Expanding PD Horizons: The Expanding PD Horizons: The SOH Experience SOH Experience

Henni Dyck PCTM, BN, MHSHenni Dyck PCTM, BN, MHSLouise McBeth RH Clinician, RNLouise McBeth RH Clinician, RN

Seven Oaks HospitalSeven Oaks HospitalRenal Health ProgramRenal Health ProgramWinnipeg, ManitobaWinnipeg, Manitoba

Overall ObjectivesOverall Objectives Sharing our experiences with the following:Sharing our experiences with the following:

1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program

2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions

3.3. Expansion of services to allow forExpansion of services to allow for ER intake ER intake of PD patientsof PD patients

ObjectivesObjectives Sharing our experiences with the following:Sharing our experiences with the following:

1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our programand challenges to our program

2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions

3.3. Expansion of services to allow forExpansion of services to allow for ER intake ER intake of PD patientsof PD patients

BackgroundBackground

Access to timely insertion of a chronic PD Access to timely insertion of a chronic PD catheter is an important aspect of a catheter is an important aspect of a successful PD programsuccessful PD program

Wait times for this service is weeks to Wait times for this service is weeks to months from consult to placement due to months from consult to placement due to limited OR time and availability of a surgeonlimited OR time and availability of a surgeon

Efficient transitions to PD, even on an Efficient transitions to PD, even on an elective basis, is challenging elective basis, is challenging

Safe and effective PD catheter placements Safe and effective PD catheter placements can be performed by noncan be performed by non--surgical specialists surgical specialists including Radiologists and Nephrologistsincluding Radiologists and Nephrologists

Background (cont)

2525--30% of patients presenting with 30% of patients presenting with ESRD have not been seen by a ESRD have not been seen by a NephrologistNephrologist

Such patients would have historically Such patients would have historically started acutely on HD, and rarely started acutely on HD, and rarely converted to PDconverted to PD

Most patients are adverse to change Most patients are adverse to change once they become familiar with one once they become familiar with one modalitymodality

Plan

VGH in BC has an established Bedside VGH in BC has an established Bedside PD Catheter Implantation Program under PD Catheter Implantation Program under the direction of Dr. Suneet Singhthe direction of Dr. Suneet Singh

We sought their leadership in developing We sought their leadership in developing our own Bedside PD Catheter our own Bedside PD Catheter Implantation Program. Training Implantation Program. Training provided to provided to Dr. Sean ArmstrongDr. Sean Armstrong, , LouiseLouise and and CindyCindy by Vancouver teamby Vancouver team

Purpose

Initial purpose of our insertion program Initial purpose of our insertion program was not to replace surgical catheter was not to replace surgical catheter insertions, but rather to increase total insertions, but rather to increase total capacity in the system, and to offer capacity in the system, and to offer this option (on an emergent basis) for this option (on an emergent basis) for those patients experiencing abrupt those patients experiencing abrupt renal declinerenal decline

Purpose (cont)Purpose (cont)

As time went on the demand As time went on the demand increased. To address this, a increased. To address this, a weekly slate was developed for PD weekly slate was developed for PD catheter placement to accommodate catheter placement to accommodate nonnon--urgent, uncomplicated casesurgent, uncomplicated cases

Since initiation of the program, the Since initiation of the program, the PD population at our site has almost PD population at our site has almost doubleddoubled

The Process in 2009: BEDSIDE

Wait: 1-3 days

Wait: depending on training availability

The Process in 2009: SURGICAL

Wait:MONTHS!!

Wait: minimum 1

week, possibly more

depending on availability of

training

11

TechniqueTechnique Success After Initial Success After Initial Insertion (87/98)Insertion (87/98) March 2009March 2009-- Feb 2011Feb 2011

88%

12%

Courtesy Sean Armstrong, MD

Major complication:1) NSTEMI (which occurred approximately 1 hour 

after the procedure)2) Bladder perforation. 

