly agreed that the session was valuable, and 65% chose or continued to choose self-care. Another evaluation is scheduled for May 2007.
Implications for nephrology practice/education: The group modality sessions assist patients in gaining a better understanding of self-care resulting in an increase in choosing self-care modalities at a potential cost savings to the program.
Vascular access clinics from the ground up--A British Columbia experience
Anita Salmon, RN, BSc, MA, CNeph(C), and Rick Luscombe, RN, BSN, CNeph(C) (Vancouver, British Columbia)
Vascular access has come to the forefront as a quality indicator for hemodialysis. Universally, programs are working on ways to achieve the best dialysis accesses for their patients. This has led to the development of vascular access specific programs, nurses specializing in vascular access care, and vascular access clinics.
In British Columbia, in 2005, the Provincial Renal Agency established the Provincial Vascular Access Services Team (PVAST) with a mandate to improve vascular access care across B.C., including development of provincial guidelines and supporting structures to facilitate system change. One of the first recommendations with respect to supporting structures was the establishment of vascular access coordinator positions in each of the province's six health authorities (HAs). A review of current literature and industry practices emphasizing the importance of interdisciplinary coordination in the provision of vascular access care led to a further recommendation, the establishment of vascular access clinics. To support HAs in implementing this recommendation, a PVAST subcommittee drafted a paper that defines vascular access clinics, describes their rationale, outlines referral criteria, goals and outcomes of service, resource requirements, and tools to support operations. This paper is intended to provide the impetus for each HA to establish a vascular access clinic(s).
The B.C. experience in coming to a provincial consensus on best practices with respect to vascular access clinics is pertinent to other centres and regions looking at ways to improve vascular access care. The presentation will discuss the PVAST subcommittee recommendations and provide "real life" experiences with vascular access clinics.
Evaluation of an intravenous erythropoietin hormone replacement therapy dosing algorithm for the treatment of anemia in hemodialysis patients
Marianna Leung, PharmD, Shari Pek, BscPharm, Joanne Jung, BscPharm, Mercedeh Kiaii, MD, FRCPC, and Beverley Jung, MD, FRCPC (Vancouver, British Columbia)
Background: The treatment of anemia and erythropoietic hormone replacement therapy (EHRT) dose titration at St. Paul's Hospital (SPH) was managed by nephrologists. Variation in hemoglobin levels were recognized and believed to be a result of inconsistencies in dose titration.
Objectives: To evaluate the efficacy of an EHRT dosing algorithm in achieving and maintaining hemoglobin levels within the desired target range, and to compare the average dose of erythropoietin and darbepoetin used during the periods before and after algorithm implementation.
Methods: Data were collected for two different periods: a-six month retrospective chart review of the individualized dosing by nephrologists and a six-month prospective evaluation of the algorithm dosing by pharmacists.
Results: The percentage of hemoglobin levels within the desired target range was not statistically significant (p=0.42) between the two groups: 50.7% for the individualized dosing period versus 49.6% for the algorithm-dosing period. The average erythropoietin and darbepoetin dose between the two periods was 10,773 units versus 11,551 units of erythropoietin (p=0.447) and 31.7 mcg versus 26.5 mcg of darbepoetin (p=0.495) for the individualized dosing and algorithm dosing periods, respectively.
Conclusion: There was insufficient evidence to suggest any difference in efficacy between the individualized dosing by nephrologists and the algorithm dosing by pharmacists.
Evaluation of the management of metabolic bone disease in hemodialysis patients
Marianna Leung, PharmD, Esther Abd-Elmessih, BSc, BScPharm, Kelly Mahannah, BScPharm, Andria Lee, BScPharm, Stephen Shalansky, PharmD, and Mercedeh Kiaii, MD (Vancouver, British Columbia)
Background: The management of metabolic bone disease (MBD) is complex and challenging amongst hemodialysis patients and has been associated with significant cardiovascular mortality. The goal of the study is to evaluate the current management of MBD on the hemodialysis unit and to further optimize management by all health care team members (physician, dieticians and pharmacists).
Objectives: A) to determine the percentage of hemodialysis patients whose calcium, phosphorus, and parathyroid hormone levels achieved the K/DOQI target; B) to determine the type of discrepancies seen in patients who have not achieved target.
Methods: A retrospective chart review was conducted. A) The data collection included use of calcium-based and non-calcium based phosphorus binders, adherence, and relevant laboratory results (calcium, phosphorus, PTH levels). B) The renal pharmacists independently reviewed the laboratory results of patients who did not achieve targets and documented the types of problems and whether the interventions made were considered appropriate based on K/DOQI guidelines.
Results: In a cross-section of 219 hemodialysis patients, 6.4% of patients were found to be within K/DOQI target with respect to calcium, phosphorous and parathyroid hormone. A total of 118 outlying laboratory values and a total of 111 documented interventions were noted in 30 patients during a four-month period. On average, there was an average of 3.9[+ or -]1.0 (2-6) problems identified per patient. The most common problem was an elevated phosphorus level greater than 1.81mmol/L.
Conclusions: This study identified areas where suggested K/DOQI targets could be more optimally achieved on this hemodialysis unit. An algorithm-based on the K/DOQI guidelines will be proposed as a reference tool for the health care team.
Innovative role--Renal nurse practitioner in British Columbia is one-of-a-kind!
Alietha Martin, RN, MN, FNP, CNeph(C) (Kelowna, British Columbia)
At a time when the health care dollar is being stretched to its limit, it is incumbent upon all health care professionals to think of new and innovated ways to approach our growing health care needs. Kelowna, British Columbia, sets the example of innovate renal health care, both provincially and nationally. The "Nurse Practitioner (NP) for Renal Health" role has allowed patients to access expert renal care much earlier than traditionally allowed. Individuals identified by their family physicians as either "at risk" or in the earlier stages of CKD can be referred to the renal NP for collaborative renal care in the primary care setting.
So, what makes this role different from other renal NP roles in Canada? The answer lies in its upstream approach to renal care. Patients who are referred to the renal NP do not yet require the care of a nephrologist. Traditionally, this would have excluded them from accessing expert renal care teams. The upstream approach of the Kelowna Renal NP, however, helps to provide the kind of timely and specific renal care necessary to reduce the complications and co-morbid conditions associated with CKD. This will help to improve patient outcomes, quality of life and, ultimately, save the health care system thousands of dollars. Even early on, this role has demonstrated the value and unique contribution it brings to our health care system--learnings that must be shared with the national renal community.
Peritoneal dialysis procedure demonstration DVD
Karen Forsberg, RN, Donna Garrod, RN, Pam White, RN, Heather Zadorozniak, RN, BSN, CNeph(C), Gloria Freeburn, Alex MacFarlane, Ian Rose, and Jason Mason (Kelowna, British Columbia)
Teaching patients and families the steps involved in performing the procedure of peritoneal dialysis can often challenge even the most experienced PD training nurse. The utilization of multiple approaches for learning ensures that each patient's unique learning needs can be matched with teaching tools to achieve a positive outcome.
Purpose: To develop a DVD that demonstrates step-by-step instructions for performing Baxter Twin Bag Exchange and Baxter Home Choice Pro Cycler procedure. The DVD is designed for patients who have chosen peritoneal dialysis as their primary modality. The DVD may be used as a supplement to the initial training and/or review post-training. The video may also be useful for educating patients who are considering peritoneal dialysis as a modality option to visually see the steps involved in PD therapy.
Patients and methods: All nine peritoneal dialysis programs in British Columbia were asked to submit procedures pertaining to Baxter Twin Bag and Home Choice Cycler set-up. Consensus in procedure was established with subsequent script development. One continuous ambulatory peritoneal dialysis (CAPD) patient and one automated peritoneal dialysis (APD) patient was selected to participate in the production of the film. Temperance Street Productions was hired to produce the video and guide us through the production process. The video has been translated into several languages including Punjabi, Cantonese, Mandarin and Tagalog.
Outcome: The draft version of the DVD has been completed with estimated time for final completion and distribution being late spring. Feedback to date has been extremely positive from all involved with the evaluation process.
Implication for education: Any peritoneal dialysis program that teaches patients the Baxter Twin Bag Exchange and/or the Baxter Home Choice Cycler would benefit from having this DVD as a supplement to their training.
Planning and implementation of electronic documentation and viewing in a hemodialysis unit
Pat Easton, RN, BScN, CNCC, Trish Wolting, RN, Sheila Embury, RN, BScN, Fay Duphette, RN, Lynn Benoit, RN, BScN, and Crystal Houze, RN, BScN (Chatham, Ontario)
The Chatham Kent Health Alliance (CKHA) Hemodialysis Unit is a satellite unit of London Health Sciences Regional Hemodialysis Centre (LHSC). Client care is an interdisciplinary approach with a team from LHSC. The team uses weekly videoconferencing of patient rounds, and monthly travel to Chatham for clinics to support staff and patients. In an effort to provide timely and accurate information and improve communication with the team at LHSC, CKHA implemented electronic documentation and clinical viewing for the dialysis unit.
This poster presentation will provide a concise account of our journey through planning the project, communicating with clients, staff and LHSC, educating staff at CKHA, as well as the team at LHSC and implementation of this very worthwhile project.
