Dialysis: Treatment Options of End Stage Renal Disease

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• Is the process of cleaning the blood by removing wastes and fluid that build up when the kidneys fail.
• Is a way to replace some, but not all, kidney functions.
• The goal of dialysis is to help keep people with kidney failure as healthy as possible.
• Dialysis can't fully clean the blood.


Normal Kidney Function Compared to Dialysis

Kidney	Dialysis
Removes all excess fluid each day	Removes some fluid on treatment days
Removes waste product each day	Removes some wastes on treatment days
Control electrolyte and acid/base	Helps restore electrolyte and acid/base balance
Controls blood pressure by fluid removal, sodium balance, and hormonal action	Helps control blood pressure by removing fluid and balancing sodium on treatment days
Makes erythropoetin, a hormone that triggers the bone marrow to make red blood cells	Can't make erythropoetin, but recombinant or genetically engineered erythropoetin is given
Controls calcium / phosphorus balance each day	Can change serum calcium levels somewhat by adjusting calcium in dialysate, can remove some phosphorus, but not as well as healthy kidney
Plays a role in hormonal balance	Has little, if any, effect on hormones
Activates vitamin D	Cannot activate vitamin D, vitamin D sterols can be given.

• Blood is pumped out of the patient's body, through an artificial kidney, or dialyzer, then back into the patient.
• Both blood and dialysate fluids are pumped through different parts of the dialyzer at the same time.
• A semi permeable membrane keeps the blood and the dialysate from mixing.
• Excess water and wastes pass out of the blood through pores in the membrane, into the dialysate.
• The used dialysate is sent down a drain.
• Only a small amount of blood is out of the body at one time.

In-center Hemodialysis
• Some patients feel safer getting treatment in a center with nurses and technicians there to help.
• They like the chance to meet other people who need dialysis and may make friends at the center
• Patient has days off between treatments not to think about dialysis.

Conventional Hemodialysis
• Patients and their partners are trained for a few weeks in how to put in needles, order supplies, run the machine, take blood samples, report problems, and respond to emergencies.

Nocturnal Hemodialysis
• Patients are trained to do their treatments from 3-7 nights each week, for about 8 hours, while they sleep
• Special connectors keep the needles from coming out in case patients toss or turn.
• Bedwetting alarms, placed beneath the needle insertion area, may be used to detect moisture and wake the patient up if even a drop of blood is lost.
• In some programs, the machine is linked by a modem to the hospital so a nurse or technician can follow each treatment.
• Patients who receive 48 hours of treatment each week ate a normal diet and had normal blood pressure without drugs.
• They did not need phosphate binders.
• Most had no fluid limits.
• They also had fewer symptoms - including less fatigue, cramping, dizziness, shortness of breath, or feeling cold.
• They felt more in control, and had better physical functioning.
• They have less heart damage than patients on conventional in-center hemodialysis                   .
• Longer treatments also remove much more b2m, the protein that causes amyloidosis

In-center nocturnal Hemodialysis
• Patient sleep in the center while getting their treatment.
• They get about 24 hours of treatment a week instead of the 9-12 they would normally get in-center

Short Daily Hemodialysis
• 2-3 hours treatment done 5-7 days per week

Newest type of home Hemodialysis

Objectives: Dialysis

Discuss how dialysis therapy is reimbursed in the United States.
• List two quality standards for dialysis treatment.
• List the steps of the continuous quality improvement (CQ1) process.
• Describe ways that dialysis staff can demonstrate professional behavior when working with patients.
• Explain the certification process for dialysis staff.

There are two types of dialysis:
• Hemodialysis (HD)
• Peritoneal Dialysis (HD)
• Hemodialysis is most common.

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Introduction

Main Goal in the treatment of CKD:
"To help each patient reach the highest level ofwellness possible".
Helping patients to reach this goal is one of the most rewarding parts of car ing for patients with CKD.