Both of the patients remain on peritoneal dialysis 

Lessons learned from initial insertions:

Multiple scars below the umbilicus

No patients with significant obesity where anatomy is distorted

Foley pre-procedure to any suspected neurogenic bladder

Once our program was established, we were invited to teach the bedside implantation technique to nephrologists/nurses from Regina General Hospital

An epiphany! An epiphany! The Regina ExperienceThe Regina Experience

Teaching the Regina group was a positive Teaching the Regina group was a positive experience and allowed us to reexperience and allowed us to re-- examine our own policies and examine our own policies and procedures. This resulted in the procedures. This resulted in the following changes:following changes:

An aggressive bowel prep regimeAn aggressive bowel prep regime

A stringent criteria for patient A stringent criteria for patient selectionselection

An abdominal xAn abdominal x--ray preray pre--procedure to procedure to ensure adequate bowel evacuationensure adequate bowel evacuation

Exclusion of patients with previous Exclusion of patients with previous abdominal surgeriesabdominal surgeries

Bowel prep

Poor

Bowel prep

Adequate

Recipe for successRecipe for success

After each implantation, we After each implantation, we reviewed/discussed the procedure reviewed/discussed the procedure and implemented further and implemented further improvements to the procedure, improvements to the procedure, most notably the following changes:most notably the following changes:

Aggressive bowel prepAggressive bowel prep

PrePre--procedure xprocedure x--raysrays

3030--40mLs of Buffered Lidocaine40mLs of Buffered Lidocaine

Verres needle instead of temporary Verres needle instead of temporary cathetercatheter

Tunneling trocar instead of curved KellyTunneling trocar instead of curved Kelly

No exit site stab woundNo exit site stab wound

Tubing (straw) with suturesTubing (straw) with sutures

Patients filled with 2Patients filled with 2--2.5 litres fluid per 2.5 litres fluid per insertioninsertion

Summary of improvements:

Success rate since new bowel cleanse regime instituted September 2011 to present

38/38

100%

Program OutcomesProgram Outcomes

oo PD patient numbers have increased!PD patient numbers have increased!oo Virtually no waiting period to implant PD Virtually no waiting period to implant PD

catheters at the bedside catheters at the bedside oo Provision of Provision of ““full servicefull service”” care as patients care as patients

transition from RH to PD within a familiar transition from RH to PD within a familiar clinic environment clinic environment

oo Late referrals are now urgently assessed, Late referrals are now urgently assessed, and if found to be suitable, have a PD and if found to be suitable, have a PD catheter placed the following daycatheter placed the following day

oo Patients have improved modality options Patients have improved modality options when seen urgently when seen urgently

Program OutcomesProgram Outcomes

NonNon--functioning catheters can be functioning catheters can be removed/reremoved/re--inserted in a timely fashioninserted in a timely fashion

Uremic patients can be admitted to Uremic patients can be admitted to hospital and started on daily low volume hospital and started on daily low volume APDAPD

Surgeon has more OR time for complex Surgeon has more OR time for complex catheter placementscatheter placements

Improved continuity of patient care Improved continuity of patient care

Cost effective to the Manitoba Renal Cost effective to the Manitoba Renal ProgramProgram

Continued opportunities to Continued opportunities to maintain/improve standards of care based maintain/improve standards of care based on best practice guidelineson best practice guidelines

Patient OutcomesPatient Outcomes

Improved patient preparedness Improved patient preparedness through intense/thorough prethrough intense/thorough pre-- procedure education = successful procedure education = successful catheter function catheter function

Little to no pain post implantationLittle to no pain post implantation

Smaller incision = patients start PD Smaller incision = patients start PD sooner with fewer complications sooner with fewer complications (leaks)(leaks)

Patient OutcomesPatient Outcomes

Little/no issues with Little/no issues with ““dry tummy dry tummy discomfortdiscomfort”” prior to initiating fills prior to initiating fills during training as we are able to during training as we are able to accommodate earlier training accommodate earlier training schedulesschedules

Increased satisfaction with their Increased satisfaction with their care continuum (RH, PD catheter care continuum (RH, PD catheter insertion, and PD train)insertion, and PD train)

PD Population GrowthPD Population Growth

Challenges to programChallenges to program

Ever increasing referrals to the RH Ever increasing referrals to the RH clinic and tremendous growth in clinic and tremendous growth in numbers created staffing and space numbers created staffing and space issuesissues

Solution to this challenge

Admit patient with new catheters to Family Medicine

Start their therapy immediately

Start their training simultaneously

The Process in 2009: BEDSIDE

Wait: 1-3 days Wait:

depending on training availability

The Process in 2011-12: BEDSIDE

Wait:1-3

days

Wait:Treatments can begin immediately with hospital admissionTraining schedule irrelevant

