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CANNT 2012 * Environments of Excellence! October 25-27 * Ottawa, Ontario.


Some of the key strategic goals of CANNT are to disseminate educational materials to CANNT members; profile scientific research; and to provide opportunities for nephrology colleagues to network.

CANNT's national conference, CANNT 2012, provides an excellent venue for accomplishing these goals of CANNT. However, only a portion of CANNT members are able to attend the national conference annually. Cognizant of this, CANNT is pleased to be printing the abstracts to be presented in both oral and poster format at this year's annual conference as a supplement to this issue of the CANNT Journal.

The following abstracts celebrate the diversity of nephrology topics being investigated and discussed across Canada. It is our hope that CANNT members interested in pursuing a profiled topic will contact our national office at 705-720-2819 or 1-877-720-2819 or to receive information regarding how to contact the author about the work.

We hope you will carefully review these abstracts!

Janet Baker & Alison Thomas, co-editors CANNT journal

CANNT 2012 promises to be an "excellent" conference where nephrology professionals ... nurses, technologists, administrators, researchers, pediatric nurses, pharmacists and more ... will be able to learn, share, network, discuss and socialize together.

Experience all that CANNT 2012 has to offer:

* Share in the five plenary addresses: be inspired towards peak performance, reaffirm your call to your profession, tackle bullying in the workplace, and incorporate wit into your everyday living!

* Choose from 54 concurrent sessions, five workshops and three satellite symposiums suited to all interests ... with topics ranging from nutrition, transplantation, pediatrics, modes of dialysis, infection control, technology, research and much, much more.

* Learn from 30+ poster presentations with contributing authors from across Canada!

* Engage with our corporate partners as they showcase their latest products and services. Come prepared with questions and issues--our exhibitors want to hear from you!

And finally, immerse yourself in this year's conference theme "Environments of Excellence"! Hosted in the state-of-the-art Ottawa Convention Centre, this conference will re-energize, motivate and engage you to achieve excellence!

Register today! CANNT 2012 information is available as follows:

1. Printed brochure available by contacting Innovative Conferences & Communications: Sharon Lapointe:, 519-652-0364 (phone)

2. Downloadable brochure online at

3. Program, abstracts, online registration and secure payment on-line at

We are excited to welcome Canadian nephrology professionals to Ottawa. Come and join us as we explore "ENVIRONMENTS OF EXCELLENCE".


Nursing Strategies to Support Self-Management in People with Chronic Kidney Disease

Sylvie Leung, RN, CNeph(C), PhD(c), Kathleen Hunter, RN, GNC(C), NCA, PhD, Belinda Parke, RN, GNC(C), PhD, Anne Sales, RN, PhD, Anita Molzahn, RN, PhD, FCAHS, and Sara Davison, MD, MSc, Edmonton, AB

Background: To successfully manage chronic kidney disease (CKD), patients need ongoing support by health professionals. Nurses are the key organizers of many self-management programs. To date, we have gaps in our knowledge of how nurses support patients in self-management of CKD.

Purpose of study: The purpose of the study is to identify common strategies that nurses use to support patient self-management in clinical practice.

Sample: Two groups participated in the interviews: nephrology nurses and patients undergoing peritoneal dialysis (PD) in the Northern Alberta Renal Program. Seven participants were recruited for each group. Patients' age ranged from 50 to 75 years, and experience with PD ranged from immediately after training to more than six years. Nurses' work experiences ranged from two to 30 years.

Method: The study design is qualitative using interpretive description (ID) as the method. This method is suitable for the study, as the intent is to transfer practical knowledge into actions. Data analysis is now in progress. Data analysis is being conducted in three stages: (1) analysis of the nurse participant data, (2) analysis of the patient participant data, (3) integration and synthesis of categories and themes from two groups.

Results and conclusion: Preliminary findings include experiences of self-management of CKD--from patients' and nurses' perspectives, common strategies to support patient self-management, and barriers to and facilitators of supporting self-management. These findings include recommendations for nephrology nursing practice.

Implication for nephrology care: Knowledge from this study will help nurses develop clinical management tools or evaluation models to improve nephrology patient care.

Changing Practice from the Frontlines: A Nephrology Nurse's Perspective

Virginia Sulit, RN, Patsy Cho, RN, MScN, Gillian Brunier, RN, MScN, CNeph(C), and Shirley Drayton, RN, BA, Cert. Mediator, Toronto, ON

Professional nursing has many challenges. At our university teaching hospital, the nurses on the medicinelnephrology ward care for patients requiring dialysis, as well as a fragile elderly patient population with complex medical conditions. Ensuring that all nurses on our ward are practising according to best practice guidelines is at times challenging. How can front-line nephrology nurses adapt to the demands of change in an increasingly complex environment?

Three years ago, our unit embarked on a journey to bring best practices to our unit. We were able to take advantage of provincial funds established to create alternative, less physically demanding roles for nurses 55 years of age or older. Since 2009, these practice change initiatives have included development of tools to teach best practice in back care, best practice in peritoneal dialysis (PD) clinical standards, best practice in PD exitsite care and best practice in transferring accountability for inpatients receiving hemodialysis.

This presentation will focus on our latest endeavour, which is navigating through the strategies used to develop a transfer of accountability communication record between the ward and the hemodialysis unit. Also, frontline nephrology nurses will gain some pragmatic insights on how to work with practice leaders to effect practice change using change strategies that involve interprofessional stakeholders to develop nursing protocols to support their practice. Frontline nephrology nurses can become drivers of change by participating in change initiatives. Accessing internal or external funding is most helpful in enabling frontline nephrology nurses to reach their potential.

Wound Care and the Nephrology Patient: An Overview of Wound Healing Principles Related Specifically to the Patient with Renal Failure

Lisa Gordey, RN, BScN, MCISc, Wound Healing, Edmonton, AB

Wound care has not typically been included as an integral part of the care of a nephrology patient. This is despite the fact that chronic kidney disease and end stage renal disease are emerging as independent risk factors for the development of foot-related complications (Ndip, Lavery, & Bouton, 2010). Nephrology and wound care literature are constantly changing, attempting to stay current in both areas is understandably overwhelming for the nephrology practitioner.

Utilizing current best practice guidelines, this presentation will provide basic knowledge and tools needed to assess and initiate treatment of wounds that commonly affect the nephrology population. Special considerations relating to the unique symptoms of renal failure and how they affect wound healing will be discussed, allowing nephrology practitioners to return to their home unit and immediately put this knowledge to use.

Home Sweet Home: A Take-Home Peritonitis Kit

Jennifer Leechik, BSN, Kathleen Collin, BSc(Pharm), Chanel Prestidge, MD, and Colin White, MD, Vancouver, BC

Purpose: We provide peritoneal dialysis (PD) to children spread over a large landmass in British Columbia and Yukon. Distance and lack of local facilities often lead to delay in initiation of peritonitis therapy. A kit was developed to enable immediate initiation of an empiric antibiotic protocol and standardize its delivery in the home and/or local facilities.

Approach: After reviewing our peritonitis episodes, organisms and sensitivities, we revised our peritonitis policies and procedures based on current best evidence. Our team chose Cefazolin, Tobramycin and Vancomycin for the kits. Kits have expiry dates, lot numbers and are individually assembled by a PD nurse and pharmacist. Each kit contains a 72-hour supply of antibiotics with provisions for sampling, reconstituting and administering the antibiotics, and replacing the transfer set. The kit includes a professionally designed booklet for parents or health care workers with step-by-step instructions for proper delivery of each antibiotic and replacement of the transfer set.

Discussion: Peritonitis is a major cause of PD failure. Promptly delivered and appropriately dosed antibiotics are paramount for effective treatment and salvage of membrane lifespan. Delay of antibiotic treatment, lack of facilities able to perform rapid sampling and antibiotic infusions often lead to poor outcomes. Late night episodes often lead to haphazard application of protocols, inefficient/insufficient dosing of antibiotics and/or situations where families forget how to use the antibiotics.

Conclusion: These kits allow best evidence-based delivery of empiric antibiotics in a timely manner to our distant patients. Measuring the cost and effectiveness of these kits is planned.

Meeting Ultrapure Standards for Water Quality

Mark Heathcote, Technologist, Ottawa, ON

The Ottawa Carleton Dialysis Clinic has undertaken the task to meet ISO 23500 standards for ultrapure water quality and dialysate. The reason for this is to perform online priming, as well as hemodiafiltration on our Fresenius 5008 hemodialysis machines.

Online priming is the priming of the extracorporeal circuit with dialysate instead of saline.

Hemodiafiltration is the injecting of dialysate directly into the extracorporeal circuit during dialysis either pre or post dialyzer.

The criteria in meeting these standards involve having clean RO water, a hemodialysis machine capable of online priming and hemodiafiltration, a good disinfection process, and a good sampling process.

We had to meet the challenges of finding a microbiology lab that would test low enough to meet ISO 23500 standards, finding a method and process to obtain samples from the Fresenius 5008 machine consisting of one sample of substitute and one sample of dialysate, as well as going through a validation phase of weekly testing for bacteria and endotoxins for a month. This required the testing of all our dialysis machines, as well as the reverse osmosis water treatment unit.

By meeting ultrapure standards for water quality, we ensure a safer treatment for the patient, the treatment option of hemodiafiltration, as well as online priming to minimize saline bag use. This will result in more effective and efficient methods of dialysis.