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Overview of Dialysis

Overview of Dialysis

• Dialysis is the main treatment for end-stage; renal disease (ESRD)
• It replaces three main kidney tasks:
     • Removing wastes from the blood
     • Removing excess fluid from the blood
     • Keeping electrolytes (electrically charged particles) in balance

There are two types of dialysis:
     • Hemodialysis (HD)
     • Peritoneal Dialysis (PD)

Hemodialysis is most common.

Overview of Dialysis: Hemodialysis

Hemodialysis
• An entry into the system is needed - vascular access.
• During treatment, needles are placed into the access.
• Blood flows out of the patient, through an artificial kidney (dialyzer) where the blood is cleaned, and back to the patient.

• The dialyzer contains a semipermeable membrane which allows some substances such as wastes and excess water out, but keeps other, such as blood cells, in.
• Wastes and water pass through the membrane into a fluid called dialysate and some substances pass from dialysate into the blood.
• The dialysis machine, or delivery system, controls the flow of blood to the dialyzer, includes safety alarms to monitor the machine during a treatment, and mixes and delivers dialysate.
• HD is most often done in a center 3 times a week, for about 4 hours per treatment.
• Some patients do HD at home, and may do short treatments 5 or 6 days a week.
• Or they may do longer treatments at night while they sleep for 3 -7 nights per week.

Overview of Dialysis: Pertitoneal

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Peritoneal Dialysis
• Access for Peritoneal Dialysis is through a catheter placed in the abdomen.
• The blood never leaves the body; instead, the lining of the abdomen, which has many tiny blood vessels, acts as a filter in the same as way a dialyzer.
• Most common - done at home, at night, while they sleep, with the use of a cycler machine.
• Can be done by hand, usually with four exchanges of fresh dialysate for used dialysate each day.
• Done 24 hours a day, 7 days a week.
• Can be done at home, at work, or while traveling.

History Of Dialysis

1943 - first hemodialysis treatment in a patient, using a cellulosic membrane, using a rotating drum artificial kidney. Developed by Dr. Willem Kolff (Dutch) - known today as "the Father of Dialysis''.

• KolflTs rotating drum device featured a large wooden
wheel dialyzer made of slats wrapped with 30-40 meters of
sausage casing (the cellophane membi we) u To gain access to the blood, a fresh artery and vein had to
be used for each treatment and tied off after.
• Because a patient had limited blood vessels, dialysis could only be used to treat patients whose kidneys were expected to recover.

1950-53: The science & technology of dialysis made great strides during the Korean War. Dialysis was used to treat soldiers with acute renal failure, improving their chances of survival.

SOURCE: http://en.wikipedia.org/wiki/Willem_Johan_Kolff

History Of Dialysis: Vascular Access

I960: The (Scribner) Shunt was developed by Dr. Belding Scribner and Dr. Wayne Quinton.
• This is the first vascular access. Made it possible to treat patients with chronic kidney failure, who would need dialysis for the rest of their lives
• A way to re-enter and use blood vessel multiple times for dialysis.
• A patient's artery and vein are linked using a plastic tube outside the skin. i But they become often infected or clotted.

1966: The arteriovenous (AV) fistula was develop by Dr. Jim Cimino and Dr. James Brescia.
• An artery and a vain are connected inside the arm.
• Cause fewer infections and blood clots than the shunt
• Even today, the AV fistula, or native fistula, lasts longest and is the best access for HD.

Source: Wikipedia.com

History Of Dialysis: Dialyzers

I960: Kiil dialyzer
• 70 pound flat plate. Their large surface areas were covered with by sheets of cellophane
• After each treatment, the membranes were cleaned and stored in a chemical bath (formaldehyde) or the plates were taken apart and the membranes replaced
• Rach comer of the dialyzer had to be uniform and "torqued down" - a lengthy task called "building a dialyzer". i Treatment took up to 14 hours, 3 times a week.

