Le passe est garant de l'avenir 50 CANNT/ACITN 1968-2018/Our Past Will Guide Our Future October 25-27, 2018 Ville de Quebec City.
The following abstracts celebrate the diversity of key topics in nephrology nursing and technological practice that are being investigated and discussed across Canada. It is our hope that CANNT members interested in pursuing a profiled topic will contact the CANNT National Office at 613-507-6053 or email@example.com to receive information regarding how to contact the respective author about their work. We encourage you to carefully review these abstracts!
Nous sommes tres heureux d'accueillir les professionnels canadiens en nephrologie--notamment le personnel infirmier, les technologues, administrateurs, chercheurs et pharmaciens--au congres de l'ACITN qui se tiendra dans la belle ville de Quebec! Comme le veut notre tradition, la rencontre de cette annee offrira une multitude d'occasions d'apprentissage pour tous les professionnels oeuvrant dans le domaine de la nephrologie.
Profitez pleinement de toutes les activites offertes dans le cadre du congres de l'ACITN 2018 :
* Retrouvez vos collegues cette annee pour le congres de l'ACITN/CANNT et celebrez le 50e anniversaire de l'association.
* La collaboration, le reseautage et l'apprentissage sont au programme, car << Le passe est garant de l'avenir >> en matiere de pratiques infirmieres et de pratiques technologiques en nephrologie.
* Participez a des seances plenieres, seances simultanees, ateliers, presentations par affiche, et profitez des occasions d'apprentissage presentees par nos membres et nos entreprises commanditaires.
* Au crepuscule, laissez-vous charmer par les splendeurs du Vieux-Quebec et partez a l'aventure--pourquoi ne pas vous laisser tenter par une visite fantome ou une croisiere sur le fleuve?
Peu importe ce que vous choisissez, le congres de cette annee sera assurement memorable.
Rendez-vous au Centre des congres de Quebec pour une rencontre qui ne manquera pas de vous dynamiser, vous motiver et vous inspirer! Inscrivez-vous des maintenant! Vous trouverez des renseignements sur le congres de l'ACITN/CANNT 2018 au www.cannt.ca
La mission de l'ACITN est de guider ses membres et de promouvoir l'excellence en matiere de soins dans le domaine de la nephrologie par la formation, la recherche et la communication. L'ACITN vise la promotion des pratiques exemplaires en offrant des occasions d'apprentissage et de reseautage, et en encourageant la pratique fondee sur l'experience clinique. Le congres national de l'ACITN 2018 constitue la plateforme ideale pour accomplir ces objectifs. Dans ce numero du CANNT Journal, nous sommes heureux de publier les abreges qui seront presentes sous forme d'exposes oraux et de presentations par affiche dans le cadre du congres annuel de cette annee.
Les abreges suivants soulignent la diversite des principaux enjeux en cours d'etude et de discussion dans tout le pays relativement aux pratiques infirmieres et aux pratiques technologiques en nephrologie. Les membres de l'ACITN qui souhaitent en apprendre davantage sur un sujet a l'etude peuvent communiquer avec le bureau national de l'ACITN au 613-507-6053 ou a firstname.lastname@example.org pour obtenir des renseignements sur la marche a suivre pour entrer en contact avec les auteurs respectifs des ouvrages. Nous vous encourageons a lire attentivement ces abreges!
1. I Need A Vacation! Supporting Home Hemodialysis Patients Who Want to Travel With Their Dialysis System
Mary L. Lewis, BScN, RN, CNeph (UK)
Sarah Thomas, BSN, RN, CNeph(C), Vancouver, BC
Home hemodialysis (HHD) is a well-established treatment option. Dialyzing in the home allows patients to live their lives as normally as possible.
In spite of the benefits and freedom that HHD offers, Canadian patients have not been able to travel with their HHD system until this past year. Vacations and work trips can take many months of advanced planning to secure a dialysis spot, and destinations are limited. Furthermore, patients often incur significant out-of-pocket costs.