* An overview of the planning/development process from an administrative, information systems and nursing perspective
* Provide a "painless" transition from paper-based documentation to electronic through communication, education and support
* Monitor and evaluate the process
* Provide feedback
* Celebrate successes
What makes this project truly unique is the fact that LHSC views charting, as well as lab and radiology results, images and transcribed reports on-line and in real time. It is a huge change in workflow and gives the team access to real-time information for decision-making. It also supports the CKHA's strategic direction as they move to an electronic patient record.
Case management in the Southern Alberta Renal Program
Kathryn Iwaasa, BN, CNeph(C), and Michelle Pike, RN, CNeph(C) (Lethbridge, Alberta)
Nursing in the Southern Alberta Renal Program (SARP) has adopted the Case Management Model of Care Delivery. It is the belief of SARP that the Case Management Model of Care will assure accountability, multidisciplinary collaboration, comprehensiveness and continuity of care.
The purpose of this project was to have all nurses in SARP utilize one form that would meet the needs of the patients regardless of where they receive treatment. Because of the large geographic service area, a secondary goal was to improve communication between the units as most of the units in SARP have been using different forms of case management. A committee of RNs and LPNs from many units in SARP assisted in the development of a paper form. Several drafts were made before an acceptable case management form was approved. The case management form was trialed four months in a few select units (in-centre and outpatient) to ensure that it met the needs of the patients in SARP. Additional changes to the form were made as a result of feedback from staff.
An electronic version of the paper case management form was the next logical step. The information technology department was consulted and the form was programmed into SARP's computer system which took six months to complete. A formal evaluation has not yet been completed, however, the preliminary feedback has been very positive. The process is ongoing.
Hemodialysis blood volume monitoring program
Naomi Taylor, RD, Monica Beaulieu, MD, Eunice Blancaflor, RN, Gina Sitter, RD, Mary Van Der Hoek, RN, Alex Weekes, RN, and Jacek Jastrzebski, MD (Vancouver, British Columbia)
Purpose: A blood volume (BV) monitoring program has been implemented for patients starting chronic hemodialysis. This program uses BV monitoring data in a systematic, multidisciplinary approach encompassing planned modifications for the management of fluid removal and hypertension. This approach was developed as opposed to using BV monitoring at the time of dialysis with reactionary interventions prompted by BV graphs.
Description: All new chronic patients have BV monitoring each run for the first six weeks of dialysis. At the end of the run, an approximation of the displayed real-time graph is recorded on the run sheet. No changes in dialysis prescriptions are made during the run. The rounding physician analyses the hemodynamic parameters of the patient including the previous BV graphs. Changes to dialysis prescriptions are made starting with the next run. As well, weekly multidisciplinary rounds are held to review the BV graphs and run sheets with changes made, as required, to dialysis prescriptions, goal weight/fluid removal targets, antihypertensive regimens and dietary counselling regarding sodium and fluid intakes.
Evaluation/outcomes: With this BV monitoring program, we have observed an increased awareness in staff of the unique issues pertaining to new hemodialysis patients and a better understanding of fluid assessment and removal with increased involvement in the process of dialysis prescription modification. Patients are more involved in their therapy regarding sodium and fluid control and changes to dialysis prescriptions. Data collection before (n=14) and after (n=15) implementation, although not statistically significant, showed trends towards: a reduced number of hypotensive episodes during dialysis; reduced use of blood pressure medications--these results suggest "more accurate" goal weight estimates are being achieved by the sixth week of dialysis.
Implications for nephrology practice: The optimal use of BV monitoring to manage fluid removal and hypertension in dialysis patients has yet to be determined. This program utilizes BV monitoring in a systematic approach to improve fluid removal and management of hypertension.
Information: Everything in its place
Frances Pentleton, RN, and Laura Hodgson, RN, BScN (Kingston, Ontario)
To implement an electronic system of documentation, we decided to reconsider the use of some outdated clinical tools. We looked at three particular areas: the Kardex, flow sheet and patient chart. We wanted a centrally located source to document all the essential information necessary to provide the safest and highest quality of care to our patients, and improve the flow of communication. Our goal was to focus on increasing the accessibility of this information and, at the same time, reducing the incidence of errors and double documentation.
The Kardex was redeveloped to become the main source of information. It encompasses not only the routine dialysis prescription, but also a central place to monitor patient demographics, hepatitis screening, vascular access, routine blood work, diagnostic tests, medications, transplantation, satellite, as well as short- and long-term issues.
The flow sheet was redesigned to allow for accurate monitoring of blood work and medications.
Patient charts were reorganized in a consistent format. The new tools were introduced recently to the staff of the renal unit. Inservice education was provided to ease the transition and to ensure the consistent use of these tools. Staff have provided input and further suggestions in order to make it valuable for all nurses.
Having as much information about our patients in a source that is readily available and as accurate as possible will allow the nurse to use his/her time to deal with the more complex issues related to patient care, will decrease workload and increase job satisfaction.
Vascular camp: Putting the evidence into practice
Kathy Lynch, RN, CNeph(C), Heather Steiner, RN, CNeph(C), Barb Gray, RN, BScN, CNeph(C), and Linda Ballantine, RN, MEd, CNeph(C) (Toronto, Ontario)
York Central Hospital Dialysis Program identified an opportunity to improve patient care and increase the vascular access skill level of staff nurses by creating a Vascular Access Camp as part of its access care initiative. The shortage of nurses and the acuity of the patients can create challenges for leaders to provide the necessary support that is often needed by novice nurses. The YCH Vascular Camp project objective was to enhance vascular access skills and bring awareness of the Fistula First Initiative all by supporting, promoting and implementing the use of best practice guidelines as the foundation for practice.
In order to provide the hands-on skill acquisition and to facilitate this knowledge transfer of evidence into clinical practice, the vascular camp project was designed to have nurses rotate through different stations over a period of three hours. Contingency plans were designed to enable all staff to attend and be paid for their time. A pre- and post-test, as well as an evaluation form was completed by each staff member in order to measure the predetermined quality outcome indicators.
The feedback obtained from staff was that vascular camp was highly successful with suggestions for this to become an annual event. Through this presentation, we will share knowledge, lessons learned and practice recommendations. We hope to provide others who are passionate about clinical excellence within their vascular access program with ideas, suggestions and tools to try a similar strategy.
Communication and its rewards
Marilyne Boudreau, RN, and Nicole Fournier, RN (Bathurst, New Brunswick)
In our hemodialysis unit, the patients formed a "Patient Representative Group". The goal of this committee is to support patients and help them communicate any concerns, problems or suggestions they may have concerning hemodialysis and everything that it involves.
Three to four times a year, the patient representative group, the nurse manager, the director of nursing, the resource nurse and if possible the dietitian, social worker and pharmacist all attend a meeting and discuss any relative subject.
Within one month after a meeting, we produced a newsletter dedicated to the patients. The "Hemo News" consists of the minutes of the last meeting, helpful hints or recipes from the dietitian, notes from the social worker. Any member of the multidisciplinary team is welcome to participate with the newsletter. There is also a section for jokes and games. In this newsletter, we include reminders about exercises, foot care, etc.
The outcome of both the patient representative group meetings and the newsletter is a better communication between the hemodialysis patients and the members of the dialysis team. The feedback from the patients is great.
Problems and concerns expressed by the patients, such as more free parking spaces, comfortable chairs and beds in the unit, patients' security in the waiting room, travelling, snacks and much more were heard and solved to the best of our abilities. One of our future projects is to form a support group with both peritoneal and hemodialysis patients.
Renal failure following diagnostic coronary angiography: Evaluation of risk stratification and renal sparing protocol
Lisa Mandziak, RN, Eliot Beaubien, MD, FRCPC, MSc, Bev Hill, RN, and Winnie MacPhee, RN, CNeph(C) (Peterborough, Ontario)
Contrast-induced nephropathy (CIN) is a well-recognized complication of coronary angiographic procedures. In severe cases, CIN can lead to renal failure requiring dialysis and, on occasion, permanent renal failure. This risk is increased in individuals with pre-existing renal disease and diabetes.
Since July 2006, Peterborough Regional Health Centre has utilized a risk assessment tool and intervention protocol to minimize CIN risk in cardiac catheterization patients. The assessment tool utilizes underlying renal function, patient, and procedure specific risk factors to estimate the risk of acute renal failure requiring dialysis. Individuals are then stratified according to risk and receive evidence-based interventions to minimize CIN risk.
All patients undergoing cardiac catheterization are asked to participate in a monitoring study. Renal function is monitored shortly following coronary angiography, three and six months post-procedure. To date, 154 patients have been prospectively evaluated. The incidence of CIN following these changes has been less than 1%. No patients have required dialysis due to CIN.
Our preliminary results demonstrate low rates of renal failure when following a standardized protocol for CIN prophylaxis. Future objectives include:
* Comparison of CIN rates post-program change with historical incidence rates.
* Ongoing refinement of risk assessment/intervention strategies.
* Expanded use of this assessment tool to other medical areas in which intravenous contrast is used.