Coil dialyzer
• Also developed by Dr. Willem Kolff.
• First to be mass produced
• Cut treatment time to 8-10 hours
• A membrane supported by a mesh screen coiled around a central core
• Primed with a large amount of blood, set in a holding container called a canister, and bathed with dialysate
• Sterile and disposable - very costly.

Mid 1960s - Cuprophane - Gambro flat plate
• Small, 30 inches long, with many layers of membranes in pair. Each pair of membranes formed an envelope.
• During a treatment, blood flowed between the pairs of membranes, and dialysate flowed around the outside.

Late 1960s- small, lightweight, hollow fiber dialyzer
• Blood flowed through the insides of the fibers - thousands of tiny hollow tubes the size of hairs.
• Dialysate flowed around the outside of the fibers
• Much improved over the years- is the only type on the market today.


Advances that made dialysis more safe and reliable:
• Better membranes that are more compatible with the tissues of the human body (biocompatible) -increase treatment comfort for the patients
• Machine alarms and automated functions in the machine help protect patients from harm

Medicare Reimbursement for ESRD Patients



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 • Public Law 92-603
• Passed by the US Congress in 1972
• The Medicare End-Stage Renal Disease (ESRD) Program
• This gives Medicare to patients who are entitled to Social Security based on their work records (93%) of all patients.
• Covers both dialysis and kidney transplants
• Medicare pays 80% of allowable costs. Insurance, state programs or patients pays the other 20%.

• Today, kidney failure is still the only disease with its own Medicare program.
• More centers began to open.
• Most centers are free-standing
• 2/3 are part of a large dialysis organization (LDO), a company that owns many centers all over the country.
• Each year, there are fewer and larger LDOs as they buy more centers.


• Centers are paid a composite rate by Medicare for each treatment.
• Based on the patient's age, weight, and height. And is different for each patient.
• Covers overhead, staff wages and training, equipment, rehabilitation, and some drugs.
• The composite rate is not raised each year for inflation the way hospitals and nursing homes rates are. Instead, congress must pass a law to raise the rate.

Insurance
• Second source of income for centers
• During the first 30 months of treatment, if patients have an employer group health plan (EGHP) through a job or a spouse's job, that plan is primary - it pays first.
• 126,000 USD per patient, per year (Medicare pays 63,000 USD)


ESRD Networks
• Set in 1978 to oversee the quality of dialysis care across the country.
• 18 ESRD Networks, most are non-profit, all are under contract with Medicare to cover a region of 1 -6 states.
• Charged to promote rehabilitation, collect and report data, and do quality improvement projects.
• Also offer a patient grievance process and provides resources to staff and patients.

Quality in Dialysis

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What is Quality Dialysis Care?
The Institute of Medicine (IOM) in 1990 defined quality care as: "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Six Aims for Improvement set by the IOM to improve care:
1. Safer, avoid harm to patients from care that should help them
2. Infective: provide care based on science to all who could benefit.
3. Patient-centered: provide care that respects and responds to patients wishes, needs, and values, and ensure that patient values guide clinical decisions.
4. Timely: reduce waits and sometimes harmful delays for those who receive and give care.
5. Efficient: avoid waste of equipment, supplies, ideas, and energy.
6. Equitable: provide care that does not vary in quality due to gender, ethnicity, geography, education level, and income.

Dialysis Quality Standards

Sections of Dialysis Quality Standards

• Reasons for measuring dialysis quality
• Centers for Medicare and Medicaid Services (CMS)
• Food and Drug Administration (FDA)
• National dialysis data can serve as standards
• ESRD Clinical Performance Measures (CPMs) project

Dialysis Quality Standards

• Since the 1970s, quality in dialysis has been checked by comparing centers to preset standards. This is called quality assurance.
• Centers that do not meet these standards risk losing their Medicare certification to provide ESRD services and the payment they receive for these services.