This presentation will share the recent travel experiences of several HHD patients who have travelled with their portable dialysis system while biking in Hawaii, wine tasting in France, or just indulging in a long weekend away without the usual dietary and fluid restrictions. Car, recreational vehicle (RV), cruise ship, and air travel options will be described.
The British Columbia Provincial Renal Agency (BCPRA) HHD travel document written to safely and effectively manage travelling HHD patients will be outlined. Tips and advice from the Canadian Air Transport Association (CATSA) and the US Board of Transport, and how to deal with the airlines will be shared.
Although most of the patient stories are positive and heartwarming, the pitfalls will also be shared. Overall, the presentation will highlight the importance of offering patients the choice and the freedom to travel.
2. Providing Hemodialysis Services in a Rehabilitation/Complex Care Setting
Lori Harwood, PhD, RN(EC), CNeph(C)
April Mullen, BScN, MHM, RN
Janice Qubty, BScN, RN
Kyle Goettl, BScN, RN, Med IIWCC
Elizabeth Clinton, Patient/Caregiver Advisor, London, ON
Each week inpatients from our local rehabilitation institute are transported to our in-centre unit for hemodialysis (HD) treatments. Inter-facility medical transportation is costly, and patients state that the travel time increases their fatigue, delays their rehabilitation, and impacts their quality of life. To improve the patient experience, create efficiency, and reduce travel costs, the renal team and teams from the rehabilitation centre are collaborating to provide HD services at the rehab centre. HD on-site should save patients/families time and energy, improve the patient experience, and decrease overall transportation costs.
This presentation will discuss the implementation of the new unit, describe how the unit operates, and also present preliminary findings from a research-based evaluation. This qualitative, theory-driven, patient-oriented research proposes to evaluate the patient experience, economic impact, and operational evaluation of this initiative. The qualitative study will investigate complexities and nuances associated with the program, which is currently lacking in the literature. Interviews will be conducted with patients and caregivers to gain understanding of the patient/caregiver experience. HD staff will participate in a focus group and the rehabilitation staff will be surveyed to gather their perceptions of how this service influences the patient's rehabilitation and quality of life, as well as the impact and challenges to the healthcare providers' role.
3. An Educational Intervention to Support Implementation of a Patient-Reported Outcome Measure for Hemodialysis Patients in Ontario
Alysha Glazer, MPH, PMP, Ontario Renal Network
Marnie MacKinnon, BPE, Ontario Renal Network
EstiHeale, MBA, Ontario Renal Network
Carey Moolji, MHSc Ontario Renal Network
Jenna Evans, PhD, BHS, Cancer Care Ontario, Toronto, ON
Peter Blake, MD, FRCPC, Ontario Renal Network, London, ON
Michael Walsh, MD, PhD, Ontario Renal Network, Hamilton, ON
Purpose: The Ontario Renal Network (ORN) developed a standardized approach to symptom assessment for eight regional renal programs in Ontario. The project, known as "Your Symptoms Matter" (YSM), uses the Edmonton Symptom Assessment System Revised: Renal (ESAS-r:Renal) questionnaire. An educational intervention was designed with the aim of engaging providers and patients in the YSM project and preparing them to use the ESAS-r:Renal tool.
Description: A "train-the-trainer" model was used to educate Project Champions who, in turn, trained members of their healthcare teams and patients to support YSM implementation. A total of 105 Project Champions across disciplines were trained.
Evaluation/Outcomes: The educational intervention was evaluated using provider and patient surveys. More than 84% of providers (n=518) agreed that the education enhanced their understanding of why and how YSM will be implemented. Providers self-reported more positive attitudes about symptom management post-education, including that it is within their scope of responsibilities (10% increase) and that a validated tool for symptom screening should be considered best practice (21% increase). Providers expressed more confidence in assessing patient symptoms using ESAS-r:Renal than in managing them.
More than 90% of patients (n=727) felt they had at least an average understanding of why and how to complete ESAS-r:Renal. Since ESAS-r:Renal was implemented, there have been 5,154 screening attempts with 95% completed and 5% declined.