A mass immunization strategy applied in a hemodialysis population
Jane Kirkwood, BScN, Vincent Cheung, MD, FRCPC, Kathleen Fair, BScN, CNeph(C), Nicole Richardson, CNeph(C), and Angel Targon, BScN, CNeph(C) (Peterborough, Ontario)
Hepatitis B immunization is typically enacted in hemodialysis units by individual prescription. This approach presents challenges with respect to tracking, drug procurement, vaccine administration and monitoring of results, particularly in large or growing programs. The Haliburton Kawartha Pine Ridge Regional Renal Program developed a hepatic B vaccination protocol for hemodialysis that applies concepts of mass immunization campaigns, much like those used in schools.
Our protocol performs vaccination and monitoring on hemodialysis patients in clusters, biannually, allowing for immunization in a large amount of people in a short amount of time. As the program covers the cost of immunization, all CKD patients have equal access to immunization. Immunization status and the immunization schedule are tracked by the hemodialysis charge nurses in the in-centre unit and the satellite unit. Schedules for those patients needing their initial immunization series or boosters are prepared in advance and followed on preset vaccination dates.
The advantages of this protocol are that it improves penetration of a captive population. By having the program cover the cost of immunization, patient compliance is increased. Tracking is simplified because titer results are reported en bloc rather than continuously. Vaccine needs are predictable and procurement is done well in advance of the vaccination dates. The mass immunization allows for one person, the charge nurse, to coordinate the campaign and do the tracking. This approach results in reduced time and manpower requirements to administer a hepatitis B program for hemodialysis.
Bringing hemodialysis charting into the 21st century
Lauri-Ann Vester, RN, BScN, and Holly O'Keefe, RN, HBScN (Thunder Bay, Ontario)
Performing hemodialysis on a thrice-weekly basis generates an incredible amount of data. These data are crucial in monitoring patient outcomes and planning future care. Storing these data in a paper chart in a meaningful and organized fashion is challenging. Computer charting is the future of hemodialysis.
Thunder Bay Regional Health Sciences Centre (TBRHSC) hemodialysis unit and two satellite units provide care to approximately 170 patients. In 2006-2007, the Thunder Bay unit made the transition from paper to computer charting. Our goal was to be able to download all data generated from each hemodialysis treatment and monitor our satellite patients' treatment in real time. A core team with management and nursing staff was formed to facilitate this changeover.
A dialysis data management computer program was highly customized. All treatment data are automatically downloaded and nursing interventions are entered at the time Journal they occur. The patient care plan is stored "online" allowing monitoring of progress and tracking efficacy of prescribed treatments. Data can be correlated and compared to national benchmarks; Kidney Dialysis Outcomes Quality Initiatives (KDOQI) and Canadian Society of Nephrology (CSN).
Factors that were fundamental during this process were patient and data safety, confidentiality, accuracy of information, organization and retrievability of the data.
Our transition into computerized charting did not proceed with out inherent challenges. As technology is made available to assist in organizing, storing and retrieving patient's data, it is our experience that it is well-worth putting the effort into.
Promoting professional practice competence and educational development within a diverse renal program
Sohani Welcher, RN-NP, MN, GNC(C), Carrie Ann Boyd, RN, CNeph(C), Lesa Chisholm, RN, Annette Ernst, LPN, Shawna Hudson, RN, BScN, CNeph(C), David Landry, RN, MN, CNeph(C), Sarah McCrae, RN, BSc, Pearl O'Brien, RN, BN, MHSA, Cynthia Stockman, RN, BScN, Patricia Ross, RN, BScN, CNeph(C), Colleen Wile, RN, CNeph(C), and Marsha Wood, RN, BN, MN, CNeph(C) (Halifax, Nova Scotia)
Purpose: To develop competency-based self-assessment tools for all nursing and support staff within the Capital Health Renal Program, Halifax, Nova Scotia.
This project is part of a Renal Program Quality Care Team initiative. The main objective involved improving and increasing team member identification and participation in professional practice development activities.
Description: The project entailed self-competency assessment tools, which were designed by the Quality Care Team. Each team member from the outpatient, in-centre and satellite clinics and inpatient unit settings were asked to identify professional practice, educational needs, and strategies related to novice and advanced role requirements based on practice standards of respective regulatory bodies.
Evaluation/outcome: The project was evaluated based on response rate within each clinical area. Initial feedback related to the process proved positive. The self-assessment tool provided pertinent educational needs for each clinical area. As a result, conventional and online resources in addition to practical opportunities were useful in meeting the team members' needs. Formal educational sessions were developed to meet other professional development needs.
Implications for nephrology practice/education: Our Renal Program Quality Care Team believes that competency should be based on professional practice standards of care as opposed to only developing specific skills and performing physical tasks. In the future, our Quality Care Team will develop yearly competency self-assessments in collaboration with renal program nursing and support staff, so that professional practice needs are met as nephrology care evolves.
Preventing and reducing complications related to diabetic foot ulcers in chronic kidney disease through comprehensive foot assessment and referral for foot care
Marsha Wood, RN, BN, MN, CNeph(C), NP, Sohani Welcher, RN, MN, GNC(C), Gloria Connolly, RN, BScN, GNC(C), Sheila Moffatt, RN, BScN, Shawna Hudson, RN, BScN, CNeph(C), Colleen Wile, RN, CNeph(C), Patricia Taylor, RN, Mary Burns, RN, Lesa Chisholms, RN, Karen Delaney, RN, BScN, CNeph(C), Corrine MacLeod, RN, Lori Paruch, RN, Edna Revels, RN, Jackie Ryan, RN, Marsha Baker, RN, BScN, Catherine Salvatore, RN, BScN, Cindy Kelly, RN, BScN, Gerry Gale, RN, and Patricia Ross, RN, BScN, CNeph(C) (Halifax, Nova Scotia)
Diabetic foot ulceration represents a major area of complication for patients with chronic kidney disease. Diabetes mellitus is the leading cause of all nontraumatic lower extremity amputations. Diabetes accounts for approximately 40% of all chronic kidney disease. Foot assessments conducted by nurse practitioners on hemodialysis patients in the QEII Health Sciences Centre found that 75% of patients with diabetes on dialysis were at moderate to high risk for lower extremity complications. No formal process for providing foot assessments for patients with CKD and diabetes existed across the nephrology program.
This poster will:
* Describe the steps used to develop a process for diabetic foot assessment and referral in the QEII Health Sciences Centre nephrology program
* Illustrate the tools developed to assist nursing staff to conduct comprehensive foot assessments
* Explain the process to refer for foot care
* Outline the plan and tools used by a core group of nurses to educate their peers to conduct a comprehensive diabetic foot assessment, and refer patients at risk.
Physical function outcomes for endurance and lower-limb strength in healthy individuals as compared to those with end stage renal disease (ESRD)
Joanna Stanisz, BSc, Irene Nicolakis, BSc, MScPT, Edwin Toffelmire, BSc, MSc, MDCM, FRCPC, FACP, and Cheryl King-VanVlack, BSc, MSc, PhD (Kingston, Ontario)
Purpose: Differences in endurance function and lower-limb strength were determined between healthy individuals and those with ESRD.
Methods: Participants undergoing hemodialysis (n=19; 20th- 70th decade) were recruited from the satellite dialysis unit at KGH. Age- and gender-matched healthy individuals were recruited from the Kingston community. Each participant performed two trials of endurance walk tests [six-minute walk test (6MWT); incremental shuttle walk test (ISWT)] and two trials of lower-limb strength tests [maximum gait speed test (MGST); sit-to-stand test (STST)]. Each trial was separated by at least seven days.
Results: Performance on all tests was lower in ESRD as compared with healthy individuals (p<0.05) (6MWT 84%; ISWT 73%; MGST 81%; STST 69%). Endurance measures decreased with age in both groups. However, the relationship was stronger in the healthy individuals (r=-0.78) as compared to those with ESRD (r=-0.59). A strong correlation was found between the MGST and the 6MWT (r=0.88) and ISWT (r=0.91) in ESRD patients, but not in the healthy group. Age accounted for a greater proportion of variability in the endurance outcomes for healthy individuals (59%) than for those with ESRD (32%). MGS accounted for more variability in the endurance outcomes for individuals with ESRD (80%) than for the healthy group (37%).
Conclusions: The functional deficits in endurance and lower-limb strength in ESRD were only 25% of those in the healthy group; much less than the reported 40% to 50% deficits using laboratory-based tests. A notable finding was that MGS was the primary determinant of performance on endurance tests in ESRD.