Reasons for measuring dialysis quality:
1. The original purpose of dialysis was not just to keep patients alive, but to allow them to be active and productive citizens.
2. Congress requires assurance that the Medicare ESRD Program is worth the money, in part by showing that good quality care is being provided. 
3. Healthcare costs in general have skyrocketed. There is pressure throughout medicine to look at how well patients are doing, in or.ler to reduce costs while still maintaining quality care.


• Centers for Medicare and Medicaid Services (CMS)
     • Is the federal body that oversees Medicare
     • Formerly called Health Care Financing Administration (HCFA)
     • Inspects dialysis centers through contracts with state Departments of Health.
     • State surveyors have checklists of standards and conditions that centers must meet to keep their certification.
     • Centers that do not meet these can lose their Medicare funding.

• Many other dialysis standards exist:
• ESRD Networks have Medical Review Boards that collect patient and center data to measure outcomes.
• The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has standards for hospital-based dialysis centers.
• The Association for the Advancement of Medical Instrumentation (AAM1) has standards for dialysis water treatment, dialysis solution preparation, and dialyzer reprocessing.


• The Food and Drug Administration (PDA) oversees the safety and effectiveness of all medical devices.
• In 1991 PDA put out Quality Assurance Guidelines for Hemodialysis Devices.
• Still in effect, cover dialyzer and blood tubing, monitoring devices and alarms, dialysis machines, dialyzer reprocessing equipment, water treatment, and all other dialysis devices.

• National dialysis data can serve as standards.
• The United States Renal Data System (USRDS)
• Puts out a report each year that compares data from all dialysis centers in the United States.
• Data include annual mortality (death) rate, number of patients, cost of treatment, and much more.
• The results may be used to find out if outcomes for all patients are getting better or worse.
• Centers can use the data to compare their outcomes with national averages.

ESRD Clinical Performance Measures (CPMs) project
• This is a team effort of CMS, the ESRD Networks, and dialysis centers.
• Compare the quality of Medicare dialysis.
• Data are gathered each year from a random sample of patients from each center.
• Are based on the National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQF") Clinical practice Guidelines
• The hemodialysis CPMs are adequacy of dialysis, vascular access, anemia, and albumin.
• A report is put out each year.

Guidelines for Dialysis Care



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  • To measure the quality of care in a center, outcomes (results of care) must be used.
•  These outcomes must be agreed upon by providers and patients and based on the most current knowledge.
•  They are then measured for each patient, for group of patients, or for centers, and are tracked over time.

• Even with standards, patients outcome like morbidity (sickness) and mortality (death) vary from center to center.
• This may be due to, in part, to differences in care at centers or in approach to care and treatment among nephrologists (doctors who specialize in kidney disease).



How can we improve outcomes for all patients?
By finding the best way to provide dialysis care and sharing these ideas with all centers.

Clinical Practice Guidelines, or expert recommendations for how to care for patients, are efforts to do just that.



Adequacy of hemodialysis
• The first clinical practice guideline for kidney failure was written in 1993 by Renal Physicians Association (RPA) nephrologists.
• It covers the dose of treatment a patient should receive.
• Healthy kidneys work 24 hours a day, 7 days a week.
• Dialysis done three times a week provides only about 15% of the function of healthy kidneys.
• It suggested a minimum dose of hemoodialysis for all patients.


Other guidelines by RPA:
1. Appropriate Patient Preparation - care of patients with advanced CKD who are not on dialysis
2. ESRD Workgroup - care of ESRD patients
3. Shared Decision Making - starting and ending dialysis.