Implications: The "train-the-trainer" model was effective in preparing providers and patients for YSM implementation, and enhancing their buy-in. The results also revealed opportunities for improving the model with additional resources on how to manage complex symptoms.
4. La Dialyse Peritoneale Automatisee Adaptee (DPAa)--Optimiser la therapie sur cycleur
Nicole Gagne, infirmiere, CNeph(C), Boucherville, QC
La dialyse peritoneale automatisee (DPA) est une modalite de dialyse tres populaire chez les patients en dialyse peritoneale. Cette presentation a pour but d'expliquer une approche innovatrice qui permet d'individualiser la prescription en DPA, afin d'optimiser l'ultrafiltration et la clairance.
La presentation couvrira la definition de la DPAa, ses avantages, une breve revue de la litterature existante et les benefices pour les patients.
Cette approche de traitement offre une alternative interessante qui peut etre utilisee pour ameliorer les resultats d'ultrafiltration et de clairance chez les patients en dialyse peritoneale automatisee.
5. Using Technology to Guide the Future of Vascular Access
Deidra Goodacre, BSN, RN, CNeph(C), Prince George, BC
Danielle McLaren, RN, CNeph(C), Kelowna, BC
Purpose: Emphasis on transplant and peritoneal dialysis as first choice modalities has led to a change in our hemodialysis client population in BC. The population is aging, and cardiac and vascular comorbidity is increasing. In BC, we are attempting to maintain a high level of fistula prevalence, but fistulas are becoming more difficult to create, cannulate, and maintain. We were unable to find a specialized ultrasound training course designed for hemodialysis nurses that could be easily replicated. Hence, we developed a course that would meet the new needs in our program based on the competencies outlined by Marticorena et al. (2015).
Description: We will discuss the successes, challenges, and lessons learned after running the course in two separate health regions. We will provide practical tips and resources for renal programs wanting to implement a course of their own. Handouts/resources will include: education funding proposal template, three easy-to-follow lesson plans with links to videos and PowerPoint presentations, pre- and post-tests, and sample case studies.
Evaluation/Outcomes: Pre- and post-course knowledge evaluations, nurse feedback, client feedback, and peer feedback will be discussed.
Implications for Nephrology Practice/Education: This course intends to fill the knowledge gap by providing a lesson plan framework and resources that can be used and implemented by any hemodialysis educator or vascular access nurse. By increasing the knowledge and cannulation skill level of dialysis nurses using innovative, engaging teaching techniques, and ultrasound technology, we will strive to provide "the highest quality vascular access care for patients with end stage renal disease" (Marticorena & Donnelly, 2012).
Marticorena, R.M., & Donnelly, S.M. (2012). Prolonging access survival: The principles of cannulation. In T.S. Ing, M.A. Rahman, & CM. Kjellstrand (Eds.), Dialysis history development and promise: Building on knowledge to secure a better future (pp. 185-192). Hackensack, NJ: World Scientific.
Marticorena, R.M., Mills, L., Sutherland, K., McBride, N., Kumar, L., Concepcion Bachynski, J.,... Donnelly, S. (2015) Development of competencies for the use of bedside ultrasound for assessment and cannulation of hemodialysis vascular access. Canadian Association of Nephrology Nurses and Technologists Journal, 25(4), 28-41.
6. Transplant 101: Is My Patient a Candidate for Transplantation?
France Martineau, BScN, LcSC Ed, RN, Montreal, QC
This presentation will serve as an introduction to the kidney transplant process and will be an interactive discussion with the audience. Four main questions will be presented and discussed:
The first question (Is my patient on the transplant list?) will provide a discussion around the following topics:
a) Has the patient had a discussion about the transplant process?
b) Are there any contraindications (e.g., cancer, compliance) to the patient being a candidate for the transplant process?
c) Why is the patient on dialysis for so many years before obtaining a transplant?