Laparoscopic PD catheter insertions: "Everyone awake in the OR"
Diane Watson, RN, BSc, CNeph(C), ACNP, Nephrology, Jannet Anderson, RN, BScN, Wing So, RN, BScN, CPN(C), and Todd Penner, BSc, MD, FACS, FRCSC (Toronto, Ontario)
Good placement of a catheter for peritoneal dialysis (PD) is of utmost importance for an individual undertaking PD for end stage renal disease (ESRD). Traditionally, PD catheter insertion was carried out by surgeons using an open insertion (OI) technique, which resulted in a blind placement, potentially contributing to catheter misplacement, poor drainage, as well as intra-operative complications. These problems often led to failure of PD and transfer to hemodialysis (HD). Commencing May 2006, PD catheters were inserted using a laparoscopic insertion (LI) technique under local anaesthetic (LA) at the University Health Network (UHN), Toronto Western Hospital. At UHN, carbon dioxide was used to insufflate the abdomen. However, this can be very painful under LA, therefore nitrous oxide ([N.sub.2]O) is used. In reviewing the first 15 LI and 15 OI cases performed by Dr. Todd Penner during 2006, we found that patients benefited from the LI technique. In the 15 LI cases, 14 were done under LA. Patients with ESRD are medically compromised, co-morbidities such as diabetes and heart disease, thus LA is preferable, providing a faster recovery time, and potentially less risk. Additionally, LI affords the benefit of direct visualization to detect and lyse intra-abdominal adhesions and perform omentopexy. This poster reviews the results of complications and interventions. Although we found the same number of complications (5/15) in both groups, in the LI group, they were less significant, and none resulted in discontinuation of PD, whereas the three complications in the OI group resulted in PD failure and transfer to HD.
Intradialytic parenteral nutrition in hemodialysis patients: Acute and chronic intervention
Margaret Avery-Lynch, RD BSc (Peterborough, Ontario)
Protein and calorie malnutrition has been encountered more frequently than expected in the hemodialysis patients. Intradialytic parenteral nutrition (IDPN) has been documented to improve nutritional status in hemodialysis patients in both acute and chronic settings. The aim of this study is to support the usage of IDPN in our malnourished hemodialysis patients. Serum concentration of albumin is one of the main indicators of mortality in the dialysis population. The serum albumin concentration for six out of eight of our hemodialysis (HD) patients receiving IDPN increased significantly. There was a mean increase of 7.0g/L of plasma albumin for the eight patients assessed. These results demonstrate that IDPN is an effective nutritional intervention for malnourished hemodialysis patients.
Effectiveness of cinacalcet for secondary hyperparathyroidism--the Manitoba Renal Program Experience
Colette Raymond, PharmD, MSc, Lori Wazny, PharmD, Lavern Vercaigne, PharmD, Dan Skwarchuk, CGE, and Keevin Bernstein, MD, FRCPC (Winnipeg, Manitoba)
Purpose: We sought to evaluate cinacalcet's effectiveness for secondary hyperparathyroidism outside the setting of a randomized controlled trial (RCT).
Methods: A non-random sample of patients with: PTH >500 ng/L and/or one of: total calcium >2.60 mmol/L; PO4 >1.78 mmol/L; contraindications to vitamin D were evaluated over a minimum of 12 weeks.
Results: Thirty-five patients received cinacalcet (29 hemodialysis, 6 peritoneal dialysis) for a median of 9 months. Over months 4-7, median laboratory values changed from baseline as follows: PTH 683 (34% > 800) to 428 ng/L, corrected cal cium 2.62 to 2.40 mmol/L, and phosphate 1.83 to 1.70 mmol/L. Of 35 patients, 17 (49%) had a PTH response (PTH month 4-7 30% less than baseline and < 600 ng/L); in responders, median PTH decreased from 745 to 261 ng/L. Conversely, 18 (51%) of 35 patients did not respond, median PTH for this group increased from 672 to 780 ng/L. Overall, 20/35 (57%) had a dose increase (median dose 46 mg/d, 75% < 60 mg). There were no obvious patterns in use of calcium, vitamin D or sevelamer. Of 14 potential candidates for parathyroidectomy (patients who met the KDOQI criteria of PTH > 800 ng/L or PTH > 500 ng/L with calciphylaxis), eight (57%) no longer met those criteria on follow-up. Two patients had a parathyroidectomy cancelled, one underwent parathyroidectomy and another two await surgery. Two patients discontinued cinacalcet due to adverse effects (gastrointestinal).
Conclusions/implications: Outside the setting of a RCT, patients using cinacalcet demonstrated similar outcomes as published RCTs.
Funding of clinical pharmacy services in the Manitoba Renal Program
Lavern Vercaigne, PharmD, Lori Wazny, PharmD, Colette Raymond, PharmD, MSc, Dan Skwarchuk, BComm(Hons), CGA, and Keevin Bernstein, MD, FRCPC (Winnipeg, Manitoba)
Purpose of project: The purpose of this project is to describe the MRP pharmacy funding model and pharmacists' activities and to evaluate the published literature in this area.
Description: The MRP provides funding for clinical pharmacy services at a ratio of one FTE pharmacist to 100 hemodialysis patients and one FTE to 300 peritoneal dialysis patients. These funding ratios have existed for all MRP dialysis expansions since 1999. Funding for renal clinic patients comes from third-party sources with a target of one FTE to 300 clinic patients. There are currently 10.175 FTE renal pharmacists who provide care to all hemodialysis (n=830), peritoneal dialysis (n=195) and certain renal clinic (n=3600) patients in the province.
The MRP pharmacists' activities include participation on rounds, comprehensive medication reviews, discharge orders for dialysis inpatients, provision of drug information, and education of patients and staff.
Evaluation: Renal pharmacists' interventions have been shown to improve patient outcomes, enhance medication adherence, and produce significant cost savings. Canadian renal pharmacist standards of practice are available to support the development and evaluation of a renal pharmacy program.
Implications for nephrology practice and education: To our knowledge, the funding structure provided by the MRP for renal pharmacists is unique in Canada. As a significant body of literature supports renal pharmacist practice, Canadian renal programs should consider developing specific funding models for pharmacists as is currently done with other allied-health professions (e.g. renal dietitians, renal social workers).
Mineral metabolism parameters within the Manitoba Renal Program: Are current clinical guidelines achievable?
Lori Wazny, PharmD, Colette Raymond, PharmD, MSc, Lavern Vercaigne, PharmD, Esther Lesperance, RT, and Keevin Bernstein, MD, FRCPC (Winnipeg, Manitoba)
Purpose: This initiative sought to compare mineral metabolism parameters within the MRP to published DOPPS II results and the CSN guidelines.
Methods: Values for mineral metabolism parameters and pertinent medications were collected for all hemodialysis units in Manitoba in June 2005. All units had renal pharmacist, dietitian and nephrologist support.
Results: See Table One (Page 38)
Conclusions: The MRP has a similar proportion of patients within individual K/DOQI targets for PTH, CCa, and PO4 as other DOPPS II countries. Fifty-three per cent to 81% of MRP patients meet individual CSN targets, whereas 28% to 42% meet the K/DOQI targets.
Implications for nephrology care: Achievement of all three targets simultaneously is still very difficult despite current drug therapies and interdisciplinary team involvement.
Topical antimicrobials applied to catheter exit site for prevention of hemodialysis catheter-related complications: A literature review
Colette Raymond, PharmD, MSc, Andrew Armstrong, BScPharm, Lori Wazny, PharmD, and Lavern Vercaigne, PharmD (Winnipeg, Manitoba)
Purpose: To review published randomized controlled trials (RCTs) evaluating topical antimicrobials applied to catheter exit site for prevention of hemodialysis catheter-related complications.
Methods: Medline and EMBASE were searched for pertinent RCTs.
Results: See Table One (Page 39).
Conclusions/implications: Topical mupirocin and polysporin triple ointment decrease hemodialysis catheter-related infectious complications in RCTs. Outstanding issues include the potential for resistance to topical antimicrobials, the effect that ointments may have on polyurethane catheters, and the potential for fungal overgrowth.
Physical, quality of life and nutritional outcomes in hemodialysis patients on exercise
Carol Heck, PhD, Pauline Darling, PhD, Charlie Yang, PT, Karen John, PTA, Sharon Lee, SW, Jacinda Frazer, SW, Raechel Saunderson, RPT, Doug Cook, RD, Donna Hardy, RD, Jocelyn Kerby, RN, Nancy Lee-Yu, RN, and Natasha Cochrane, OT (Toronto, Ontario)
Purpose: To evaluate physical performance, quality of life (QoL) and nutritional status of end stage renal disease (ESRD) patients on hemodialysis following implementation of exercise.
Relevance: Patients with ESRD have high mortality, high morbidity and a low QoL, which has been shown to be related to malnutrition and compromised physical functioning.
Subjects: Subjects (n=39) were randomized to either exercise (3x/week) or attention placebo (non-exercise control) group. Participants were primarily male (59%), aged 51.6[+ or 1]15.2 years, and had been on HD 45.8[ + or 1]50.72 months.
Methods: Data collected at baseline, six and 12 weeks post-intervention included: physical performance [six-minute walk tests (6MWT), timed-up-and-go (TUG)]; QoL [SF-36 Health Survey (SF36) and Illness Intrusiveness Rating Scale]; measures of nutritional status [estimated dry weight, Subjective Global Assessment score, lean body mass, dietary energy and protein intake]; biochemical values from routine blood work, and functional measures [Human Activity Profile (HAP) and functional autonomy (SMAF)].
Results: The following significant (p<0.05) changes were noted in the exercise group only: TUG scores improved from 11.9 +/-10.4 to 8.3 +/- 3.8 seconds, 6MWT distance improved from 407.0 +/- 136.8 to 469.4 +/- 136.3 metres, improvement in HAP from 63 to 74, a sub-score improvement on SMAF. There were no significant improvements in the QoL measures or changes in nutritional status in either group over the course of the study.