Developing Protocols for a r Home Peritoneal

Dialysis Program F Gillian Brunier, RN(EC), MScN, CNeph(C), and Shirley Drayton, RN, BA, Toronto, ON

Practice protocols are used by nurses to provide effective health care and to ensure there is consistency among health care providers' practice. Protocols provide a clear, logical structure for managing different clinical scenarios in a designated area of practice. Today, practice protocols are expected to be evidence based. For nephrology nurses, it is important that they understand how to develop practice protocols that are evidence based.

This presentation will focus on explaining the differences between practice guidelines and practice protocols. It will also provide an overview of how to establish a protocol and list some of the resources that can be used by nurses to write a protocol. Specific examples of protocols for managing patients who are to have a peritoneal dialysis (PD) catheter inserted will be discussed. Other examples of protocols, detailing how best to prevent PD infections in patients on home PD, will also be reviewed. Finally, there will be a discussion on how to evaluate the quality of different best practice guidelines and protocols.

The development of well-written protocols will provide nephrology nurses with more autonomy and help ensure that there is consensus among the different members of the nephrology health care team. They will also help optimize care for our home dialysis patients and potentially provide legal protection.

My KidneyCare Centre Kiosk: Description of an Electronic Self-Management Tool for Patients with Chronic Kidney Disease

Stephanie Ong, BScPhm, MSc, Eveline Porter, BScN, MN, Sarbjit Jassal, MB, MD, Alexander Logan, MD, and Judith Miller, MD, MSc, MHSc, Toronto, ON

Background: Few IT solutions for self-management of complex conditions such as chronic kidney disease (CKD) exist.

Objectives: To describe the development and functionalities of an electronic self-management tool for CKD patients and present preliminary benefits evaluation results. Methods: We used a multi-methods study design, entailing focus groups of patients and clinicians, a systematic literature review of IT solutions for chronic disease self-management, and a national survey of IT solutions used by Canadian nephrology programs.

Results: Themes extracted from the three phases formed the design principles for My KidneyCare Centre, a web-based self-management application that educates patients about CKD, allows them to monitor progress and set learning goals, and provides a tool for patient-provider collaboration. The touch-screen self-assessment kiosks had the following functionalities:

Patient view: self-assessment using the Edmonton symptom assessment scale, documentation of issues and concerns, identification of team members to see, and selection of learning topics.

Clinician view: patient self-assessment report summary, symptom score trends, and clinician recommendations.

Clinic summary report: patient printout generated at visit end reflecting self-identified learning needs and clinician recommendations.

Both patients and staff felt that the kiosk improved visit quality and strengthened patient-provider relationships. Although most kiosk users were aged 61 to 70 years, 75% found the kiosk not difficult to use.

Conclusions: My KidneyCare Centre is the first multifunctional self-assessment kiosk for a complex chronic disease. By expanding to personal computers, tablets, and/or smart phones to increase adoption, it is hoped that such solutions will empower and engage CKD patients in disease management.

Hemodialysis Vascular Access in Children after the Introduction of the Pediatric Priority for Renal Transplantation: A 14-Year Retrospective Cohort Study

Julie Paquet, RN, CNeph(C), Johanne Gagnon, RN, CNeph(C), Anne-Laure Lapeyraque, MD, Michel Lallier, MD, and Aicha Merouani, MD, Montreal, QC

Purpose of the study: 'Ihe policy to allocate a pediatric priority for deceased donor's kidneys for children under the age of 18, irrespective of HLA matching and waiting time, took effect on 08/02/2004 in Quebec. To assess its impact on the choice of vascular access (VA) for chronic hemodialysis (HD) patients, we retrospectively analyzed information on the choice of the VA, as well as the waiting time before renal transplantation (RT).

Results: Seventy-eight children aged 13.7 [+ or -] 4.7 years old treated on HD between 1997 and 2011 in the dialysis unit of CHU Ste. Justine were divided into two periods: period A: 01/01/1997 08/01/2004 and period B: 08/02/2004-12/31/2011.

The listing time before RT analyzed in 50 patients was 253 days with respective median values in period A (n = 24) and period B (n = 26) of 702 days (6-1910) and 63 days (2-692).

The choice of the VA was a permanent catheter for 25% in period A and 60% in period B, while arteriovenous fistulas (AVF) were performed for 75% in period A and 40% in period B.

Conclusions: In this retrospective study on the type of VA used in chronic HD after the introduction of the pediatric priority for RT in Quebec, we observed a shift in favour of catheters over AVF in patients waiting for their RT.

Implications for nephrology care: This represents challenges in the organization of care for these patients who had a decreased time on HD before their RT, with questions on what type of VA to choose when HD is required.

Shower and No-Dressing Technique for Tunneled Central Venous Hemodialysis Catheters: 2012--An Update

Andrea Pember, RN, and Suzanne Seiler, RN, London, ON

The shower and no-dressing technique for tunneled CVC was initiated at the London Health Sciences Centre (LHSC) in 2008 as a pilot project, developed by the Vascular Access Interest Group, and led by NP (JulieAnn Lawrence Murphy). The procedure has now been rolled out to include all the dialysis units at LHSC, which includes two in-centre units, 10 satellite units and a home hemodialysis unit.

We have been able to positively demonstrate, through statistical analysis of infection control, the reduced numbers of blood stream infections (BSI) with individuals who have adopted this procedure, compared to the hemodialysis patients with a conventional permcath dressing. As well, we know with interactions with our patients that we are providing them with a safe way to shower, as we know many of our patients shower anyway.

We have promoted the use of "champions" in each of the dialysis units who are responsible for teaching the procedure to our patients. We use our inclusion and exclusion criteria to enrol patients, and require a written order by an MD/ designate.

We now have almost four years of data in regards to infection and numbers of patients, which we can share. We currently use a database to keep track of all patients enrolled and tracking infections.

Recently (fall 2011), Accreditation Canada recognized LHSC for leading practice with regards to the procedure of shower and no-dressing technique for tunneled central venous hemodialysis catheters.

The Trials and Tribulations of Switching to Single Needle for Safety

Dana Vae Ross, RN, CNeph(C), and Sharon Calverley, RN, CNeph(C), Ottawa, ON

Purpose: To share clinical experiences, insights and lessons learned with single needle (SN) nocturnal home hemodialysis.

Description: Patient safety is critical for home therapies. In 2008, the Home Dialysis Unit (HDU) implemented new hemodialysis machines capable of SN dialysis. Our goal was to reduce the risk of ex-sanguination in the event of a venous bloodline disconnect or a needle falling out. Initially, we had limited knowledge and experience in the practical application of teaching and supporting SN patients and scant resources were available. Issues encountered included learning a new machine, the concept and principles of SN, patient reluctance relating to change, access monitoring, alarm troubleshooting and many others. We will discuss the solutions that were developed to deal with these.

Evaluation: Safety motivated our decision to use SN. However, there were trade-offs. Clinically, SN patients did not always experience the benefits of a liberal diet, optimal clearance results, blood pressure control and improved sense of well-being that nocturnal double-needle patients report. We discovered SN has its place, but is not the answer for everyone.

Implications: Our knowledge, expertise and practice have evolved and valuable lessons have been learned following implementation of SN. By sharing our experience we hope to help other units contemplating the transition to single-needle nocturnal hemodialysis.

Green Infection Control: The New/Old Way to Kill Bugs!

Rejean Quesnelle, Toronto, ON

Green Infection Control: The New/Old Way to Kill Bugs! is the fourth in the ongoing Green Dialysis presentation series. This time, the focus is on infection control practices within our dialysis units. We hear a great deal about "superbugs", antibiotic resistant organisms that are now plaguing our hospitals. To ensure that all of our hemodialysis-related equipment (machines, chairs, water systems, staff, etc.) are safe for use, we require some means of disinfection--chemical, heat, or otherwise. This protocol is done after the patient's use, for the reduction of cross-contamination and the proliferation of bacterial organisms. What we have now come to realize is that certain forms of disinfection, namely the use of certain chemicals, can, in fact, have adverse reactions and lead to the negative impact on one's health, the health of other staff and patients, the increase in resistant organisms and the reduced health of the planet. There are new and innovative ways that we can incorporate within our dialysis environment to ensure that all of the above concerns become a thing of the past.

Topics covered during the presentation include: infection control practice basics, traditional disinfection protocols, disinfecting chemical agents of yesterday and today, the concerns and dangers, the new tools and the future of infection control.

Green Dialysis hopes to prove that eco-minded and sustainable practices can not only be simple to implement, but also a healthy trend that will soon become the norm for you, your patients and Mother Earth.

Evaluation of a New Model of Care to Support Home Peritoneal Dialysis Patients: The Nephrology Integrated Care Demonstration Project

Mary Ann Murray, RN, PhD, CONC(C), GNC(C), CHPC(C), Connie Twolan, RN, BScN, MHS, CNeph(C), Glenda Owens, RN, BCommerce, MScN, Chris Ferguson, RN, BScN, MHS, Monique Benard, RN, CNeph C), JaniceVerch-Whittington, RN, BScN, Karen Lapierre, RN, GNN(C), Marlene Steppan, RN, BScN, and Wendy Gifford, RN, PhD, Ottawa, ON

Purpose of project: To evaluate patient and service delivery outcomes following implementation of a new regional model of peritoneal dialysis care.