ConclusionsConclusions

PD is a more cost effective kidney PD is a more cost effective kidney replacement therapy with similar replacement therapy with similar outcomes and quality of life outcomes and quality of life compared to other therapies (for compared to other therapies (for the first 2 years)the first 2 years)

Minimally invasive and safe Minimally invasive and safe techniques, in the hands of techniques, in the hands of experienced nephrologists, should experienced nephrologists, should be the mainstay of PD catheter be the mainstay of PD catheter placement programplacement program

Utilization of surgical technique Utilization of surgical technique should be reserved for more should be reserved for more complex casescomplex cases

Conclusions

Numerous strategies are necessary Numerous strategies are necessary from a program perspective to boost from a program perspective to boost PD ratesPD rates

Bedside PD catheter insertion by a Bedside PD catheter insertion by a trained interdisciplinary team seems trained interdisciplinary team seems to be a viable strategy in more to be a viable strategy in more efficiently transitioning patients on to efficiently transitioning patients on to PDPD

ObjectivesObjectives Sharing our experiences with following:Sharing our experiences with following:

1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program

2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions

3.3. Expansion of services to Expansion of services to educatingeducating ER ER nursesnurses on specific PD procedureson specific PD procedures

BackgroundBackground

Initially, all SOH PD patients requiring hospital admission were sent to SBH, our sister PD program

Significant impact to SBH as our PD patient population continued to grow

Desire to care for our own patients within our facility

A planned approach to expanding inpatient PD services was needed, particularly as Family Medicine staff at SOH had no experience with PD patients

Buy-in from stakeholders required

PlanPlan

1. Develop criteria for PD admission2. Finalize PD forms and PD standing

orders3. Educate FM nurses4. Place PD policy/procedures on medical

unit5. Communicate with FM physicians6. Communicate with Utilization Manager 7. Establish PD supplies on medical unit

including re-stocking process through MM

Criteria for admission

Single system involvement such as uncomplicated peritonitis requiring admission for pain control as well as observation for resolution of infection

Patients with community acquired pneumonia not requiring assisted/mechanical ventilation

Criteria for admission (cont)

Cellulitis, exit site or tunnel infections requiring IV antibiotics not able to be arranged in the community

Pancreatitis not requiring MICU admission or urgent surgical review

Admissions for rehabilitation/decreased mobility/stroke/placement/spousal respite

Education Rollout for FM nursesEducation Rollout for FM nurses

8 hour education day8 hour education day

30 nurses30 nurses

Theory, skills, return demos for twin bag Theory, skills, return demos for twin bag and cyclerand cycler

Resources included copies of procedures, Resources included copies of procedures, pocket guides, videopocket guides, video

Once admissions started:Once admissions started:

Return demo on the unitsReturn demo on the units

OnOn--going support from educators and PD going support from educators and PD nursesnurses

ChallengesChallenges

Delay between training of nurses and Delay between training of nurses and first admissions (3 months)first admissions (3 months)

Initially nurses were taught both twin Initially nurses were taught both twin bag and cycler thinking we would bag and cycler thinking we would implement both simultaneouslyimplement both simultaneously

It became evident early on that staff It became evident early on that staff did not have a clear understanding of did not have a clear understanding of the cyclerthe cycler

Concepts of dialysis were not easily Concepts of dialysis were not easily grasped due to a lack of exposuregrasped due to a lack of exposure

Medical unit model does not include a Medical unit model does not include a CRNCRN

No after hours resource availableNo after hours resource available

Lessons learnedLessons learned

Train and implement one therapy at Train and implement one therapy at a timea time

Implement new concepts once staff Implement new concepts once staff comfort increasescomfort increases

Work closely with the nephrologistsWork closely with the nephrologists

Be prepared to provide ongoing Be prepared to provide ongoing support to the unit for an extended support to the unit for an extended period of timeperiod of time

PD supplies need to be considered in PD supplies need to be considered in terms of space needed and volumesterms of space needed and volumes

Tools to guide unit nursesTools to guide unit nurses

Pocket guidePocket guide

Baxter postersBaxter posters

VideosVideos

Quick reference card for cyclerQuick reference card for cycler

Conclusion

Although challenging, it is important to establish availability of trained nurses on in-patient units to support PD modality

Continuity of patient care (better patient experience and accessibility to patient record information)

ObjectivesObjectives Sharing our experiences with following:Sharing our experiences with following:

