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Intradialytic Hypoxemia in Chronic Hemodialysis Patients
1. LONG TERM PARTNERSHIP WITH LONG TERM CARE Amy Chan, Anita Lee, and Barbara Gray Mackenzie Health Hospital, Richmond Hill, Ontario, Canada The first in Ontario, Mackenzie Health Hospital established a partnership with Long-Term Care (LTC) to provide direct hemodialysis (HD) care for residents residing in a LTC home. First piloted in 2013, funding was provided for 20 beds designating 3 floors of the hospital’s South-wing. Resident’s age ranges 52-94 years old; 40% have 8 or more comorbidities, 70% have consented to full cardiac and respiratory resuscitation and 52% uses arterial-venous fistula/graft (AVF/G) as their primary vascular access. Recommendations will be presented to address the identified challenges in the groundworks of the LTC partnership. Challenges categorized as: Communication, Safety and Logistics. Each challenge is thoughtfully reviewed by the nephrology and LTC team and processes were developed to meet these challenges. Communication was improved with the development of communication tool between LTC and HD units. The tool communicates assessment findings that impacts dialysis delivery. HD admission package must be completed by Community Care Access Centre prior to LTC admission, which contains information that places residents appropriately. Safety was enhanced through education with LTC staff on the care needs of residents living with chronic kidney disease, reporting of abnormal assessment findings, management of HD vascular access and the use of enuresis device. Logistics were managed by understanding residents’ schedule behavior, medical history in which the HD unit accommodates. In summary, there is an anticipated need for dialysis care in the LTC setting. Health organizations considering partnership with LTC should review challenges and recommendations presented to facilitate a seamless partnership.
3. INTRADIALYTIC HYPOXEMIA IN CHRONIC HEMODIALYSIS
2. STREAMLINE® EXPRESS AT THE UNIVERSITY OF VIRGINIA (UVA) DEMONSTRATES STAFF TIME MANAGEMENT SAVINGS WHILE MAINTAINING PATIENT QUALITY OUTCOMES. Kim Deaver, Brenda Burns, Emaad Abdel-Rahman, Ken Renel. Streamline Express is a pre-attached Streamline® bloodline with a single-use dialyzer. A 2-month trial done by UVA Augusta Dialysis (16 station facility with 90 patients and 23 staff) from 12/2014-1/2015 evaluated Streamline Express for the following potential benefits: achieving patient quality outcomes with a pre-attached bloodline and dialyzer of one size, reduced number of touch points for possible contamination and reduced machine set up time and standardize priming process for staff. All patients transitioned to a 1.6m2 surface area dialyzer. 1,298 treatments were performed on Streamline Express with no changes to lab protocols or orders except medications. The data shows that patient quality outcomes after converting to Streamline Express are almost identical to those previously using Streamline with 5 types of dialyzers. Indicators: Fig 1 Avg. Lab: Fig 2 Fig 3: Time
4. INCREASING PNEUMOCOCCAL AND HEPATITIS B VACCINATION RATES FOR PATIENTS ON HEMODIALYSIS IN THE RURAL SETTING: Cheryl George, Lynda K. Ball, Nellie Hedrick, Linda Duval, HSAG: ESRD Network 13, Oklahoma City, OK, USA Analysis of vaccination rates within Network 13 indicate RI the target population was achieving benchmark vaccination rates [Hepatitis B = 74.9% / Pneumococcal Pneumonia = 70.7%]. Overall immunization rates were calculated at the facility level and ranked into deciles for both pneumococcal and Hepatitis B vaccinations to systematically target facilities with the lowest rates. A disparity analysis reflected rural dialysis facilities had lower immunization rates than urban facilities. Using March 2015 as baseline, 20 rural hemodialysis facilities (1157 patients) with low vaccination rates were selected to participate. The project goal was to achieve at least a ten percentage point increase in both Pneumococcal and Hepatitis B vaccination rates by October 2015. Several strategies were employed: WebEx orientation; education; root cause analysis for facility or patient-specific barriers; facility action plan; investigating reporting mechanisms; development of tools and resources; provision of a monthly comprehensive data collection tool for self-reporting; review of provider vaccination policies and procedures; and, facility staff/patient input. Educational puzzles were developed as a fun way to engage patients in the project. Patient refusal to vaccinate was a main issue. A patient survey was conducted to identify the root causes, and educational materials were then designed to address any misconceptions. Staff were asked to utilize these Network materials to re-educate patients. Results indicated a statistically significant (p<0.001) increase in both Hepatitis B and pneumococcal vaccinations, as well as a decrease in patient refusal of the pneumococcal vaccination (p<0.01). There was a 2.9% decrease in patient refusal for Hepatitis B vaccination, but this was not significant. This material was prepared by ESRD Network 13, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The ideas presented do not necessarily reflect CMS policies or positions.