NKF-KDOQI™ - National Kidney Foundation's Dialysis Outcomes Quality Initiative was formed in 1995, supported by a grant from AMGEN

• Wrote guidelines on four key areas:
          •Anemia
          •Hemodialysis adequacy - built on the 1993 RPA guidelines
          •Peritonea] Dialysis adequacy
          •Vascular access

1999 - the NKF has increased the scope of DOQ1 to include all phases of kidney disease, and updated the first set of guidelines
• Now it is known as the Kidney Disease Outcomes Quality Initiative (KDOQI)
• Its goal is to improve the care and outcomes of all people with CKD


2003: a new NKF Program called Kidney Disease: Improving Global Outcomes (KDIGO) was launched.
• Mission: to improve the care and outcomes of kidney patients around the world.
• Is an effort to write and implement global clinical practice guidelines
• To work, the KDOQI guidelines must be put into daily practice.



Example: Anemia
• Anemia is a shortage of oxygen-carrying red blood cells
• It causes fatigue, heart disease, and many other problems.
• The KDOQ1 anemia guidelines help centers identify and treat anemia so patient stay healthier.
• You maybe able to help reduce anemia by making 'sure patients get more of their blood back after a treatment, keeping dialyzers from clotting, and stopping excess blood loss when you put in or take out the needles.

Example: Adequacy
• Patients sometimes get less than the minimum dose of dialysis.
• The KDOQI guidelines suggest that the doctor prescribe a higher dose, so patients will at least read) the minimum amount of treatment or more.
• You can correctly draw blood for testing, and check that the entire prescription is given • Example: you could make sure the correct blood flow rate is used, and explain why patients should stay on for the prescribed time.
                         
Example: Vascular Access
• The vascular access guidelines give ways to check and preserve a patient's access.
• You can help protect patient's accesses when you use good technique to put in needles, help patients put the right pressure on needle sites after a treatment, and report problems with the access to a nurse or doctor right away.
• KDOQI guidelines have also been written for heart disease, CKD, nutrition, high blood pressure, bone disease, and lipid disorders.

DOPPS (The Dialysis Outcomes and Practice Patterns Study)
• Is a long term study of patients in 12 countries (Australia, Belgium, Canada, France, Germany, Japan, Italy, New Zealand, Spain, Sweden, the United Kingdom, and the United States).
• Goal: To help patients live longer by looking at practice patterns in centers.
• The data are used to help find treatment factors that can be changed to improve patient outcomes.

Continuous Quality Improvement in Dialysis

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• Improving patient outcomes by giving high-quality, efficient care has become a goal of the dialysis industry.
• There are efforts by CMS and insurance companies to control costs and improve quality.
• One way to meet these goals is the use of continuous quality improvement (CQ1).
• Like quality assurance, CQI is a way to improve care.
• The focus of quality assurance is on audits and reviews to look for problems. The focus of CQI is to see how things are working, take steps to make them better, and , prevent future problems

 CQI can be both "top-down" and "bottom-up"
• Top-down means management commits to a CQI culture and uses resources to help CQI projects succeed.
• Bottom-up means workers find best practices and barriers to better care, and make changes to improve care.

CQI projects can be:
• Clinical (e.g., anemia, adequacy, vascular access).
• Technical (e.g., water treatment, dialyzer reuse).
• Organizational (e.g., staff schedules, patient safety).

Example of a four-step CQI process:
Steps 1 through 3 are where the CQI models may differ.

I. Identify Improvement Needs
Goal: To find an area that needs to be improved. There arc four sub steps to finding improvement needs:
     1. Collect data
     2. Analyze the data
     3. Identify the problem / need for improvement
     4. Prioritize activity

II. Analyze the Process
• This step has four substeps:
     1 .Choose a team - CQI teams should include different members of the care team based on the problem: doctors, nurses, dietitians, technicians, social workers, and patients.
     2.Review the data - The CQI team should review the data collected in the first step.
     3.Study the process / problem - Review the literature on the problem to see if there are standards or guidelines for it. Find reasons why the problem may have occurred.
     4.1dentify patterns / trends - Review all of the possible reasons for the problem, using the data.