1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program

2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions

3.3. Expansion of services to Expansion of services to educatingeducating ER ER nursesnurses on specific PD procedureson specific PD procedures

BackgroundBackground

SOH PD patients were directed to the SBH SOH PD patients were directed to the SBH emergency department after hours. emergency department after hours. Resources at SOH to treat PD specific Resources at SOH to treat PD specific issues were nonissues were non--existentexistent

SOH staff initially consisted of one CRN and SOH staff initially consisted of one CRN and 1.3 EFT PD training nurses1.3 EFT PD training nurses

On call nephrologists were not onOn call nephrologists were not on--sitesite

PD was an unfamiliar specialty to SOHPD was an unfamiliar specialty to SOH

As the As the SOH PD patient population SOH PD patient population increased, there was a greater impact on increased, there was a greater impact on SBHSBH’’s resourcess resources

OptionsOptions……

1.1. Implement an onImplement an on--call systemcall system2.2. Opening seven days per week and Opening seven days per week and

increasing nursing resourcesincreasing nursing resources3.3. Train core group of ER nurses Train core group of ER nurses 4.4. Train all ER nurses (this option was Train all ER nurses (this option was

chosen)chosen)

Required skill set (KISS Required skill set (KISS principle)principle)

Signs & symptoms of peritonitis Signs & symptoms of peritonitis

Sample collection of effluent for Sample collection of effluent for peritonitis diagnosisperitonitis diagnosis

CAPD bag exchangesCAPD bag exchangesNot required:Not required:PD dressingsPD dressingsPD flushesPD flushesCycler operationCycler operation

Teaching strategyTeaching strategy……

Consideration was given to the Consideration was given to the adaptive nature of an ER nurseadaptive nature of an ER nurse

Thus: doing a 30 minute blitz Thus: doing a 30 minute blitz training highlighting the specific training highlighting the specific taskstasks

Challenges/lessons learnedChallenges/lessons learned

Low volume resulting in insufficient Low volume resulting in insufficient experienceexperience

Unpredictability of patient visits Unpredictability of patient visits makes it difficult for renal educators makes it difficult for renal educators to reinforce learning or assess to reinforce learning or assess competencycompetency

Resources must be made available Resources must be made available (written materials, process (written materials, process algorithm)algorithm)

Well defined criteria for ER physicians Well defined criteria for ER physicians to follow (who is acceptable)to follow (who is acceptable)

Use a minimal amount of supplies i.e. Use a minimal amount of supplies i.e. only 2 litre 1.5% dianealonly 2 litre 1.5% dianeal

Newest initiative Newest initiative –– not well establishednot well established

Challenges/lessons learnedChallenges/lessons learned

ThankThank--You!You!

References

Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2001 to 2010

Figueiredo, A., Goh, B.L., Jenkins, S., Johnson, D.W., Mactier, R., Ramalakshmi, S., Shrestha, B., Dirk, S., & Wilkie, M. 2010. Clinical Practice Guidelines for Peritoneal Access. Peritoneal Dialysis International, 30 (4) pp. 424-429.

Zaman, F., 2008. Peritoneal Dialysis Catheter Placement by Nephrologist. Peritoneal Dialysis International, 28 pp. 138-141.

Expanding PD Horizons: The SOH Experience Overall Objectives�Sharing our experiences with the following:Objectives�Sharing our experiences with the following:BackgroundBackground (cont)PlanPurposePurpose (cont)The Process in 2009: BEDSIDEThe Process in 2009: SURGICALSlide Number 11Lessons learned from initial insertions:Slide Number 13An epiphany! �The Regina ExperienceBowel prepBowel prepRecipe for successSummary of improvements:Success rate since new bowel cleanse regime instituted�September 2011 to presentProgram OutcomesProgram OutcomesPatient OutcomesPatient OutcomesPD Population GrowthChallenges to programSolution to this challengeThe Process in 2009: BEDSIDEThe Process in 2011-12: BEDSIDEConclusionsConclusionsObjectives�Sharing our experiences with following:BackgroundPlanCriteria for admissionCriteria for admission (cont)Education Rollout for FM nursesChallengesLessons learnedTools to guide unit nursesConclusionObjectives�Sharing our experiences with following:BackgroundOptions…Required skill set (KISS principle)Teaching strategy…Challenges/lessons learnedChallenges/lessons learnedThank-You!References