Conclusion: The results of this study provide evidence that exercise had a positive impact on the physical performance and functional measures for patients on hemodialysis.
Strategies for teaching a deaf patient nocturnal home hemodialysis
Stella Fung, RN, BHlthSc(N), CNeph(C), Rose Faratro, RN, BHHSc, CNeph(C), Celine D'Gama, RN, BSN, CNeph(C), and Elizabeth Wong, RN, BScN, CNeph(C) (Toronto, Ontario)
Home nocturnal hemodialysis, besides providing better clearance and flexibility for patients with end stage renal disease, also allows for a healthier lifestyle.
Teaching a novice ESRD patient to become proficient in doing home hemodialysis can be challenging, especially one with a physical disability.
In order to teach this deaf patient, the team researched the literature, contacted interpretation service for the deaf and used patientcentred care to carry out the plan of care.
Hemodialysis teaching is broken down into four basic components: access care, operation of the machine, management of dialysis complications and water treatment. All information was given in brief, clear English avoiding medical jargon where possible.
The nurse-patient interaction was one-on-one through an ASL (American Sign-Language) interpreter. Teaching tools were both visual and tactile with video, pictures and diagrams. Communication was done through sign language, lip-reading, and written notes.
An alarm vibrator was devised to capture all audible alarms on the machine to alert the user. The home hemodialysis nurses and technologists were trained to respond to various alarm situations.
At home, communication was made through Bell relay service, TTY phone (teletype writer), and e-mail. Regular home visits are scheduled to follow up the home condition and dialysis treatments. Dialysis log had been designed for the client to communicate with the team on the internet.
The experience with teaching a deaf ESRD patient to do home hemodialysis opens the door to future clients with disabilities.
The benefits of having a structured volunteer program in a renal unit
Peter Rughi, RN, BHScN, CNeph(C), Gary Buchanan, and Deb Folkes, BA (Toronto, Ontario)
We are a large regional dialysis program within a community hospital. The hospital is fortunate to have a successful and well-managed volunteer resource department that facilitates its volunteers of all ages to participate in many duties throughout the institution; a benefit to several departments, staff and, in particular, our patient population.
For several years, we have recognized the advantages of having volunteers in our renal unit. However, an ongoing challenge to spark interest and a commitment to stay persisted.
Through much discussion with staff, our multidisciplinary team and the volunteer resource department, we concluded that the recruitment of the right type of person required much planning, support and involvement of staff culminating with the implementation of a unit-specific program.
We felt that our unit was a different fit and that we would have to focus on recruiting a unique type of volunteer. In collaboration with the volunteer resource department and a very dedicated and committed volunteer, we developed a specific orientation presentation for new volunteers and put several strategies in place to offer continuous support for them. This program has been in place for more than two years. All the shifts are covered and our volunteers take pride in what they do and feel a great sense of self-worth and meaning.
This poster presentation serves to describe the planning, implementation and successes of this program.
Evaluating the journey: End-of-life care for renal patients and their families
Suzanne Gunby, RN, Sue Eacott, RN, Mary Stock, RN, Martin Ruaux, RN, BScN(c), and Kathleen Willison, RN, MSc, CHPCN(C) (Hamilton, Ontario)
A review of national data reveals that withdrawal of dialysis is the second most common cause of death among renal patients in Canada. The physiology of death by renal failure is well appreciated amongst renal care providers and well-documented in the literature, yet the psychological issues around the acceptance of withdrawal from active treatment and end-of-life care for the families of ESRD (end stage renal disease) patients has received little attention. As nurses accompanying patients and their families at this critical crossroad of their treatment decision, it is essential that we not only manage the physical symptoms as they decline, but also provide education, acknowledgement and support to those who are engaged in this journey.
The intervention developed by the team focused on the following:
* The delivery of modular education sessions for the nursing and allied health team, encompassing the domains of symptom issues, psychological care, spiritual support and after death care
* The creation of a pamphlet to provide information to commonly asked questions by families
* Inclusion of an additional supportive intervention whereby staff send condolence notes to families after the death.
This poster provides some preliminary results of an evaluation of these interventions utilizing Donabedian's framework of structure, process and outcomes to ultimately determine the utility of these interventions for staff and the families whom we serve.
PD or not PD: A joint collaboration to enhance PD exposure
Mary Van Der Hoek, RN, BSN, CNeph(C), Barb Atwater, RN, Nancy Erb, RN, CNeph(C), Patricia LaCroix, RN, Teri Pentland, RN, BSN, CNeph(C), Linda Dame, MSW, Claire Skjelvik, MSW, and RS Singh, MD (Vancouver, British Columbia)
As of 2004, there were more than 32, 000 patients with end stage renal disease (ESRD) in Canada, with peritoneal dialysis (PD) accounting for only 11.4% (Canadian Organ Replacement Registry, 2006). Although the number of persons with ESRD is increasing each year, PD penetration has been steadily declining in the past 10 years. PD penetration has been relatively constant in the past two to three years, with current PD penetration at 18%.
In an effort to enhance PD exposure, with a desire to increase PD growth by 3% to 5%, the PD and chronic kidney disease (CKD) clinics collaborated to increase client and staff awareness on this modality. This joint effort resulted in a "PD awareness clinic", which is being held monthly. The objectives of this clinic are:
* To provide opportunities for potential clients and families to meet with the multi-disciplinary team (PD nurse, physician, social worker and dietitian).
* To establish networking opportunities with other clients living with kidney diseases.
* To introduce a client living with kidney disease, with PD therapy as the modality of choice.
* To provide more in-depth education on PD therapy for clients who have already chosen PD as the modality of choice or for those who need more information.
This presentation will provide a more detailed review of this initiative, as well as discuss the process and outcome measures the program wishes to achieve.
Getting on the right track
Cindi Wheeler, RN, CNeph(C), Shirley Drayton, RN, BScN, Trish Trieu, RN, MScN, Celi Espiritu, RN, and Janette Sviridov, RN, BScN, CNeph(C) (Toronto, Ontario)
The home dialysis team at Sunnybrook Health Sciences Centre is committed to promoting best practices in peritoneal dialysis. In 2006, the average monthly percentage of home dialysis patients who were admitted to hospital was 6%, with the majority of patients admitted to the nephrology inpatient unit (NIU). Home dialysis patients admitted to the NIU for acute medical problems such as peritonitis, experienced many frustrations as a result of inpatient staff performing dialysis procedures not always consistent to the teaching approach by the home dialysis team. This resulted in high patient anxiety and confusion, increased workload for home dialysis staff and increased tension among staff members.
Consistency is pivotal for home dialysis patients. To reinforce proper techniques and practices, the home dialysis team and the nephrology inpatient team collaboratively set out to improve communication between departments and to provide a consistent approach to management of patients on peritoneal dialysis.
The goals of the Home Dialysis and Nephrology Inpatient Team are:
* To assess and revise policies and procedures for consistent practice
* To provide educational sessions for both areas;
* To use a multidisciplinary team approach to patient care teaching
* To promote interdisciplinary patient rounds.
This poster presentation will demonstrate how the nephrology inpatient unit and the home dialysis team worked together for successful patient outcomes.
Responsiveness of hemodialysis patients to education about home dialysis
Mina Kashani, RN, BHSc(N), CNeph(C), and Sanober Motiwala, MHA (Toronto, Ontario)
Background: Despite evidence in the literature that demonstrates that home dialysis is more convenient and improves quality of life, many patients in the province of Ontario are started on and maintained on hospital-based dialysis therapies. Ontario's Ministry of Health and Long-Term Care (MoHLTC) has set provincial targets for dialysis modality distribution that all dialysis programs are expected to achieve by 2010: 60% in-centre hemodialysis (HD), 30% home peritoneal dialysis (PD), and 10% home HD.
Objective: Progressing toward meeting those targets, a patient education program was developed by home dialysis staff to inform in-centre HD patients about alternative treatment options, with the intention of encouraging clinically suitable patients to migrate from in-centre HD to home PD. This study evaluated the effectiveness of the education program, and captured patient perceptions of home dialysis that impact transfer to PD.
Methods: All clinically suitable in-centre HD patients were included in the study sample (n ~150). Subjects received education on PD by a home dialysis nurse. Baseline data were collected on demographics, living arrangements, pre-dialysis treatment and awareness of alternative care options. Responsiveness to the education was measured and correlated with patient characteristics.
Results and clinical implications: Thirty-seven in-centre HD patients received the full education program following initial contact. Four of those 37 expressed a desire to transfer to PD and three to home HD. This study also provided staff with insights into decisions about modality selection. Ultimately, findings will be used to improve current dialysis education to better meet patients' information needs.
Is bigger better?
Leslie Shepherd, RN, Kathy Forbes, RN, and Debbie Hartman, RN (Kingston, Ontario)
In keeping with the advancements in technology in the area of hemodialysis, our renal program has recently changed dialyzers. We were using OP160 dialyzers and are now using OP200 dialyzers.