Description: A gap analysis, undertaken by an intersectoral, interprofessional regional dialysis working group, revealed the need to better support home dialysis patients. Subsequently, through the reorganization of work processes a new model of community-based care delivery was created, guided by an articulated standard of care (guideline with associated tools and documentation templates). In this new model, patients receive care from specially trained community service providers who have access to tailored consultation and support from expert peritoneal dialysis nurse case managers. Through a partnership arrangement, a Community Care Access Centre nephrology case manager was dedicated to the regional program.

Evaluation/outcomes: Patient outcomes (retention on modality, technique failure rates, infection, satisfaction); provider outcomes (knowledge, perceived confidencelcompetence, satisfaction); and organizational outcomes (financial and human resource intensity) are being assessed six months post-implementation through chart audits, interviews and review of organizational data. Preliminary results, standards of care and accompanying procedures and documentation underpinning the project will be presented.

Implications for nephrology practice/education: Results will inform future reorganization of work including issues of training and assessment of competency for the individual and care teams related to best practices for peritoneal dialysis. Results will help to identify strategies to build capacity among providers, better understand how the environment and context of care impacts health human resources, and identify infrastructure mechanisms to support effective care delivery processes for community-based renal care.

How to Improve Patient and Clinical Outcomes Using Lean Management in Nephrology Units

Chantal Saumure, BSN, MBA, Moncton, NB

Lean Management (LM) is a modern method currently adopted in many health care organizations to improve clinical processes and patient outcomes. LM also has the merit of offering results that will drive customer-focused, high-quality, and cost-effective care, including a better quality of life environment in the workplace.

As chronic kidney disease (CKD) continues to increase in Canada, as does the demand of optimal nephrology care, where rationalized resources are always at stake, programs should seriously consider LM as a key component for success. An effective LM process has to be incorporated in the organizational structure for a renewed, efficient and optimal care delivery model. However, literature is scarce on the implementation of LM in nephrology units.

This presentation will highlight, based on literature and a practical case study, the major challenges and drivers of LM implementation in an outpatient nephrology clinic at the Dr. Georges-L.-Dumont University Hospital Centre in Moncton, NB. Our findings are categorized as follows: 1--structural factors, 2--professional factors, 3--patient factors and 4--technology factors. We will present an adapted evidence-based framework for the implementation and monitoring of LM process in a nephrology unit.

Troubleshooting Skills for the New Renal Technologist

Clarence Graansma, Charge Renal Technologist, Kitchener, ON

Being able to reliably troubleshoot problems with equipment is one of the most important skills a Renal Technologist needs to acquire and improve in his or her career. Most Renal Technologists have formal education in biomedical and renal technology and may receive additional formal training to service and maintain specific equipment but, often, general troubleshooting skills are learned informally over time on the job. At Grand River Hospital we recently started two new technologists and needed to improve their troubleshooting skills in a short time so that they could work effectively on equipment with minimal supervision. We came up with a program that summarized the troubleshooting process into five steps: investigate, diagnose, repair, validate and document. This presentation will cover the various steps and methods of effective troubleshooting and explain our approach.

The Introduction of Sustained Low-Efficiency Dialysis (SLED) in The Intensive Care Unit (ICU): A Collaborative Approach Between the Hemodialysis Unit and the ICU--A Pilot Project

Sharon Slivar, RN, MEd, Roselyn Castaneda, RN, MHS, CNeph(C), Deborah Dalton-Kischel, RN, CNCC(C), and Gail Sprott, RN, BScN, CNeph(C), Ottawa, ON

Acute Renal Failure (ARF) is a common complication in the ICU (Kumar et al., 2004). Over the past 25 years there have been significant technological advances in the delivery of Renal Replacement Therapy (RRT). Some modalities of RRT include peritoneal dialysis (PD), intermittent hemodialysis (IHD), continuous renal replacement therapies (CRRT) and, more recently, the use of Sustained Low-Efficiency Dialysis (SLED), a form of hybrid therapy that uses slow blood and dialysate flow rates over an 8-to 12-hour period on a daily basis (Marshall et al., 2004; Kumar et al., 2004). Before implementing any programs using complex technology such as SLED, policies, procedures and protocols should be developed to address issues such as role demarcation, troubleshooting of equipment, required supplies and equipment, to name a few. This presentation will focus on the elements to be considered when planning and implementing a SLED program. A pilot SLED program was initiated in one of our ICUs. The authors will discuss their experience in the implementation of this project including the following: Why SLED?; the difference between CRRT and SLED; nursing advantages; the planning phase (creation of a multidisciplinary committee); the training of staff; roles and responsibilities of the team members; results from the evaluations of the pilot project; and the challenges and successes encountered. Although there is a paucity of nursing literature on SLED, we hope by sharing our collaborative experience, nursing knowledge can be enhanced.

Opportunities for Enhancing Diabetes Care for Peritoneal Dialysis Clients: Utilizing a Chronic Disease Prevention and Management Approach to Improve Health Care Outcomes

Christina Vaillancourt, MHSc, RD, CDE, Emily Harrison, RN, BHScN, CNeph(C), and Heather Reid, BScPT, MHSc, Oshawa, ON

The Ontario Renal Network reports that 50% of incident patients have diabetes. In Ontario, there are programs that focus on either chronic kidney disease (CKD) or diabetes. This results in uncoordinated care, duplication and confusion for clients. The Chronic Disease Prevention and Management (CDPM) model suggests that the health care system needs to be redesigned to facilitate smooth transitions, patient empowerment and coordinated flow of information to support self-management and prepared practice teams. Lakeridge Health is committed to the adoption of CDPM. In 2010-2012, the program facilitated the completion of a web-based survey collecting data from registered dietitians (RD) (N=18) in Ontario with practices in adult peritoneal dialysis programs (PDP) to examine the integration of CDPM into PDP. Data collection included program-specific data regarding program models, facilitators and barriers to the provision of dialysis-specific diabetes care. Results identified three major themes: clientfocused care; RDs as unrecognized CDPM champions and the missing CDPM puzzle pieces of collaboration and integration of care. The conclusions suggest that many PD teams have embraced CDPM. However, some barriers still exist that affect the full adoption of CDPM. Building upon this study and in the continued focus to utilize the principles of CDPM, LH is progressing with a more purposeful program re-organization. Specifically, the regional nephrology and diabetes programs are integrating, which includes: consolidation under one directorship and management portfolio, a CKD and diabetes clinic with endocrinology presence, cross-appointed staff, and the creation of common education materials. The integration of nephrology and diabetes programs addresses many of the identified barriers in the study, resulting in a patient-centred environment of excellence, which eases disease burden by providing clear disease management for the individual living with these complex chronic illnesses.

Vascular Access: It's Not in VAIN

Patty Quinan, RN, MN, CNeph(C), Toronto, ON

It is universally accepted among nephrology nurses and practitioners that arteriovenous (AV) fistulae are the best vascular access for chronic hemodialysis patients. AV fistulas are associated with decreased mortality and morbidity, fewer hospitalizations and interventions, and improved long-term survival when compared to AV grafts and central venous catheters (CVC).

Nurses play a vital role in improving patients' outcomes. Good clinical assessment of vascular access, close monitoring of treatment parameters related to access and prompt reporting of access problems are all factors necessary for achieving and maintaining a functional vascular access.

The purpose of this session is to provide nephrology nurses (from novice to expert) with a theoretical and practical review of vascular access. This session includes information on venous and arterial mapping, AV access creation, assessment and troubleshooting strategies for successful cannulation of new and developed AV accesses, CVCs and strategies to improve catheter patency, prevention and standardized reporting of catheterrelated blood stream infections (CR-BSI), monitoring machine and access parameters, and common surgical and radiological interventions. Case studies including radiological images will be presented of patients with catheter-related central occlusion, insertion of tunnelled CVC, stenosis treated with angioplasty, vascular access thrombosis, stent placement, and coiling of collateral/accessory veins. Opportunities for discussion will be encouraged.

The implication for nursing practice is to increase nurses' knowledge and understanding about vascular access in order to optimize patient outcomes, reduce vascular access-related complications, and help prolong vascular access survival.

PARADISE Almost Found: Realizing Peritonitis Analysis of Rates Advancing Dialysis Information and Staff Education

Brenda Cyr-Mockler, RN, CNeph(C), Susan McMurray, RN, BN, CNeph(C), and Sharon Calverley, RN, CNeph(C), Ottawa, ON

The Ottawa Hospital peritoneal dialysis (PD) program is an active program caring for approximately 140 patients. The program strives for optimal patient outcomes and, in doing so, regularly monitors infection rates. Prior to 2009, peritonitis rates were 1:28.

In the spirit of excellence, the PD team wanted to improve the peritonitis 2009 rate of 1:32 patient months. Thus, the PARADISE project was launched and with subsequent positive patient outcomes. Peritonitis rates steadily improved with results in 2010 of 1:37 patient months.

To sustain the gains and further optimize patient outcomes we continued to implement targeted interventions. The practice enhancements included: a home visit protocol; standardized documentation; targeted patient and nurse education; and an interprofessional team approach to care planning related to peritonitis problem solving.

All of these practice enhancements contributed to an improved peritonitis rate of 1:41 patient months in 2011. Lessons learned, resources developed to support these initiatives and strategies to address barriers will be shared during this presentation.

Creating Environments of Excellence requires attention to the ongoing monitoring and interpretation of data to advance best practices and optimize patient outcomes.

The Ottawa Hospital peritoneal dialysis program's journey to paradise continues.