The innovative technology demonstrated time savings. To determine whether Streamline Express could help reduce machine set-up time, set-up time performance was observed. Avg. machine set-up time with Streamline bloodlines and separate dialyzer was 13 m 44 s vs. 2 m 54 s with Streamline Express. Initial morning set-up labor was decreased by 50% requiring 1 staff to set-up 16 machines, vs. 2 staff previously. Streamline Express is a new technology standardizing patients to one dialyzer greatly improving the inventory, storage space complexity and reduced the loss of systems due to altering patient schedules or chair assignments. The elimination of 4 touch contamination points may improve infection control and saved time during set-up by 50%. Streamline Express allowed extra time to be applied to other needed areas such as charting, patient care, and interaction. These types of innovations can have a significant impact on patient quality outcomes, infection control, and the efficiency of the dialysis facility as a whole.
PATIENTS Sheila Deziel, Cheryl Vaughn, Fresenius Renal Technologies, Waltham, MA, USA Background: Kidney disease is associated with impaired respiratory function, including ‘cardio-respiratory-renal’ syndrome and central sleep apnea. While highly prevalent, hypoxemia during hemodialysis (HD) is rarely recognized as a clinical problem. Methods: We investigated several patient case vignettes regarding their SatO2 during hemodialysis in relationship to clinical signs. We discuss the potential pathophysiology linked to the symptoms and why observation of oxygen saturation (SatO2) during HD may be important. Results: The case vignettes include the following scenarios. Uremic destabilization of respiratory control and narrowing of upper airways due to fluid overload are alleged cause of sleep-associated intradialytic hypoxemia. We show a vignette of a sharp drop in SatO2 while patients sleep, followed by intradialytic hypotension. Other cases demonstrate that ultrafiltration may improve SatO2, most likely due to improved pulmonary diffusion. One case shows the relationship of refill and SatO2 by a concurrent sharp decline of both relative blood volume (RBV) and SatO2 in a patient who removes the nasal oxygen supply and the subsequent improvement as the nurse replaced it. Other vignettes show muscle cramping may coincide with drops in SatO2 and central venous oxygen saturation (ScvO2) despite minimal RBV change. The pathophysiologic basis of the relationship between cramping and hypoxemia is not clear, but studies show that CPAP therapy may improve cramping. Conclusion: Our clinical observations suggest that intradialytic hypoxemia can be associated with intradialytic morbid events and may warrant closer clinical attention.
Advances in Chronic Kidney Disease, Vol 23, No 2 (March), 2016: pp 127-129
127
3. INTRADIALYTIC HYPOXEMIA IN CHRONIC HEMODIALYSIS
2. STREAMLINE® EXPRESS AT THE UNIVERSITY OF VIRGINIA (UVA) DEMONSTRATES STAFF TIME MANAGEMENT SAVINGS WHILE MAINTAINING PATIENT QUALITY OUTCOMES. Kim Deaver, Brenda Burns, Emaad Abdel-Rahman, Ken Renel. Streamline Express is a pre-attached Streamline® bloodline with a single-use dialyzer. A 2-month trial done by UVA Augusta Dialysis (16 station facility with 90 patients and 23 staff) from 12/2014-1/2015 evaluated Streamline Express for the following potential benefits: achieving patient quality outcomes with a pre-attached bloodline and dialyzer of one size, reduced number of touch points for possible contamination and reduced machine set up time and standardize priming process for staff. All patients transitioned to a 1.6m2 surface area dialyzer. 1,298 treatments were performed on Streamline Express with no changes to lab protocols or orders except medications. The data shows that patient quality outcomes after converting to Streamline Express are almost identical to those previously using Streamline with 5 types of dialyzers. Indicators: Fig 1 Avg. Lab: Fig 2 Fig 3: Time
