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BARBARA BRECKLER RN BSN QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP - Adequacy Improvement 1 February 2013

QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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Page 1: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

BARBARA BRECKLER RN BSN QUALITY IMPROVEMENT DIRECTOR

NORTHWEST RENAL NETWORK

QIP - Adequacy Improvement

1

February 2013

Page 2: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Objectives

Provide an overview of:

  Definition and measurement

  Prescription   Sampling Technique

2

Page 3: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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.

Page 4: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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

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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

Page 6: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Disclaimer

6

Always

follow your companies policy and procedures

along with Nephrologist’s orders.

Page 7: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Prescription

Many Prescription Factors Impact Kt/V

Prescribed Kt/V EDW

BFR Access Function

Needle Size Dialyzer

DFR Liters Processed

Time on Dialysis

Page 8: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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

Page 9: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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”

Page 10: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Prescription

Heparin

Are you using a heparin bolus?

If so, are you waiting at least 5 minutes to initiate dialysis?

Page 11: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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)

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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?

Page 13: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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

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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.

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Prescription

Dialyzers

For patient’s who don’t respond to conventional interventions, consider:

in-series dialyzers

Page 16: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Prescription

Dialysate Flow Rate

Is the dialysis solution flow rate less than prescribed?

Dialysis solution flow rate affects the clearance of small solutes (urea).

Page 17: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Prescription

Liters Processed

BFR x Treatment time / 1000

If less than prescribed:

Evaluate Access Function Time on Dialysis

Page 18: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Prescription

Time on Dialysis

Time incorrectly calculated

Time not adjusted for interruptions in treatments

Premature disconnection

Page 19: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

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

Page 20: QIP - Adequacy Improvement · 2015-01-07 · QUALITY IMPROVEMENT DIRECTOR NORTHWEST RENAL NETWORK QIP ... “wastes” from a patient’s blood during treatment. Studies have shown

Questions? 20

Barbara Breckler [email protected]

206.923.0714

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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.