New Hope for a Transplant

Mary Rada, BSc, RN, CNeph(C), and Diane Dumont, BScN, RN, CNeph(C), Ottawa, ON

It is well known that there is a growing number of people with end stage renal disease (ESRD) each year. Though renal transplantation is the preferred treatment for potential candidates, there continues to be an increasing disparity between the supply and demand for organs. Living donation not only helps meet that need, but also offers potential recipients the best possible transplant outcome. Unfortunately, not all living donors are matches for their intended recipients. More than 50% of ineligible donors are due to incompatible blood type or tissue type. In the past, an incompatible living donor meant the only hope for a transplant was a long wait on the deceased donor waitlist. The purpose of this presentation is to increase awareness about the transplant options for people with ESRD. One of the options we will focus on is the Living Donor Paired Exchange (LDPE) registry, which is run by Canadian Blood Services. This nation-wide registry matches incompatible donor/recipient pairs with other incompatible pairs creating a direct exchange or a chain of several transplants. This presentation will describe The Ottawa Hospital's experience with LDPE, how it works, the challenges and the successes. There have been well over 100 transplants done across Canada through the LDPE registry since its launch in 2009. The Ottawa Hospital has participated in many chains resulting in an increase in living donor transplants within our program. This program has and will continue to greatly impact people with ESRD, as it offers new hope for a living donor renal transplant.

Moving Beyond the "Perpetual Novice": Understanding the Experiences of Novice Hemodialysis Nurses and Cannulation of the Arteriovenous Fistula

Barbara Wilson, RN(EC), MScN, CNeph(C), Lori Harwood, RN(EC), PhD(c), CNeph(C), and Abe Oudshoorn, RN, PhD, London, ON

Cannulation of the arteriovenous fistula (AVF) is an essential skill, as part of the hemodialysis (HD) treatment. With declining rates of AVFs, opportunities to become expert in this skill have become limited. A previous qualitative study investigating the culture of vascular access cannulation identified a number of factors that hinder HD nurses from becoming expert cannulators. The term "perpetual novice" was coined to acknowledge the failure of some HD nurses to transition from novice to expert despite working in HD for a number of years. This study provides further exploration of the concept of "perpetual novice" in an effort to describe the attitudes and culture surrounding cannulation of the AVF from the perspective of the novice cannulator. A qualitative research design was used based on an ethnographic methodology. Nine hemodialysis nurses were interviewed using a semistructured interview guide. Results revealed the interplay between personal and environmental/contextual factors that make it difficult for the HD nurse to move beyond the novice cannulator. On a personal level, the HD nurses' approach to learning, previous experience, emotional reaction to stress, as well as interpersonal relationships with colleagues play significant roles. Environmental/contextual factors that hinder cannulation skill development include limited learning opportunities, attitudes and demands from patients, unit flow and time pressures, as well as continuity issues inherent in the current model of nursing care. Results of this study will be helpful in directing future educational, operational, and supportive interventions for novice HD nurses around cannulation competence.

A Nutritional Supplement Program for Malnourished Hemodialysis Patients

Jill Bondy, RD, Shelly Kett, RD, Donna Mallet, RD, Cindy Cockram, RN, CNeph(C), Colleen Cuddy, RN, BScN, MHS, Janet Graham, MHScN, Swapnil Hiremath, MD, MPH, Sara Kilcollins, RN, Cindy Leroux, RN, BScN, CNeph(C), Danielle Reklitis, RN, BScN, CNeph(C), and Marcel Ruzicka, MD, PhD, FRCPC, Ottawa, ON

Introduction: Malnourished hemodialysis (HD) patients have an increased risk of overall morbidity and mortality. We assessed whether provision and integration of nutritional supplements with dialysis treatments improved nutritional status of these patients.

Methods: This prospective observational study included HD patients with low protein catabolic rates (PCR < 0.9g/kg) and hypoalbuminemia (albumin < 35 g/L). A nutritional supplement drink was given at each HD session, and consumption of the beverage occurred on the HD unit during treatment. Patients reached the end point and were discontinued from the program once PCR was > 0.9g/kg for three consecutive months.

Results: Over the period of 24 months, 20 patients met the inclusion criteria. For the 17 patients who participated in the nutrition supplement program, the baseline PCR was 0.79g/kg +/-0.03, and baseline albumin was 28 g/L+/-2. Nine patients met the end point and completed the program after an average of 7.4 months. Five patients died or transferred, and three patients remained on the program. For those who completed the program, PCR was 1.1 g/kg+/-0.1, and albumin was 32g/ L+/-2. Data presented are means +/-standard deviation.

Conclusions: The nutritional supplement program was successful in achieving endpoints in more than 50% of patients. Whether the improvement in nutrition status decreases Creactive protein and improves overall morbidity and mortality remains to be seen.

Extending Our Reach: Introducing Mobile Electronic Devices in a Regional Home Dialysis Program

Susan Leslie, RN, CNeph(C), Monique Sunstrum, RN, CNeph(C), Rene Corriveau, RN, MScN, Pamela Laprise, RN, BScN, CNeph(C), and Mary Ann Murray, RN, PhD, CON(C), GNC(C), CHPCN(C), Ottawa, ON

Purpose of project: To assess the feasibility of mobile electronic devices to aid communication and care in home dialysis. The overall goal is to determine how these devices impact care delivery processes and patient outcomes.

Description: There is emerging recognition that mobile electronic devices can optimize care and facilitate communication processes. Accordingly, mobile electronic devices were implemented into a Home Dialysis nurse case management model of care. RN case managers, the unit care facilitator and Advanced Practice Nurse were provided with portable electronic devices and given user education. The etechnology was implemented to foster timely patient assessment, monitoring and education; enhance interprofessional communication; and to enable access to documentation systems during home and off unit clinic visits. Devices were equipped with access to resources, procedures, decision support tools and best practice guidelines.

Evaluation/outcomes: Device and software functionality in a home dialysis setting; perceived utility/impact on care processes, patient outcomes; satisfaction with user interface and team communication in improving care and access to services are being evaluated. Preliminary results will be presented.

Implications for nephrology practice/education: The successful implementation of information technology systems depends on staff support and engagement. As part of enhancing home therapies, renal programs will increasingly depend on nephrology nurses to deliver informatics-enabled transformation. Failure to embrace the digital opportunities jeopardizes improvements in quality, productivity and efficiency of patient care and service delivery. Leveraging opportunities to test and evaluate e-technologies at the direct point of care can help harness the power of informatics to enhance home therapy best practices and build environments of excellence.

Development of Cannulation Skills with Bedside Ultrasound-Guided Cannulation Using Phantom Models

Rosa Marticorena, RN, and Sandra Donnelly, MD, Toronto, ON

Once a fistula or a graft for hemodialysis is deemed ready for cannulation, its functional longevity is determined by cannulation practice.

Cannulation complications caused by inaccurate needle placement can result in significant extravasations and hematoma formation that may delay a dialysis treatment or render the access inaccessible for treatment until healing occurs.

Cannulation is a skill obtained during hemodialysis training and is refined thereafter with continuous daily practice.

Hemodialysis nurses with minimal exposure to cannulation practice face a big challenge when they look after patients who require cannulation. The use of imaging technology at the bedside may represent the solution to this problem.

Purpose of study: To promote excellent cannulation practice with the application of real time ultrasound guided cannulation by nurses that have minimal exposure to cannulation practice.

Methods: An educational bedside ultrasound module, which included theoretical and hands-on practice components using phantom models, was delivered. Application of realtime ultrasound guided cannulation with the help of a mentor was evaluated. Complication rates pre and post intervention will be collected and analyzed.

Results: The results of this intervention, measured by a lesser rate of cannulation misadventures and, ultimately, by a lesser rate of patients decreasing or missing dialysis treatment over time will be presented.

Implications for nephrology practice: Increased opportunity for development of cannulation skills and prevention of cannulation complications that impact quality of dialysis delivery in a setting with minimal exposure to cannulation practice.

Back to Basics: Optimal Blood Pressure Measurement and Implications for Patient Outcomes and Nephrology Practice

Francine Poirier, RN, CNeph(C), Janet Mooney, RN, CNeph(C), Lise Gaudet, RN, and Pamela Laprise, RN, BScN, CNeph(C), Ottawa, ON

Purpose: To strengthen nephrology nurses' knowledge and practice related to effective blood pressure (BP) measurement.

Description: Accurate measurement of BP is fundamental to nephrology patient care and BP measures often drive treatment planning. This has important implications for patients' quality of life. While BP measurement is considered a basic nursing skill, studies and clinical experience indicate that optimal technique is often not followed; equipment may be incorrectly calibrated; and/or BP cuffs may not be correctly fitted to the patient arm size. As well, as patients are often engaged in self-care, it is imperative that patients receive focused teaching in correct BP measurement.

Outcome/evaluation: Practical strategies, resources and tips, as well as a synthesis of the evidence supporting best practices in BP measurement will be profiled. Clinical examples of how to take BPs in the right way, at the right time, with the right equipment and with the right patient education will be offered. Patient teaching strategies and resources to support patients will be described. Techniques for equipment calibration will be demonstrated.

Implications: Excellence in nephrology nursing depends on attention to core nursing skills. Over time, nurses may experience desensitization to the importance of good BP technique with resultant skill decay. Raising awareness and reaffirming best practice in BP technique can only result in better patient outcomes and nursing practice.