The purpose of our presentation is to determine if the change from OP160 dialyzers to OP200 dialyzers will enhance solute clearance due to its larger surface area, and if the change will improve patient outcomes.
These outcomes will be determined using a retrospective chart review collecting data on specific blood values: urea, creatinine, hemoglobin, calcium/phosphate product, and Kt/V. This data collection will include collecting of above values prior to the change in dialyzer. The specific blood values will be assessed, for the purposes of this review, prior to changing to the OP200 dialyzer and six months after the change to the OP200 dialyzer.
Our goal is to show improved hemodialysis adequacy as a result of utilizing the best available technology at this time.
Our poster will outline the results of the data collected as well as our conclusion as to whether or not the change to the OP200 dialyzer has led to improved patient outcomes.
Keeping our peritoneal dialysis patients at home
Janet McComb, RN, CNeph(C), Debra Grant, RN, BN, CNeph(C), Sharon Mulkerns, RN, CNeph(C), Sharon Csernak, RN, CNeph(C), Julie Foster, RN, CNeph(C), and Wilma Cohrs, RN, BScN (Kingston, Ontario)
The goal of the Provincial Peritoneal Dialysis (PD) Initiative to increase the use of PD in Ontario to 30% by 2010 prompted us to have a closer look at our program statistics. We weren't growing and retention was our primary issue. Patients were being lost to in-centre hemodialysis due to high peritonitis rates.
This meant that the patients who chose a home-based therapy weren't able to dialyze at home, and we felt we weren't doing all we could to help them maintain the quality of life they enjoyed with peritoneal dialysis.
We were committed to improving our peritonitis rates and established a team led by nurses and fully supported by our manager, to organize timelines, examine root cause(s) and develop key initiatives.
Peritonitis infection rates and causative organisms were determined using infection management software. As one of our key initiatives, we reviewed the current literature around peritonitis prevention, and were able to connect with other units to share and incorporate best clinical practice.
Our successes: development of new patient teaching manual: implementation of regular home visits using a new home visit form, changeover to luer lock connectology, enhanced collaboration with community health partners to ensure optimal care in the home, and clinic monthly education blitz topics to name a few.
Our peritonitis rates are improving; we have increased our patient numbers, and most importantly, because of the efforts of the renal team, new ideas and enhanced education, we are keeping our patients at home.
Development of a program to enable nursing students to complete their clinical consolidation in a hemodialysis unit
Ann Dugas, RN, CNeph(C), and Anne Dugas, RN, BScN, CNeph(C) (Ottawa, Ontario)
As a recruitment and retention strategy, The Ottawa Hospital's nephrology program embarked on a project in the fall of 2006 to entice consolidating student nurses to select nephrology as the start point of their career. The purpose of the project was to explore diverse methods to recruit and inspire an interest to sustain a career in nephrology nursing. Since the skills associated with hemodialysis are not part of the core curriculum, a proposal was put forth to develop and operationalize a plan, identifying the opportunities that would be offered to the students in order to meet their learning objectives. During their eight-week consolidation period they gained exposure to hemodialysis and were also introduced to all of the treatment modalities for chronic kidney disease.
The immediate outcome is positive with successful hiring of the students. Evaluation tools were designed to solicit feed back from the students and their preceptors in addition to assessing the impact on the hiring unit. Retention will be evaluated post orientation, at year one and three years.
The long-range implications of hiring from this previously untapped resource are currently unknown. The initial implications will only be realized after their orientation period is complete in the fall of 2007. It is anticipated that this computer literate and technically savvy generation of nursing students will thrive in the hemodialysis setting provided they receive the appropriate support to hone their basics nursing skills and integrate into the team.
The self-management experience of people with mild to moderate chronic kidney disease
Lucia Costantini, RN, MN, Heather Beanlands, RN, PhD, Elizabeth McCay, RN, PhD, Daniel Cattran, MD, and Michelle Hladunewich, MD (Burlington, Ontario)
Purpose: This study examined self-management experiences of men and women living with mild to moderate (stages 1-3) chronic kidney disease (CKD).
Methods: This qualitative exploratory study used semi-structured interviews to elicit participants' perceptions of health, kidney disease and supports needed for self-management. Interview transcripts were analyzed using content analysis to uncover themes related to the self-management experience and perceptions of the nurses' role in supporting self-management efforts.
Results: Participants included six men and eight women with varied demographic characteristics. The data revealed an iterative process of Renegotiating life with CKD which included three prominent phases: discovering kidney disease, learning to live with kidney disease, and hope for the future. Participants highlighted the need for specific, timely information in all the phases. Participants also expressed a desire to be involved in treatment decisions and highlighted the importance of guidance and support from health professionals to successfully self-manage the illness. Physicians and dietitians were the only health professionals identified by study participants as care providers. References to nurses were non-existent in the interview dialogue.
Conclusions: This study highlights the complexity of self-management and demonstrates the need for further research to examine specific self-management strategies and to explore nurses' role in supporting self-management in people with early CKD.
Implications for nephrology care: People with early CKD in this study emphatically asked for more support and guidance from healthcare providers to successfully self-manage their disease. Nephrology nurses are uniquely positioned to provide this while collaborating with other care providers, to facilitate self-management.
Supporting end-of-life decision-making from a nephrology nursing perspective
Gillian Whamond, RN, BASc, CNeph(C), and Sandra Hislop, RN, BScN, CNeph(C) (Orillia, Ontario)
In June 2006, Orillia Soldiers Memorial Hospital (OSMH), Ontario, received a fellowship from the Ministry of Health and Long-Term Care to promote the End-of-Life Project, the purpose of which is to ensure a process is in place to determine advanced care directives for patients who are admitted to intensive care units (ICU) in Ontario. Because we are the regional dialysis centre for our area and many of our ICU admissions are critically ill renal patients, nephrology nurses were invited to be part of this project.
The project included the development of a record of patient and family communication to address patient wishes on admission to hospital and the introduction of three new policies in our hospital regarding advance care directives, No cardiopulmonary resuscitation, and pronouncement of death. Workshops were held that included a presentation to assist nurses to examine their own personal values and beliefs and a demonstration of the use of an ethical decision-making framework through the examination of a complex case study.
Policies were well-received and understood by the nurses who felt increased confidence in the implementation of these policies and in their interactions with patients, families and the multidisciplinary care team around end of life care.
As nephrology nurses at OSMH, we feel passionate about providing support to our patients and their families and felt honoured to participate in a project that will enable all nurses to better care for renal patients. We will continue to disseminate this information to our peers.
So much data--So little information! Integrating and streamlining patient data for effective indicator tracking and outcome measurement
Donna Leafloor, RN, BScN, MHSM, and Monique BEnard, RN, CNeph(C) (Ottawa, Ontario)
Excellence in health care requires management and utilization of comprehensive information regarding both individual patients and the patient population as a group. This presentation will focus on an information management project undertaken in the home dialysis unit of The Ottawa Hospital in 2007. The purpose of the project is to address two challenges and, thereby, enhance the program's capacity to implement a comprehensive quality plan. One challenge is to produce an integrated, longitudinal view of key patient, patient care, and outcome data. The second challenge is to generate population-based statistics that are required for the calculation and tracking of key indicators. These two sets of information will support continuous quality improvement (CQI), reporting to the Ontario Ministry of Health and Long-Term Care, and strategic planning for our patient population.
In the home dialysis unit, comprehensive spreadsheets have been developed, that combine data previously collected in multiple locations. These user-friendly spreadsheets integrate longitudinal patient information, calculate population statistics, and provide monthly and on-going calculation of key operational and clinical indicators. This presentation will focus on the tools that have been developed, how they are operationalized and utilized, and their impact.
Benefits of electronic health records to renal nurse practitioner care
Sandra Allen, RN, BN, CNeph(C) (Saint John, New Brunswick)
The electronic health record (EHR) is a secure and private lifetime record of an individual's health history and care within the health system (Canada Health Infoway, 2005). End stage renal disease (ESRD) clients often do not see a primary care provider and, instead, rely on the nephrology health care team to provide primary and preventative care. For this reason, there is a need to integrate primary and preventative care into the overall nephrology care plan thus avoiding fragmented care. The prevention-focused educational background of the nurse practitioner (NP) lends itself to primary health care (PHC) issues. More specifically, the in-depth knowledge of the multi-system involvement of ESRD requires management of comorbid illnesses such as hypertension and diabetes. The renal NP has the benefit of regular contact with these clients, as well as knowledge and motivation to keep ESRD clients healthy and out of the hospital (Aiello, 2003). Information technology in the form of the EHR can profoundly affect clinical workflow, enhance and expand the NP's ability to work with client data and information. EHRs have the potential to greatly improve client safety by making it possible for clinicians to have information available to enable them to make informed decisions. In this way, the EHR provides a secure, real-time, point-of-care information resource for clinicians (Ball & Lillis, 2000). Key benefits to client care and renal NP practice that can occur as a result of implementation of EHRs are explored. This poster is a visual representation of key benefits to renal NPs practice.