III. Identify Root causes
From research, discussion, and data, decide the exact causes of the problem.

IV. Implement the "Plan, Do, Check, Act" Cycle
• The last step is to use the plan, do, check, act (PDCA) cycle.
• The four steps to the PDCA Cycle are:
     1. Plan - Make a plan to address the problem. Include outcomes, solutions to the problem, a task list for each team member, and a time frame.
     2. Do - Implement the plan.
     3. Check - Monitor the results of the plan, assess results after the plan is done, and assess the plan for any needed changes.
     4. Act - Adopt the plan in the center on a formal basis and continue to monitor progress.

The PDCA cycle is an ongoing process. Once a solution to the problem is started in the center, you cant assume that the problem is solved. The new process needs to be checked to ensure that it is being used in a day-to-day practice.

Dialysis Technician Professionalism





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   • When you become a hemodialysis patient care nurse / technician, you become a member of the healthcare team that cares for patients at your center.
•  As a nurse / technician, you will have more direct patient contact than any other staff member .
•  One of the key skill is to behave in a professional way.
• The Merriam-Webster Dictionary defines professionalism as a way of "exhibiting a courteous, conscientious, and generally businesslike manner in the workplace".


What are some ways you can be courteous to your patients while being both caring and professional?
• Address patients by their titles (e.g., Mrs. Smith).
• Don't use a first name without permission.
• Don't use nicknames - especially ones that could make a patient feel dependent (e.g., baby or sweetie),
• Use "please" and "thank you" when talking to patients, families, and other staff members.
• Treat everyone with respect and pride, Maintain the patient's dignity. Always introduce yourself and other members of the team to new patients, so they feel more comfortable with the center.

What are some ways you can show you are conscientious?
• Get to work on time.
• Be ready to work when you arrive.
• Don't talk about your personal life to patients or other staff member when in the patient care area.
• Never discuss or burden patients with your personal problems.
• Don't talk around or over patients, as though they weren't there.
• Never talk about one patient in front of another patient.
• Protect everyone's privacy and confidential information.

What are some ways you can show a business-like manner?
• Wear appropriate clothes that are clean and well kept.
• Groom yourself well:
• Trim your fingernails and keep them free of inappropriate decorations.
• Keep makeup tasteful and minimal.
• Brush or comb your hair neatly,
• Don't wear too much perfume, cologne, or aflershave
• Keep things peaceful and the level of noise to a minimum.
• Don't shout across the treatment area.
• Don't rush or run around the treatment area.
• Don't always appear to be too busy or indifferent - patient may feel unsafe.
• Take the appropriate amount of time with every patient.
• Make certain all equipments is ready and working when the patient arrives.
• Keep the patient care area clean, swept, and free of blood.

Knowing how to keep boundaries is a key part of professionalism. Boundaries keep the relationship between you and your patients appropriate and safe. They also protect everyone from misunderstandings. 
• What are some examples of boundaries?
     • Never date patients.
     • Never ask for or borrow money from patients.
     • Never invite patients to your home or to activities that are not related to the center.
     • Never discuss your personal problems with patients.
     • Never accept tips, money, or gifts from patients.
     • Never touch patients in an inappropriate manner.
     • Never invade a patient's personal space - it can make the patient afraid and be dangerous for the staff.
     • Confidentiality - maintaining patient privacy.

Dialysis Technician Associations

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• Remember that knowledge is power, and power is confidence.
• It takes time and discipline to leam all you will need to know, but you will reap the rewards in many ways.
• Knowledge can be seen in the positive outcomes of patients, and felt as a result of your discipline and commitment

The dialysis nurses/technician organizations can help you leam more about dialysis.
• National Association of Nephrology Technicians/Technologists - the only group in the country just for dialysis technicians.
• Council ofNephrology Nurses and Technicians (CNNT)
• Certified Clinical Hemodialysis Technician (CCHT)
• American Nephrology Nurses Association (ANNA)
• Renal Nurses Association of the Philippines (RENAP)