The Change Journey: Inspiring Excellence in In-Centre Hemodialysis (ICHD) through the Application of Process Improvement and Lean Methodology Principles

Heather Reid, BScPT, MHSc, Carl Reid, LEAN Six Sigma Black Belt, and Shaunette Williams, RN, Oshawa, ON

In 2010, the Regional Nephrology Program at Lakeridge Health (LH) began a more "formal" change initiative and process improvement journey to assist in driving excellence in patient outcomes, staff satisfaction and meeting the goals of the Ontario Renal Network (ORN).

The new role of "Renal Quality Leader (RQL)" was implemented to facilitate this journey and to improve the work life of staff by increasing staff satisfaction, to support improved patient outcomes. The RQL and manager struck the multidisciplinary ICHD team: Communication-Workload-Clutter (CWC) working group. The CWC brought extensive knowledge and experience and applied LEAN methodologies to develop several improvement opportunities. A process was implemented to capture the "voice of the staff' and the "voice of the patient." In a Value Stream Mapping session, the group utilized Gemba walks, spaghetti mapping and heat mapping as mechanisms to identify known wastes, barriers and issues.

The two largest forms of waste identified were "waiting" due to inefficiencies throughout the process and "defects" as a result of tools that lack the intended effectiveness. They developed and prioritized an improvement plan consisting of greater than 12 initiatives, some of which were implemented immediately. The solutions were aimed at standardizing work to tighten connections; increasing communication and transparency for both staff and patients, and eliminating clutter to improve productivity and reduce workload.

Preliminary outcomes achieved included the completion of a systematic method to offload supplies and reduce unnecessary time to locate equipment while simultaneously increasing valuable space in the equipment/supply rooms and hallways.

"An Old Friend Revisited": Review of Peritonitis Prevention

Initiative Irene Ryll, RN, Carol Ozubko-Malcolm, RN, CNeph(C), Sylvanie Williams, RN, CNeph(C), and Donna Ma/loch, RN, BScN, Edmonton, AB

It has been five years since the home peritoneal dialysis unit at the Northern Alberta Renal Program (NARP) at the University Hospital in Edmonton, Alberta, focused on improving peritonitis rates, as a continuous quality initiative (CQI). Peritonitis continues to be the leading cause of technique failure and catheter loss and contributes to morbidity and hospitalizations (Piraino, JASIV, 1998). In 2007, 60% of peritoneal dialysis (PD) attrition in our program was due to transfer to hemodialysis of which 39.3% was due to infectious reasons.

In the first quarter of 2007, our program's peritonitis rate was 1:19.3 per patient months. The PD team sought to identify areas to improve this. Consequently, we developed the CQI project to reduce peritonitis rates to meet and exceed the international standards. Upon review, Staphylococcus aureus and coagulase-negative Staphylococcus were the most common organisms accounting for 46.1 % of all peritonitis episodes. As these organisms are associated with connectology, we initiated a patient survey to identify causes of contamination. We learned that the majority of patients were not masking or performing adequate hand washing prior to procedures.

Along with revising existing protocols, we also focused on the importance of masking and hand washing for all PD patients. Peritonitis rates for 2007 improved from 1:23.4 to 1:27.2 in 2008, 1:26.9 in 2009, 1:23.2 in 2010 and 1:27.9 in 2011. This poster will highlight our program's progress since the CQI project was initiated in 2007 and discuss our current status.

Peritoneal Dialysis Champions in the Emergency Department to Reduce Calls Back and Create Capacity

Lisa Kaye-Lillebuen, RN BScN, CNeph(C), Donna Hackman, RN, CNeph(C), Margaret Dymond, RN, BSN, ENC(C), and Frances Reintjes, RN, BScN, BScSpec, Edmonton, AB

At the home peritoneal dialysis unit of the Northern Alberta Renal Program (NARP) in Edmonton, Alberta, we found that on-call nurses were spending a significant amount of time while on call providing support to the emergency department (ED) staff. Nurses were being called back after regular hours to do procedures such as twin bag exchanges, transfer set changes, and assisting with peritonitis protocols. Although the nurses in the ED receive an orientation to basic peritoneal dialysis (PD) procedures, PD patients represent only a small proportion of ED patients, so most do not feel comfortable performing PD.

On-call practices, as well as nurse-to-patient ratios for PD vary between programs across Canada. In our unit, we have 8.4 nurses for 170 patients and our on-call hours are Monday to Friday 1530-2200 and 0730-2200 on weekends. NARP is encouraging home-based therapies and with program growth and limited resources, we wanted to find a way to build capacity in the ED to improve patient care and reduce calls back for basic PD procedures that emergency nurses are capable of performing.

The purpose of this presentation is to highlight our education initiative to improve capacity in the ED through the use of "PD champions" and the development of a flow chart that assists nurses with decision-making regarding who to call for help and when. This new role has helped decrease the amount of calls back to the ED and more timely care for our patients.

Striving for Excellence Between Two Worlds

Carol Ozubko-Malcolm, RN, CNeph(C), Frances Reintjes, RN, BScN, BScSpec, Irene Ryll, RN, Sylvanie Williams, RN, CNeph(C), and Donna Mallach, RN, BScN, Edmonton, AB

The Northern Alberta Renal Program (NARP) at the University of Alberta Hospital in Edmonton, Alberta, has demonstrated excellence in dialysis care for 50 years of which at least 30 have included pediatric peritoneal dialysis (PD) care. This poster presentation highlights some of the features of our practice setting.

The home peritoneal dialysis unit in NARP is a predominantly adult PD program, which also cares for pediatric patients. Our program includes children from northern Alberta, Saskatchewan, and the Northwest Territories; and while the nephrologists and allied health team change at transition into the adult program, continuity for the patient is maintained, as the nurse and clinic setting remain the same.

Pediatric care is managed in a multidisciplinary setting including 8.4 nurses (six FT, four PT). Primary nursing is the model of care. Our program tracks many parameters including nursing time spent on training, clinic visits, nursing procedures, and on call activities through daily service logs. These data have never been reported. In 2011, we cared for 11 pediatric patients in a program of 170 PD patients. Those 11 represented 3,955 hours of care and remarkably monthly nursing workload varied from 7% to 22% for those 11 pediatric PD patients. Service log data assist in program planning and understanding of the requirements for successful pediatric care and outcomes.

Advance Care Planning: The Patient Perspective

Jane Ridley, RN(EC), MScN, CNeph(C), Charlotte McCallum, RN(EC), MN, ACNP, CNCC(C), Marlene Rees-Newton, MSW, RSW, Dennis Smith, RN(EC), MN, and Susan Scott, MSW, RSW, London, ON

Advance care planning (ACP) is a complex process that requires thoughtful and deliberate conversations. Over the past several years, a task team of allied health professionals in a teaching nephrology program has been developing a process and tools to enhance the quality and consistency of ACP with hemodialysis patients.

The team is preparing to conduct a CQI project with 10 dialysis patients who have not yet had end-of-life (EOL) care/resuscitation discussions with the dialysis team. These 10 patients will receive what has been the standard discussion about resuscitation status and selection of a power of attorney for personal care (POA-PC). Within a week, one of the task team will conduct a brief interview consisting of a series of predetermined questions regarding how they felt about the EOL care talk, whether or not the discussion was helpful in planning for their future health care changes, and any concerns they have about EOL care.

The same 10 patients will then be guided through the new proposed process for ACP. This will involve providing them with written information on ACP and selection of a POA-PC, as well as spending time with either a social worker or nurse practitioner to guide them through the process of ACP. This will be followed with an interview asking the same questions to determine if this process was more valuable to them.

Illiteracy is Not an Issue for Learning PD

Kristi Kristensen, RN, Vancouver, BC

The United Nations Educational, Scientific and Cultural Organization (UNESCO) defines literacy as "the ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts. Literacy involves a continuum of learning to enable an individual to achieve his or her goals, to develop his or her knowledge and potential, and to participate fully in the wider society" (2012). The latest literacy study by Statistics Canada shows that more than three million Canadians aged 16 to 65 have problems dealing with printed materials.

With this statistic in mind, it is not surprising that we often face literacy challenges in our patient education. In addition, our unique patient population encompasses many immigrant groups, which compounds the challenges for our peritoneal dialysis (PD) nurses. This poster will showcase how the PD nurses at St. Paul's Hospital in Vancouver help one of our patients overcome the literacy hurdle and learn PD so he can remain at home because illiteracy is not a barrier to learning PD.

Hemodialysis: New Start Unit--The Beginning and Its Purpose

Monique Vail, RN, CNeph(C), Ottawa, ON

The New Start Kidney Unit (NSKU) was started in September 2007 at the Ottawa Hospital. Its purpose is to transition all new hemodialysis patients in the Ottawa Hospital through this unit. While in New Start, patients would complete an eight-step care map including education and teaching of different types of modalities. The program helps to facilitate assessment of eligibility and suitability of transplant and home therapies. The unit helps to give optimal care to the new patient to promote self-care. Another objective of the unit includes identifying vascular access needs.

This presentation will show proof of the program's success with results of a study conducted showing 30% of New Start patients choosing home therapy as a modality. In conclusion, the presentation will give a case study of an actual patient's progress through New Start.

Medication Reconciliation in a Pediatric Nephrology Clinic

Dana Kennedy, BScPhm, ACPR, Regis Vaillancourt, OMM, CD, BPharm, PharmD, FCSHP, Anne Chretien, RN, Celine Boulanger, RN, and Paula Tam, RN, Ottawa, ON

Purpose of the project: A quality assurance assessment will be performed to optimize the medication reconciliation process within the pediatric nephrology clinic.