Peritonitis in North America: The current state and best-demonstrated practices
Susan McMurray, RN, BN, CNeph(C) (London, Ontario)
Peritonitis has always been a major concern for peritoneal dialysis (PD) patients and staff. Fortunately, peritonitis rates have improved dramatically over the last 20 years. This has been partly due to exceptional patient education. Adult Peritoneal Dialysis-Related Peritonitis Treatment Recommendations: 2000 Update (Keane et al., PDI, 2000).
This presentation will review the causative organisms and outcomes of peritonitis in North America based on the article Microbiology and Outcomes of Peritonitis in North America (Mujais, S., KI, November, 2006). In addition, the current 2005 ISPD recommendations for peritonitis will be briefly reviewed. As well, a discussion of best-demonstrated practices for the prevention of infectious complications will be examined according to Fender et al, Prevention of Infectious Complications in Peritoneal Dialysis: Best Demonstated Practices, KI, November, 2006.
The purpose of this presentation is to examine current literature related to peritonitis and apply the information to everyday clinical practice in order to enhance outcomes for PD patients.
Utilizing electronic documentation to enhance the implementation of an anemia management protocol in hemodialysis patients
Keri Aitken-Toby, RN, Shelley Parker, RPh, Julie Scott, RPh, PharmD, and Laura Gregor, MD (Kitchener, Ontario)
A nursing- and pharmacy-driven protocol for anemia management was implemented in a community hospital based outpatient renal program with more then 300 hemodialysis patients.
A key aspect of protocol implementation involved ensuring an accurate method for documentation of the data collected and initiated interventions; that also facilitated interpretation of monthly results. At the time of implementation, achievement of this objective required implementation of a combination of both electronic and paper documentation. Nurses and pharmacists were trained to utilize electronic charting systems (Nephrocaree, Horizons HEDe), as well as to initiate paper documentation on an approved anemia management log, and initiating changes to orders on standard physician order sheets. In the summer of 2006, laboratory results from Horizons HED" were interfaced with Nephrocarei allowing better efficiency of nurses and pharmacists' time to complete the protocol, as well as less risk of error. Ongoing quality control audits ensure accuracy of protocol implementation as well as the documentation that is occurring.
The progression towards completing all documentation electronically continues. The goal is to have the approved anemia management log integrated within the Nephrocare[R] charting system as a part of the anemia care map. Utilization of an electronic patient charting system has improved efficiency of gathering pertinent anemia laboratory results, ease with which interventions are documented and facilitated collection of program-wide statistics for quality assurance initiatives.
Process-guided development of a multidisciplinary renal management clinic
Eveline Porter, RN, MN, CNeph(C) (Toronto, Ontario)
A pre-dialysis renal management clinic (RMC) has been shown to enhance education, modality selection and medical management of individuals with chronic kidney disease (CKD) and, as a result, lengthen the time prior to starting dialysis. At the University Health Network (UHN), Toronto, we developed a patient-centred RMC utilizing a CKD program planning framework called MOMENTUMi. The framework assisted us to develop our vision, mission and, ultimately, our program components of: interdisciplinary team, research, comprehensive education, clinical management, continuous quality improvement and support systems.
This paper will discuss the process of how the team was able to develop a unique framework that guided the development of our clinic. The "clinical management" component was identified as our first priority and, from this, the team developed referral guidelines, clinical targets, clinical activity guidelines and a clinical pathway of CKD care. Through ongoing quality management team meetings, the framework serves as a continual guide to program development and evaluation.
The clinic started in 2000, with 40 patients and four primary nephrologists, operating one-half day per week, and has now expanded to 250 patients, nine nephrologists and operates one-and-a-half days per week. The RMC patient-centred framework has been integral in the development and expansion of this clinic.
As we recognize the exponential growth of individuals with CKD in Canada, this framework may serve as a useful resource for other CKD programs.
"Healthy start" peritoneal dialysis
Monique Fisher, RN, and Karen St Amand, RN (Regina, Saskatchewan)
Purpose: Does early initiation of peritoneal dialysis, along with the use of low volume extraneal therapy affect quality of life and preservation of residual urine output in end stage renal disease?
Description of project: Since 2004, the Regina Qu'Appelle Health Regina (RQHR) has started approximately 10% of our patients on "healthy start" peritoneal dialysis (PD) prior to deteriorating to the point of meeting the usual requirements for initiating peritoneal dialysis. These patients did not exhibit all the symptoms of uremia, but were started early for a variety of reasons. All were started on lower volume (1000 mls) extraneal therapy. The extraneal solution dwelled for eight to nine hours per day. No other solutions or exchanges were performed throughout the 24-hour time period.
Evaluation/outcomes: A retrospective chart review was done on 14 patients from our program. Seven of the patients started PD earlier than the other seven that meet the standard requirements for starting PD.
A standardized QOL assessment tool and chart review assessment of patients' renal function was used to evaluate outcomes. Initial assessment to date indicates that these patients generally remained healthier, had a better quality of life, and also maintained or improved their residual renal function.
Implications for practice: The positive outcomes that these patients are experiencing would lead us to consider the healthy start program for other patients in the future.
Cardiac events in patients with high-volume hemodialysis access flows
Rosa Marticorena, RN, BScN, Diane Deabreu, RN, Margaret Huybers, RN, Joyce Hunter, RN, Niki Dacouris, BSc, and Sandra Donnelly, MD (Toronto, Ontario)
Objectives: The impact of high volume hemodialysis (HD) access flow (QA) in the cardiac status of chronic HD patients has been recognized since the early years of HD. QA greater than 2000 ml/min has been associated with the development of left ventricular hypertrophy, high-output cardiac failure, worsening of coronary ischemia amongst other cardiac complications in this population. However, the impact of high volume hemodialysis QA, in cardiac morbidity has not yet been reported. The purpose of this study is to determine the rate of hospital admissions and emergency encounters due to cardiac events associated with QA greater that 2000 ml/min in patients receiving chronic hemodialysis treatment.
Materials and methods: Thirty chronic hemodialysis patients at St. Michael's Hospital in Toronto, Ontario, who had a QA measurement > 2000 ml/min for at least six months were evaluated prospectively during the periods of January 2002 to December 2006. All cause of emergency encounters and hospitalizations were obtained and stratified into cardiac versus non-cardiac events.
Results: Mean QA was 2580 ml/min (SD[+ or -]450). A total of 199 hospital admissions (37 cardiac-related) and 310 emergency encounters (98 cardiac-related) occurred in these patients during the study period. Of the 30 patients, 77% had hospital admissions (33% cardiac-related) and 73% had emergency encounters (40% cardiac-related).
Conclusions: QA greater than 2000 ml/min cause an important rate of cardiac related hospital admissions and emergency encounters in hemodialysis patients. Studies need to be performed to determine if specific ranges of QA would help prevent these events.
Use of sodium thiosulfate and pamidronate for the management of calciphylaxis
Colette Raymond, PharmD, MSc, Cory Lang, BSP, Lori Wazny, PharmD, Lavern Vercaigne, PharmD, Claudio Rigatto, MD, FRCPC, MACP, MSc, and Adrian Fine, MD, FRCPC (Winnipeg, Manitoba)
Purpose: We describe a case of calciphylaxis responsive to multiple therapeutic interventions including intravenous pamidronate and sodium thiosulfate.
Description: A 50-year-old continuous ambulatory peritoneal dialysis dependent woman developed a painful ulcerated and ischemic left foot and painful plaques on her buttocks. She had an elevated corrected serum calcium (CCa) (2.82 mmol/L) and phosphate (PO4) (2.42 mmol/L; sevelamer as phosphate binder). A bone scan revealed calciphylaxis on calves, thighs, overlying the sacrum and both buttocks, with calcification of the heart, lungs, stomach and kidney (week 0). Therapeutic interventions included: hemodialysis 3x/week (week 0), left below knee amputation (BKA) for calciphylaxis and gangrene (week two). Pamidronate 30 mg was administered intravenously every hemodialysis session for five sessions (weeks three to four). Calciphylaxis on thighs, right foot and buttocks persisted (weeks four to eight), therefore sodium thiosulfate 25 g was administered intravenously over one hour after each dialysis session for 12 weeks (weeks eight to 20). A right BKA was performed for painful ischemia (week nine) and calciphylaxis.
Evaluation: Calciphylaxis lesions on thighs and buttocks improved clinically (week 10) following sodium thiosulfate administration. A bone scan (week 12) demonstrated that calciphylaxis on buttocks and thighs had resolved, although organ calcification remained. Pain control improved significantly (week 13). At week 18, CCa and PO4 were 2.73 and 1.69 mmol/L, respectively. A bone scan showed calciphylaxis to be completely resolved (week 33). No medication-related adverse effects were observed.
Outcome/implication: We describe a multifaceted approach to calciphylaxis that adds to the limited literature describing pamidronate and sodium thiosulfate for this purpose.
