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BARBARA BRECKLER RN BSN QUALITY IMPROVEMENT DIRECTOR
NORTHWEST RENAL NETWORK
QIP - Adequacy Improvement
1
February 2013
Objectives
Provide an overview of:
Definition and measurement
Prescription Sampling Technique
2
Adequacy Definition and Measurement
Adequacy:
A term referring to the effectiveness of removing
“wastes” from a patient’s blood during treatment.
Studies have shown that more dialysis
is better for our patients.
Adequacy Definition and Measurement cont.
4
QIP Adequacy Measure for cy 2013 is
Kt/V > 1.2 for HD
2006 KDOQI Guidelines
recommend a spKt/V dose target of
1.4 with a minimum of 1.2
Adequacy Definition and Measurement cont.
5
Kt/V is a mathematical description equaling
the intake of protein and removal of urea during dialysis
to determine if patients are receiving enough dialysis:
K= dialyzer urea clearance
t= length of time of dialysis treatment
V= volume of urea distribution
Disclaimer
6
Always
follow your companies policy and procedures
along with Nephrologist’s orders.
Prescription
Many Prescription Factors Impact Kt/V
Prescribed Kt/V EDW
BFR Access Function
Needle Size Dialyzer
DFR Liters Processed
Time on Dialysis
Prescription
Prescribed Kt/V
It is an estimate of what the patients Kt/V should be, based on the dialysis prescription.
It is the physician’s aim for adequate dialysis
Prescription
Estimated Dry Weight
If the patient is an amputee- Is it documented accurately?
Is the patient consistently coming off dialysis above or below their EDW?
Amputation and EDW affect the “V”
Prescription
Heparin
Are you using a heparin bolus?
If so, are you waiting at least 5 minutes to initiate dialysis?
Prescription
Blood Flow Rate
Maximize prescribed BFR based on- access type and maturation:
Mature AVF/AVG: BFR 400-450 ml/min
CVC: manufacturer’s recommendations (350 ml/min)
Prescription
Access Function
Questions to answer:
CVC: Minimum BFR achieved? Is a thrombolytic needed?
AVF/G: Are you able to achieve prescribed BFR? Recirculation? Prolonged bleeding post treatment?
Prescription
Needle Size
Gauge Suggested BFR ml/min
Anticipated pre-pump pressure mm/Hg
17 200-250 -150
16 250-350 -200
15 350-450 -220
14 >450 -260
Prescription
Dialyzer
Is the dialyzer the correct size? *
Considerations include: surface area + clearance.
Loss of surface area due to leaks or clotting?
* Larger is not always better.
Prescription
Dialyzers
For patient’s who don’t respond to conventional interventions, consider:
in-series dialyzers
Prescription
Dialysate Flow Rate
Is the dialysis solution flow rate less than prescribed?
Dialysis solution flow rate affects the clearance of small solutes (urea).
Prescription
Liters Processed
BFR x Treatment time / 1000
If less than prescribed:
Evaluate Access Function Time on Dialysis
Prescription
Time on Dialysis
Time incorrectly calculated
Time not adjusted for interruptions in treatments
Premature disconnection
Sampling Technique
Dilution of BUN sample with Saline Drawing pre-dialysis BUN after initiation
of dialysis Drawing post dialysis BUN before the end of
dialysis treatment Drawing post-dialysis BUN more than 5 minutes
after the end of treatment
Sampling errors can cause inaccurate Kt/V
Northwest Renal Network
Mission Statement:
The mission of Northwest Renal Network is to promote optimal dialysis and transplant care for
kidney patients in Alaska, Idaho, Montana, Oregon and Washington.