Description: Patients in the pediatric nephrology clinic often have very complex medication regimens with multiple medications, administration times, and dosing forms. Patients/ families often find it difficult to remember to take or give medications at the appropriate dose and time. The pediatric nephrology nurses perform medication reconciliation and take a medication history on every patient at each visit. The nephrology pharmacist also prepares patient-specific medication calendars as an education tool for families that have difficulty with their complex medication regimens. The goal is to improve and facilitate patient compliance and education. This process allows physicians to have an updated medication history during their assessments for proper dosing changes and therapeutic assessment.

Evaluations/outcomes: The percentage of medication reconciliations that were performed in the transplant and chronic kidney disease clinics will be determined. The average number of medication changes from one clinic visit to another and the number of discrepancies (i.e., doses written in mL instead of mg) will also be analyzed. This will help to optimize the medication reconciliation process within the pediatric nephrology clinic.

Implications for nephrology practice/education: The pediatric nephrology team has established a medication reconciliation practice for outpatients. They hope to share their experiences with other departments in order to improve medication compliance and education, as medication reconciliation is an important patient safety practice that is considered to be a standard of care.

Calciphylaxis Prevention is the Best Medicine

Sylvia Burns, RN, and Shirley Sawler, RN, Sydney, NS

Calciphylaxis is a rare and serious disorder characterized by systemic medial calcification of the arterioles that leads to ischemia and subcutaneous necrosis. It is most commonly found in patients with end stage renal disease (ESRD) or who have recently received a renal transplant. Although considered a rare complication, several of our hemodialysis patients have been diagnosed and treated for calciphylaxis in our Cape Breton dialysis population.

Our poster presentation will focus on various aspects of calciphylaxis, including:

* Calcium phosphorus balance in the renal population

* Diagnosis--how it is made

* Treatment options--daily dialysis, medications

* Cost analysis with statistical graphing.

Conclusion: Our goal is optimal patient renal care, which would include the scope of prevention of such complications, and education of the renal staff and patient population.

Best Volume: Best Practice

Valerie Cameron, RN, Gail Barbour, RN, CNeph(C), Jane Ridley, RN(EC), MScN, CNeph(C), Dennis Smith, RN(EC), MN, Kathryn Walton, RN, and Ruth Anne Wright, RN, CNeph(C), London, ON

Achievement of dry weight is an ongoing challenge in hemodialysis patients. Patients who are above their dry weights are at risk for problems associated with volume overload; patients who are under their dry weights can experience listlessness, headaches, and dizziness among other symptoms. Identification of dry weight is often achieved through trial and error (Daugirdas, Blake, & Ing, 2007, p. 163). The Nephrology Standards of Nursing Practice direct us to conduct "comprehensive health assessments using a variety of assessment techniques including evidence-based tools/techniques for ... collecting patient information" (CANNT, 2008, p. 13).

This presentation will present the results of a CQI project to evaluate volume status of conventional in-centre hemodialysis patients at the end of their dialysis treatments. Volume status will be assessed through traditional fluid assessment (chest assessment, central and peripheral edema assessment) and with Blood Volume Monitoring (BVM) technology. We are interested in determining if patients have any refill at the end of their treatments leaving them above their dry weights.

Electronic Medication Administration Records: The Road to an Environment of Excellence

Andrea Brown, RN, CNeph(C), Roxanne Brasier, RPN, Reshma Dole, RPh, Ryan Leppart, RPh, Karen Rehill, RPh, Sandy Thompson, RN, Elizabeth Whistle, RN, and Marlyn Young, RN, Oshawa, ON

In 2011, the Regional Nephrology Program at Lakeridge Health (LH) had the unique opportunity to implement a new way to document the administration of medications through the use of an electronic medication administration record (eMAR). Previously, paper MAR'S were used, creating a potential for an increased risk of error through the transcription process, time delays, and lack of pharmacist involvement.

The use of the new eMAR system improved timeliness, drug administration safety, and decreased medication errors. The main purpose of the MAR is to indicate to the clinical staff what medications have or have not been given. An eMAR also provides a summary of patient information and is considered part of the patients' permanent electronic health record. The eMAR is a step towards LH's goal of a complete patient profile and integrated patient record. Ultimately, eMAR reduces errors, provides functionality of dose warnings, allergies and lab results, and removes the need for manual documentation. The eMAR also features:

* Access dictionaries that provide the ability to control users' access to medications, documentation, and medication edits

* Allows utilization of customer-defined screens to capture all necessary patient data

* The ability to view medications immediately upon order entry in order to document administration accurately.

The successful implementation of eMAR in the Regional Nephrology Program at LH has once again demonstrated the ability of the staff in the program to achieve best practices within the nephrology arena, as well as align our program with our overall hospital vision of "Excellence Every Moment, Every Day."

Out-patient Hemodialysis Unit--Dramatic Improvement on Hand Hygiene Compliance

Kim Wilson, RN, DSW, and Kit-Yu Wong, RN, BScN, BA, London, ON

After applying a multidisciplinary team approach, the hand hygiene compliance rate increased dramatically from 30% to 80%. This presentation will outline the barriers to infection control in a hemodialysis setting and the challenges of adapting the parameters of an in-patient area to an outpatient area. It will utilize a three-dimensional display board reflecting the necessity to maintain proper hand hygiene protocol by identifying its benefits and challenges. By sharing our experience we will help other hemodialysis units overcome their own obstacles and offer helpful feedback.


a) Addressing hand hygiene rates in the past and its improvement since implementing a multidisciplinary approach.

b) Distinguishing between hospital environment and patient environment.

c) Improving hand hygiene practices decreases antibiotic resistant organism transmissions, decreases line sepsis rates and antibiotic use, and decreases hospital admission and length of stay. Overall, this decreases mortality and healthcare costs.

d) Recognizing the challenges of increasing hand hygiene compliance by identifying barriers, which include environmental concerns, education, and time factors.

e) Outline the steps initiated such as ongoing audits by Infection Control Safety Champions, providing ongoing question sessions, outlining four moments of hand hygiene throughout the health care team, providing instant feedback, and collaborating with infection control and management.

f) Validation of our hand hygiene initiative by identifying improved hand hygiene audit results.

Renal Retreat

Ellen Blundon, RN, Thunder Bay, ON

Background: The renal service had a "Renal Retreat" as part of Thunder Bay Regional Health Sciences Centre's organizational culture change, embracing patient and family centred care (PFCC). It was a day for all members of the renal team, as well as patient and family members, to come together and challenge "that's the way we have always done it" mentality; to work collectively to address items we do well and those that could be improved. Stories and experiences were shared.


* Participating in the retreat > 75 including two satellites via teleconference

* Organizing took several months to ensure all three nephrologists were present and high vacation time was over

* Round table discussions with patient and family members, staff and a facilitator

* "Brainstorming"

* Intra Professional Champions

* Patient and Family Advisors

* An opportunity to foster a common, shared understanding of PFCC

* Exemplify the word "family" in a renal patient's life, is any person who plays a significant role.

Conclusion: Patient and family advisors offer valuable input. We currently have advisors on the renal care team who participate in policy and program planning. Changes will not move forward without advisor involvement. As we journey through this cultural transformation, we are truly seeing a change.

A Quality Improvement Initiative: Matching Hemodialysis Patient's Potassium Bath with Potassium Blood Values

Jennifer Lee, BSc, RD, Aida Vigilia, RN, Nasuralah Rahaman, MHSM, BSc, RN, and David Mendelssohn, MD, FRCP(C), Weston, ON

Purpose: Hypokalemia can occur in hemodialysis patients post dialysis treatment and may result in sudden death due to ventricular dysarrhythmias. At our dialysis unit, there was no standard process to detect potential mismatches between serum potassium and dialysate potassium or make recommendations for potassium bath adjustments. Our goal was to establish a standard process for potassium bath adjustment based on preand post-dialysis potassium values.

Description: Six Sigma Quality Improvement methodology was used to identify root causes contributing to post-dialysis hypokalemia. Using Cause and Effect Analysis, four root causes were identified. A potassium bath policy was developed and approved by the nephrologists.

Outcomes: Pre and post potassium were collected and adjustments to potassium bath were made based on the potassium bath policy. At baseline, 64/306 (21%) baths for conventional and daily hemodialysis needed adjustment to the potassium prescription. After six months, the number of bath changes had decreased to 9/306 (3%) using the potassium bath policy, as a new equilibrium state was reached.

Implications for nephrology practice: Preliminary results indicate that the use of a standardized potassium bath policy in making adjustments to a patient's potassium bath markedly reduces mismatches between pre dialysis potassium and dialysate potassium, and reduces the risk of hypokalemia.

Expect the Unexpected: Leveraging Continuous Quality Improvement to Influence Change Processes in Peritoneal Dialysis Care

Monique Benard, RN, CNeph(C), April Cyr, RN, CNeph(C), Roselyn Castenada, RN, MScN, CNeph(C), Nicole Brosseau, RN, CNeph(C), Normand Briault, RN, and Pamela Laprise, RN, BScN, CNeph(C), Ottawa, ON

Purpose of project: The purpose was to evaluate home dialysis patients' experiences with peritoneal dialysis exchanges and to identify best practices for change management.