Recruitment and retention: Successful strategies for recruitment and retention in nephrology clinical trials
Valerie Cronin, RN, BA, SCM, MA, CCRP, Roanda Pretorius, MSc, CCRA, CCPE, and Sonia Schellenberger, MHSc (Ottawa, Ontario)
Recruitment and retention in nephrology randomized controlled trials presents significant challenges for the research team. Patients in this population have several co-morbid illnesses with frequent clinical visits. Consequently, the population is less likely to participate in a clinical trial. Furthermore, it is a reasonable expectation that some participants will not complete the study, others will withdraw consent or be withdrawn from the study and some will be lost to follow-up. A high dropout rate after randomization can result in small sample sizes reducing the statistical power to test study hypotheses, treatment effects and overall evaluative effects of the study. These losses can result in biased results, difficulty interpreting study findings and inability to generalize results. The purpose of this presentation is to focus on successful recruitment and retention strategies of nephrology patients, based on experiences at The Ottawa Hospital (TOH), during a multi-centre, double-blind randomized controlled trial. From the hospital transplant database, patients were pre-screened according to predefined criteria and further evaluated during their routine transplant clinic visits for eligibility. Once identified, patients were consented, screened and randomized according to study protocol. The recruitment period for this study is two years. In nine months 52% of the agreed enrolment was completed. Of the other 11 participating centres, TOH is the highest recruiting centre. Effective recruitment strategies and follow- up mechanisms that promoted patient retention were implemented. Recruitment and retention strategies utilized at TOH, may provide guidance for principal investigators and research coordinators involved with clinical research.
Complete conversion from Epoetin Alfa to Darbepoetin Alfa in the Manitoba Renal Program (MRP): Conversion ratios and cost savings
Lori Wazny, PharmD, Colette Raymond, PharmD, Lavern Vercaigne, PharmD, Esther Lesperance, RT, Dan Skwarchuk, BComm(Hons), CGA, and Keevin Bernstein, MD, FRCPC (Winnipeg, Manitoba)
Purpose: This initiative sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for MRP patients after a province-wide switch between agents.
Methods: Hemodialysis (HD), peritoneal dialysis (PD) and patients with chronic kidney disease (CKD) were included. Laboratory parameters and darbepoetin alfa doses were measured over three months and compared to three months of historic epoetin alfa use (same administration route). Dose conversion ratios were calculated by dividing mean doses of epoetin alfa by darbepoetin alfa. Costs were compared using current wholesaler prices.
Results: In 2005, 857 patients received darbepoetin alfa and were compared to data on 746 patients who received epoetin alfa in 2003-2004. Demographic characteristics were similar.
Conclusions/implications: If darbepoetin alfa is priced at a 200 IU: 1 ug ratio to epoetin alfa, average annual cost savings of $1,758, $1,144 and $624 per patient for HD, PD, and CKD patients could be obtained, with similar anemia parameters to epoetin alfa.
Therapeutic leisure activities for hemodialysis clients: A pilot project
Judy Dravucz, Recreational Therapist, Kristie Emms, Occupational Therapist and Linda Kerr, RN, CNeph(C) (Calgary, Alberta)
A six-month pilot project, starting January to July, 2007, was initiated utilizing both individual and group therapeutic activities during hemodialysis treatment. Activities were mainly focused on cognitive stimulation and some involved a physical aspect. An anonymous satisfaction survey was administered both before and after the activity trial. A general attendance/participation record was kept to track success.
The goals were:
* To have a 20% participation rate in the implemented activities.
* Increase client satisfaction on average by two points.
* Provide four different activities in a four-week calendar month.
Desired outcomes: Clients will have a positive experience and enjoy the programs that are offered during dialysis.
* To implement activities as an ongoing service for clients in hemodialysis.
* To increase client involvement in implementation and planning of future programming.
* To share results with other hemodialysis units and therapy staff to promote future learning.
* To increase awareness of importance of quality of life programming in dialysis clients.
Table One. (1) Usual (2) Opposite (3) Hyper- (4) Roos abduction Qa mL/min* 1460 1350 865 1000 (1010-2220) (920-2150) (625-1370) (640-1500) Venous 155 160 195 200 Pressure (140-175) (135-185) (180-220) (183-212) MmHg Arterial -115 -110 -95 -87 Pressure (-85 -135) (-85 -130) (-120 -60) (-115 -55) MmHg (4) Roos (5) Adson Qa mL/min* 1180 (770-1930) Venous 1000 190 Pressure (640-1500) (170-205) MmHg 200 (183-212) Arterial -87 -85 Pressure (-115-55) (-105-60) MmHg * All measures reported as Median (25th Percentile-75th Percentile)
Table Two. (3) Hyperabduction (4) Roos [DELTA]< 50% [DELTA] p [DELTA] [DELTA] p [greater value < 50% [greater value than or than or equal to] equal to] 50% 50% N 29 15 35 11 Baseline 1260 1850 0.331 1490 1230 0.699 Qa Venous 200 185 0.307 200 190 0.380 Pressure Arterial -80 -120 0.003 -80 -95 0.086 Pressure (5) Adson [DELTA] [DELTA] P < 50% [greater value than or equal to] 50% N 41 4 Baseline 1460 1395 0.999 Qa Venous 190 200 0.459 Pressure Arterial -85 -92 0.617 Pressure
Table One. Results Measurement K/DOQI Range DOPPS II n=4,261 PTH (pg/mL), <150 48% [N/A] [patients prescribed 150-300 26% [N/A] vitamin D or cinacalcet] >300 26% [N/A] CCa (mmol/L), [patients <2.1 9% [N/A] prescribed Ca containing 2.1-2.37 43% [N/A] PO4 binders; average dose >2.37 49% [N/A] elemental Ca] PO4 (mmol/L), [patients <1.13 9% [77%] prescribed any PO4 binder] 1.13-1.78 44% [85%] >1.78 47% [88%] Patients meeting K/DOQI all 3 targets targets Measurement MRP n= 546 CSN Range PTH (pg/mL), 45% [14%] <100 [patients prescribed 28% [27%] 100-500 vitamin D or cinacalcet] 27% [66%] >500 CCa (mmol/L), [patients 9% [94%;2.9 g/d] <2.1 prescribed Ca containing 40% [87%;2.3 g/d] 2.1-2.6 PO4 binders; average dose 51% [83%;1.9 g/d] >2.6 elemental Ca] PO4 (mmol/L), [patients 13% [77%] <0.80 prescribed any PO4 binder] 42% [99%] 0.80-1.78 45% [96%] >1.78 Patients meeting 6% CSN targets all 3 targets Measurement MRP n=546 PTH (pg/mL), 31% [15%] [patients prescribed 57% [30%] vitamin D or cinacalcet] 12% [76%] CCa (mmol/L), [patients 9% [94%;2.9g/d] prescribed Ca containing 81% [86%;2.1g/d] PO4 binders; average dose 10% [77%;1.9g/d] elemental Ca] PO4 (mmol/L), [patients 3% [73%] prescribed any PO4 binder] 53% [91%] 44 [96%] Patients meeting 26% all 3 targets
Table One. Results Study, year Patients, catheter type Sesso, 1998 136 incident non-tunneled non-cuffed Johnson, 2002 50 incident tunneled cuffed Lok, 2004 169 incident and prevalent tunneled cuffed Kamalia, 2004 31 incident non-tunneled non-cuffed Johnson, 2005 101 incident tunneled cuffed Study, year Design Treatment Sesso, 1998 Open Mupirocin 2% + PI [dagger] 10% vs 10% PI Johnson, 2002 Open Mupirocin PI 10% vs 10% PI Lok, 2004 Double blinded Polysporin triple vs placebo ointment (chlorhexadine in both) Kamalia, 2004 Open Mupirocin 2% + PI [dagger] 10% vs 10% PI Johnson, 2005 Open Mupirocin vs medihoney (10% PI in both) Study, year Outcome (per 1000 patient days) Sesso, 1998 0.71 vs 8.92 (bacteremia) * Johnson, 2002 0 vs 6.6 (exit site infection) * 1.6 vs 10.5 (bacteremia) * Lok, 2004 1.02 vs 4.10 (any infection) * 0.63 vs. 2.48 (bacteremia) * Kamalia, 2004 5.9% vs 35.7% (catheter related infection) * Johnson, 2005 0 vs 0 (exit site infection) * 0.97 vs 0.85(bacteremia) * * p<0.05 [dagger] povodine iodine (PI) Mupirocin decreased staphylococcal isolation from skin and catheters, clinical infections and hospitalizations, and increased duration of catheter use compared to PI. Polysporin decreased mortality, hospitalizations and catheter removals compared to placebo. Therapy related adverse effects and mupirocin resistance were not observed.
Table One. Patient Group Epoetin Darbepoetin Conversion alfa Alfa Ratio Hemodialysis n=482 n=604 244:1 Mean Hb (g/L) 113.6 114.4 Mean weekly dose 12,939 units IV 53.1 ug IV Weekly Cost $ 191 $ 157 Peritoneal Dialysis n=153 n=142 222:1 Mean Hb (g/L) 113.9 118.2 Mean weekly dose 9,273 units SC 41.8 ug SC Weekly Cost $ 145 $ 123 Chronic Kidney Disease n=111 n=111 219:1 Mean Hb (g/L) 114.2 115.5 Mean weekly dose 5,516 units SC 25.2 ug SC Weekly Cost $ 86 $ 74 All patients had similar iron parameters on epoetin alfa and darbepoetin alfa, respectively.
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