4. INCREASING PNEUMOCOCCAL AND HEPATITIS B VACCINATION RATES FOR PATIENTS ON HEMODIALYSIS IN THE RURAL SETTING: Cheryl George, Lynda K. Ball, Nellie Hedrick, Linda Duval, HSAG: ESRD Network 13, Oklahoma City, OK, USA Analysis of vaccination rates within Network 13 indicate RI the target population was achieving benchmark vaccination rates [Hepatitis B = 74.9% / Pneumococcal Pneumonia = 70.7%]. Overall immunization rates were calculated at the facility level and ranked into deciles for both pneumococcal and Hepatitis B vaccinations to systematically target facilities with the lowest rates. A disparity analysis reflected rural dialysis facilities had lower immunization rates than urban facilities. Using March 2015 as baseline, 20 rural hemodialysis facilities (1157 patients) with low vaccination rates were selected to participate. The project goal was to achieve at least a ten percentage point increase in both Pneumococcal and Hepatitis B vaccination rates by October 2015. Several strategies were employed: WebEx orientation; education; root cause analysis for facility or patient-specific barriers; facility action plan; investigating reporting mechanisms; development of tools and resources; provision of a monthly comprehensive data collection tool for self-reporting; review of provider vaccination policies and procedures; and, facility staff/patient input. Educational puzzles were developed as a fun way to engage patients in the project. Patient refusal to vaccinate was a main issue. A patient survey was conducted to identify the root causes, and educational materials were then designed to address any misconceptions. Staff were asked to utilize these Network materials to re-educate patients. Results indicated a statistically significant (p<0.001) increase in both Hepatitis B and pneumococcal vaccinations, as well as a decrease in patient refusal of the pneumococcal vaccination (p<0.01). There was a 2.9% decrease in patient refusal for Hepatitis B vaccination, but this was not significant. This material was prepared by ESRD Network 13, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The ideas presented do not necessarily reflect CMS policies or positions.
The innovative technology demonstrated time savings. To determine whether Streamline Express could help reduce machine set-up time, set-up time performance was observed. Avg. machine set-up time with Streamline bloodlines and separate dialyzer was 13 m 44 s vs. 2 m 54 s with Streamline Express. Initial morning set-up labor was decreased by 50% requiring 1 staff to set-up 16 machines, vs. 2 staff previously. Streamline Express is a new technology standardizing patients to one dialyzer greatly improving the inventory, storage space complexity and reduced the loss of systems due to altering patient schedules or chair assignments. The elimination of 4 touch contamination points may improve infection control and saved time during set-up by 50%. Streamline Express allowed extra time to be applied to other needed areas such as charting, patient care, and interaction. These types of innovations can have a significant impact on patient quality outcomes, infection control, and the efficiency of the dialysis facility as a whole.
PATIENTS Sheila Deziel, Cheryl Vaughn, Fresenius Renal Technologies, Waltham, MA, USA Background: Kidney disease is associated with impaired respiratory function, including ‘cardio-respiratory-renal’ syndrome and central sleep apnea. While highly prevalent, hypoxemia during hemodialysis (HD) is rarely recognized as a clinical problem. Methods: We investigated several patient case vignettes regarding their SatO2 during hemodialysis in relationship to clinical signs. We discuss the potential pathophysiology linked to the symptoms and why observation of oxygen saturation (SatO2) during HD may be important. Results: The case vignettes include the following scenarios. Uremic destabilization of respiratory control and narrowing of upper airways due to fluid overload are alleged cause of sleep-associated intradialytic hypoxemia. We show a vignette of a sharp drop in SatO2 while patients sleep, followed by intradialytic hypotension. Other cases demonstrate that ultrafiltration may improve SatO2, most likely due to improved pulmonary diffusion. One case shows the relationship of refill and SatO2 by a concurrent sharp decline of both relative blood volume (RBV) and SatO2 in a patient who removes the nasal oxygen supply and the subsequent improvement as the nurse replaced it. Other vignettes show muscle cramping may coincide with drops in SatO2 and central venous oxygen saturation (ScvO2) despite minimal RBV change. The pathophysiologic basis of the relationship between cramping and hypoxemia is not clear, but studies show that CPAP therapy may improve cramping. Conclusion: Our clinical observations suggest that intradialytic hypoxemia can be associated with intradialytic morbid events and may warrant closer clinical attention.
Advances in Chronic Kidney Disease, Vol 23, No 2 (March), 2016: pp 127-129
127