Description: A quality improvement initiative was instituted to complement a conversion in assisted peritoneal dialysis equipment within a large regional nephrology program. Leveraging the Plan/Do/Study/Act framework, patient outcomes were monitored and the change process evaluated. An intersectoral team involved in all stages of the change developed a plan to assess patient responses and to expedite the change process (Plan). The plans were implemented (Do), including case-by-case monitoring of patient responses and weekly monitoring of change processes (Study). When a problem with the change process pathway arose, the plan was revised (Act) and monitoring continued (Plan repeated). When issues related to patient experience were identified, the treatment plan was tailored and adapted for the larger patient population when required.

Evaluation/outcomes: Preliminary findings, process pathways and strategies to address identified patientrelated issues will be presented.

Implications for nephrology practice/education: Using a systematic process grounded in quality improvement principles facilitates progress toward establishing environments for excellence. This can lead to better processes, provide insights into areas that need further attention and foster the development of evidence-based interventions to improve patient care and outcomes. Given the changing needs of patients and emergence of new technologies, implementing quality improvement cycles in tandem with change initiatives is critical to providing best care for patients and for engaging nephrology nurses in creatively transforming their practice and patient care processes.

Appetite for Life

Ann Chretien, RN, BScN, Maureen Jones, RN, BScN, BEd, CCLS, and Cathy Walker, RD, Ottawa, ON

Instilling health and dietary knowledge in adolescents with kidney disease can be challenging. The medical condition itself, the social isolation from frequent hospital visits and the imposition of lifestyle changes can seem restrictive to youth.

The challenge for the health care professional becomes how to present the health information so that the learning is relevant, integrated and sustainable.

To help meet this challenge, a cooking program for dialysis youth was implemented utilizing an interdisciplinary approach to provide an opportunity to learn, research, plan and prepare renal friendly recipes.

The purpose was to provide a supportive environment with an orientation toward positive outcomes and activities that involve multiple learning styles and are hands-on, experiential and relevant.

With the support of the dietitian, nursing and the child life specialist, weekly group cooking sessions offer the youth the opportunity to prepare a variety of renal-friendly recipes of their choice, integrating nutritional information and learning strategies to enhance their knowledge acquisition.

The recipes are printed in a cookbook format, journaling their culinary adventures. The book then serves not only as a reference manual, but also as an evaluation/reflective tool.

The outcome measured by anecdotal feedback from the youth and families plus the requests made to continue and expand the program speak to the success of the format.

The implications for practice are that in order to achieve youth buy-in, compliance and optimal health results, the team needs to apply core strategies to enhance youth's meaningful engagement by being involved in program planning, implementation, and evaluation/reflection.

Hemodialysis: A Nurse's Pocket Guide

Grace Archer, RN, Carolyn Bartol, RN, BScN, CNeph(C), Lisa Canning, RN, Leslie Jackson, RN, and Renee Taylor, RN, Halifax, NS

There are 135 nursing staff working within the Capital District Health Authority (CDHA) dialysis program. There are two in-centre units and eight satellite units in which registered nurses (RNs) and licensed practical nurses (LPNs) work.

Annually, CDHA is provided with monies to fund Improving Nursing Practice Grants. The intent is to provide an opportunity for nurses, individually or in groups, to work together to address daily workplace issues. The program is based on the belief that nurses have the knowledge and capacity to solve problems, create quality practice settings, improve patient care and advance nursing practice.

The range of dialysis experience and knowledge among nursing staff led to identification of a need to give nurses a handbook for quick reference in the clinical area. A group of RNs at the Halifax in-centre dialysis unit were awarded a grant to develop a nurse's pocket guide to address learning needs of nurses working in the various dialysis unit settings.

The pocket guide topics included calculations of fluid removal, ultrafiltration profiling, complications during dialysis, transonic monitoring guidelines, blood work and related medication use, anaphylaxis management, and a list of patient teaching resources.

The guide was formatted to a pocket size, for portability, to address clinical concerns and complications as they arise.

The response to the effectiveness of the pocket guides was evaluated and a poster was presented during National Nurses Week for the district health authority.

Environment of Excellence: Establishing a Self-Care Unit within a Busy Hemodialysis Unit

Carolyn Bartol, RN, BScN, CNeph(C), Carrie-Ann Boyd, RN, CNeph(C), Rachael Blair, RN, BScN, CNeph(C), Shondal Byrne, RN, BScN, CNeph(C), Janet Campbell, RN, Risa Leblanc, RN, BScN, Gary McNeil, RN, Matthew Phillips, RN, BScN, Colleen Wile, RN, BScN, CNeph(C), Halifax, NS

Self-care dialysis is now offered as a treatment option for patients within the in-centre hemodialysis unit in Halifax.

The purposes for expanding into self-care as an option were to: foster self management, independence and control among the patients/families who are currently receiving in-centre hemodialysis treatments; provide the option for new patients to develop self-care strategies immediately upon starting hemodialysis; and promote the choice for home hemodialysis by building capacity for self-care.

The philosophy for self-care included: all patients have the ability to perform some or all of their care; patients are individuals with varying needs and learning styles necessitating individualized care plans; and the maintenance of the multidisciplinary team approach is essential to enable collaboration that will attain the highest possible level of patient care and satisfaction.

Pre-dialysis patients were informed of the option of self-care by the renal clinic nursing staff. In-centre hemodialysis patients were informed through the waiting room education sessions and an individual follow-up questionnaire and discussion. The in-centre nursing staff was educated and encouraged to promote it among patients. The initial patient teaching was performed by one nurse from the home dialysis program. An expanding core group of nurses was mentored by the home dialysis nurse.

Future goals are to increase the number of patients and nurses involved in self-care dialysis, in order to empower patients to self-manage, and to allow nurses to work to their full scope of practice.

New Patient Pathway Tracey

Brown, BScN, RN, London, ON

Problem: Ensuring a consistent approach to the first three runs of dialysis is essential to enabling completeness in initial nurs ing assessments and documentation. It has been identified by the nurses in a teaching hospital dialysis unit that the current process of starting new patients on dialysis is unsatisfactory. The nurses feel there is an inconsistent approach to care of the new patient and an inadequate documentation system.

Approach: The current state of practice was assessed through process mapping and retrospective chart audits of previous new starts. Using this information we conducted an analysis of system gaps and identified areas for improvement.

Outcomes: The goal of this quality improvement project was to identify the nursing responsibilities that are necessary for a patient-centred approach to initiation of dialysis. We will create a new process map and outline a pathway for the new patient starting dialysis that ensures all necessary initial assessments and supporting documentation are completed within the first three treatments.

Relevancy to practice: Having a standardized approach to nursing patients during their first three treatments will enhance patient care through improving the consistency of performing initial nursing assessments and completeness of documentation.

The Role of Nurse Navigator (NN) and Peritoneal Dialysis (PD) Access Coordinator to Help with Transition of Patients to Home Dialysis

Mina Kashani, RN, BHScN, CNeph(C), Toronto, ON

This poster presentation will discuss the impact of having the new role of nurse navigator (NN) over a one-year period of September 2011-2012, determining the effectiveness of having one dedicated nurse to provide modality education and Renal Replacement Therapy (RRT) to patients in different areas of nephrology, i.e., Kidney Care Clinic patients, nephrology in-patients, urgent start and the in-centre hemodialysis patients.

Furthermore, it will discuss the role of the nurse navigator to:

* Determine a standardized process to home dialysis modality education for patients within the program so that patients make informed modality decisions

* Review and identify patient eligibility/exclusion criteria of referred home dialysis patients throughout the hospital

* Educate those patients who are appropriate for the home dialysis program throughout the hospital

* Create referral/review criteria so that all eligible home dialysis program patients are referred to the NN and plan of care identified for the designated patient.

We did not previously have a designated PD access coordinator, so the role function was added to the NN's job description. As it is a new function, it would be interesting to analyze the impact of creating a pathway for referring patients for PD catheter insertion and the navigation through home dialysis.

Many programs have adapted or are in the process of adapting the NN position. This poster will help outline the pros and cons of the role of NN and what to consider to make it successful.

Acute Starts: Where Are They Now?

Susan M. Porteous, RN, CNeph(C), Hamilton, ON

The preferred method to start dialysis is in a planned manner, following modality education and to a modality of choice. The Kidney Function Program (KFP) aims to prepare end stage renal disease patients for a smooth transition to their modality of choice. Unfortunately, there are patients who start dialysis in an unplanned, crash or acute manner. What happens to these acute starts? Do they remain on hospital-based hemodialysis (HD)? Do they receive education on all modalities?

I have identified acute starts as those patients who start HD due to a sudden change in patient status leading to sudden dialysis start, and continue on chronic HD.

Objective: The goals of this study are to identify the number of acute starts in a nephrology program in a five-month period and any potential interventions or strategies to educate these patients on all modalities.

Method: A retrospective database review was done for a period of five months on acute HD starts, and where they are dialyzing at present.

Results: Between August 1, 2011, and December 31, 2011, a total of 30 patients were identified as acute HD starts and as of February 29, 2012, all of these patients remain on hospital-based HD, with 16 in-centre, and 14 at a satellite.

Conclusion: These data demonstrate a need for a health care professional (nurse practitioner) to identify the acute starts. There is a need for a collaborative approach between this new nurse practitioner, our KFP and our independent therapies' program to repatriate these patients to the KFP for modality education.

Core Values: Getting "On Target" with "HEART" in the Work Environment--StaffAwareness of our Facility's Core Values has brought forth a Culture of Excellence and Pride

Monique Moore, RN, CNeph(C), and Kathaleen Bijman, RN, BScN, CNeph(C), Cornwall, ON

Employees come into the work environment bringing with them a value system that is shaped from past experiences, knowledge and behaviours. The leadership roles within the facility, in turn, articulate and demonstrate the organization's values, visions and goals. These are often referred to as "core values." The two value systems need to be at a parallel to each other so that a harmony of views and respect result. But staff and leaders can forget the why, the "HEART" of what we do or the "Target", the how we manifest our facility's values in our actions. Therefore, over time, a misalignment of values could be developed. The Ottawa Carleton Dialysis Clinic and the Cornwall Dialysis Clinic are directed by core values, but the awareness and meaningfulness of these values waned within the employee population. The two clinics wanted to inspire and rekindle the organization's core values, but how? Thus, a poster with "HEART" was created, depicting the "On Target" core values. These core values were portrayed creatively for staff with examples/explanations integrated on it. Then, to bring the staff "On Target" with each piece of the "HEART", we devised the core value treasure chest. Staff and leaders are encouraged to applaud each other's core values in action by recognizing each other's contributions, strengths and innovations. Acknowledgement and appreciation on a monthly basis brought forth excitement, pride and stimulus back into our core values. This poster presentation will demonstrate how our work environments found their "HEART", and are now back On Target!

Development of Two Pediatric Intraperitoneal Antibiotic Dosing and Delivery Tools

Kathleen Collin, BSc(Pharm), Jennifer Leechik, BSN, Colin White, MD, and Chanel Prestidge, MD, Vancouver, BC

Purpose: Distance and lack of local pediatric facilities require our physicians to initiate antibiotic therapy for peritonitis via phone calls to parents or health care providers. Correct antibiotic dosing calculations can be complex. Our purpose was to develop user-friendly antibiotic dosing tools to reduce the risk of medication error and ensure rapid and accurate administration of our empiric antibiotics.

Approach: During a redevelopment and standardization of current evidence-based peritonitis guidelines, we developed two tools for physicians to follow: an antibiotic dosing worksheet and antibiotic mixing instructions.

Results: Each antibiotic worksheet allows sequential dosing calculations with clearly designated and "letter labelled" outcomes at each step. Each step builds on those preceding it and feeds results into subsequent calculations. Worksheets have clear suggestions for making modifications for patient size, calculating loading versus maintenance doses, change in dwell volume, choice of APD versus CAPD and presence of residual urine output. A format for the "outpatient prescription" of that antibiotic is suggested. The antibiotic mixing instructions provided to the physicians, as part of their peritonitis treatment algorithm, are identical to those provided to families in their Take-Home kits.

Discussion: Prompt delivery of appropriately dosed antibiotics is paramount to successful preservation of the peritoneal membrane. Failure to adhere to evidence-based guidelines and improper calculations can lead to sub-optimal or super therapeutic dose, neither of which are acceptable outcomes.

Conclusions: Delivery of peritonitis protocols can be effectively translated into dosing and mixing worksheets, which minimize risk of drug errors even where drug doses require significant modification. Mirroring of physician and patient mixing instructions allows for clarity and certainty during phone calls. Future direction to move to an electronic calculator from a paper-based set of worksheets to further minimize errors is desired.

Applying International Society of Peritoneal Dialysis Guidelines/Recommendations (2010) for Management of Peritonitis

Elizabeth (Betty) Kelman, RN-EC, MEd, CNeph(C), Toronto, ON

Purpose: Review the diagnosis and management of peritonitis utilizing the ISPD Guidelines/Recommendations (2010) in a clinical practice setting.

Description: A review of the definition, diagnosis and pathophysiology of peritonitis will be presented. This will be followed with a description of two patients and the adaptation of recommendations related to individual peritonitis courses.

Outcomes: A discussion of the relevance of recommendations and the need to adapt according to clinical setting will be summarized.

Implications for nephrology practice: This will be a basic review of the current approach to the management of peritonitis with the intent to discuss the interpretation of recommendations and value of experiential approach to patient care.

Why Was This Patient Admitted for Peritonitis?

Elizabeth (Betty) Kelman, RN-EC, MEd, CNeph(C), Toronto, ON

Purpose: To determine the differences in patients who are managed in the home setting versus hospital admission for the management of peritonitis in a single hospital setting.

Description: The approach of the home peritoneal dialysis unit is to support and maintain patients in the home; yet, a percentage of patients with peritonitis are admitted for management. The question asked post admission is "Why was this patient admitted?" This presentation will examine patient characteristics, peritonitis course and outcome over a one-year period in a single hospital setting to determine factors influencing admission.

Outcomes: Based on the findings, potential barriers to management of peritonitis in the home setting will be reviewed.

Implications for nephrology practice: In an attempt to understand the rationale for admission, factors contributing to management will be discussed with the potential to improve practice and approaches to patient care.

Falls in the Dialysis Population

Anuradha Sawant, PT, DPT, PhD(c), Dennis Smith, PHC-NP, MN, Charlotte McCallum, NP-Adult, MN, CNeph(C), Janet Groom, RN, BScN, CNeph(C), Sue Malloy, RN, Shelley Clarke, RN, Denise Soanes, RN, Fern MacDougall, RN, and Esther Gervais, RN, London, ON

The incidence of falls in people on hemodialysis (HD) is higher than their nonuremic community dwelling counterparts. The incidence of falls in HD patients has been reported to be 1.18 to 1.6 falls/per person year. The difference in the incidence rates could be due to the age of the participants. One study recruited participants of all ages and the other recruited participants over the age of 65 only. The incidence of falls observed by Cook et al. (2006) are closer to those observed in nursing homes (1.6 fall/bed-year), while the incidence of falls for persons living in the community ranges from 0.32 to 0.70 fall/person-year. Since various factors lead to falls in this population we set out to evaluate the incidence of falls in the London Health Sciences Centre (LHSC) regional satellite dialysis units. We evaluated the fall incidences with a single question defining falls as "coming inadvertently to the ground." We observed 37.8 per cent of falls in this population. Rehabilitation services are required for appropriate assessment and interventions for the management and prevention of injurious falls. LHSC is unique in providing physiotherapy/rehab services to our population. However, a population-specific falls assessment tool may be required to identify the at-risk population.

Using Technology to go "Green"

Kim Watkins, RN, BScN, CNeph(C), Debbie Potter, RN, CNeph(C), Cathy Egan, RN, and Kathleen Stringer, RN, CNeph(C), Ottawa, ON

The environment is on everyone's mind these days. Everyone is being urged to Reduce, Reuse, or Recycle. With that in mind, our dialysis unit is looking at ways to decrease the amount of disposables we use. Technology exists on our hemodialysis machines to use solution from our RIO water system to prime the bloodlines. This method of priming creates less waste (Prime bag, saline line, and saline bags) and has the additional benefit of introducing less sodium to our patients.

Our technicians are currently testing our R/O water to ensure it is clear of endotoxins and bacteria. Once this has been verified, a procedure will be developed and training will be initiated with the dialysis staff to prime the dialysis machines with the R/O solution.

The outcomes we are anticipating:

* Our amount of disposables will decrease substantially

* Improving our time efficiency when priming our machines

* Decreased sodium given to our patients with priming and boluses.

By using available technology, it is possible to enhance patient outcomes and reduce waste.

A Student-Centred Curriculum: A Novel and Integrative Approach

Erick-Antonio Chacon, RN, BSN, CNeph(C), MN, and Josephine Dalmacio, RN, Burnaby, BC

Nephrology nursing education presents challenges for educators. Our revised nephrology nursing curriculum is delivered via distance, online, classroom and across various clinical sites around the province. Our innovative, student-centred, evidence-based curriculum is informed by the Canadian Nurses Association (CNA) Core Competencies, and is delivered through two different models. The first is the advanced certificate that contains seven courses and the second is our compressed timeframe (CTF) 14-week program, which consists of two courses with eight weeks of hemodialysis clinic. Students are registered nurses who require two years of acute care experience. Most students come from areas unrelated to nephrology. The challenge is to prepare nurses to practise safely and competently in an environment that expects nephrology nurses that are not just proficient in tasks. Rather, the emphasis is on having critical thinking skills and providing care across the renal disease continuum.

The purpose of this abstract is to present novel learning strategies in preparing different types of learners to be competent practitioners. The curriculum utilizes behaviourist, phenomenological, constructivist and postmodernist approaches such as problem-based learning (PBL), simulation, learning portfolios, case studies, interactive webinars, guest lecturers, client narratives, and critical reflection to facilitate learning in preparation for entry-level practice. The poster presentation highlights the use of advanced technology such as the nurse-client simulation and interactive multimedia, which has exciting implications for the future of nephrology nursing. The incorporation of these innovative pedagogies into our program will be discussed.
Potassium bath changes

              Baseline  Month1  Month2  Month3  Month4  Month5  Month6

Conventional        56      13      52      13       5       2       8

Daily                8       2       2       0       7       9       1

Total               64      15      54      13      12      11       9

Janet Baker & Alison Thomas, Co-Editors, CANNT Journal
COPYRIGHT 2012 Canadian Association of Nephrology Nurses & Technologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2012 Gale, Cengage Learning. All rights reserved.

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Publication:CANNT Journal
Date:Apr 1, 2012
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