The next step in the process is to determine the best time to speak to a patient about a kidney transplant and when the referral should be initiated.
The third topic for discussion will revolve around the patients' long-term survival and how a transplant improves this, as well as a discussion around the risks and benefits of a kidney transplant.
Lastly, we will discuss eligibility of patients for transplant. This will include a case review of a patient who was declined for a kidney transplant along with a review of the transplant data over the past five years including number of transplants, number of referrals, and the criteria used for evaluating deceased donors.
7. L'epuisement professionnel et l'empowerment des infirmieres travaillant en hemodialyse au Quebec
Christina Dore, infirmiere, PhD, Universite du Quebec en Abitibi-Temiscamingue, Laval, QC
Linda Duffett-Leger, infirmiere, PhD, Universite de Calgary, AB Mary McKenna, PhD, Universite du Nouveau-Brunswick, NB
La profession infirmiere est reconnue pour etre stressante avec des taux eleves d'epuisement professionnel. La recherche indique que l' << empowerment >> est une strategie positive pour soutenir la pratique et le bien-etre au travail des infirmiers (eres). En management, il y a deux perspectives distinctes de l'empowerment. La premiere, qualifiee de structurelle et la seconde, qualifiee de psychologique. L'empowerment structurelle se concentre sur les mesures prises par l'organisation pour ameliorer le pouvoir partage entre le gestionnaire et les infirmiers (eres) et la prise des decisions influencant la facon dont les infirmiers (eres) accomplissent leur travail. L'empowerment psychologique se concentre sur les caracteristiques de l'individu contribuant a un etat cognitif d'empowerment et un sentiment de controle sur les situations. Recemment, la recherche indique que les sites Web professionnels pourraient promouvoir l'empowerment et reduire le risque d'epuisement. Actuellement, aucune information ne permet d'evaluer la gravite de l'epuisement professionnel ou le statut d'empowerment des infirmiers (eres) en hemodialyse au Quebec. La presentation a pour but de rapporter les resultats d'une etude mixte: une enquete quantitative en ligne aupres de 308 infirmiers (eres) en hemodialyse a demontre que 38% avaient des niveaux eleves d'epuisement emotionnel, 69% des niveaux moderes d'empowerment structurel et 64% des niveaux moderes d'empowerment psychologique. L'empowerment structurel et psychologique etaient significativement lies a l'epuisement professionnel. Ensuite, une approche participative utilisant des groupes de discussion avec un total de sept infirmiers (eres) en hemodialyse et des consultations aupres d'un comite aviseur a permis de formuler des recommandations sur les exigences a inclure dans un site Web. Les resultats indiquent qu'un futur site Web professionnel pour les infirmiers (eres) en hemodialyse devrait inclure: des informations professionnelles, de la formation continue, des informations sur les habitudes de vie saine et le reseautage. Dans l'ensemble, cette recherche a des implications importantes pour les infirmiers (eres), la pratique et la recherche. Les niveaux d'epuisement etaient eleves chez les infirmiers (eres) d'hemodialyse au Quebec, semblables a d'autres resultats nord-americains; et les infirmiers (eres) d'hemodialyse etaient en faveur de la creation d'un site Web pour repondre a leurs besoins professionnels et personnels.
8. Ontario Renal Network (ORN) Person-Centred Decision-Making: Implementing Goals of Care Conversations
Jade Rust, MPH, Ontario Renal Network
Jennifer Minelli, M Eng, Ontario Renal Network
Tara Walton, MPH, Ontario Renal Network
Sharon Gradin, PMP, BScN, RN, Ontario Renal Network,
Marnie MacKinnon, BPE, Ontario Renal Network, Toronto, ON
Peter Blake, MD, FRCPC, Ontario Renal Network, London, ON
Purpose: In the Ontario Renal Plan II, palliative care was identified as a priority for people living with advanced chronic kidney disease. A province-wide intervention is being implemented to ensure that by 2019 all chronic dialysis patients will have their Goals of Care (GOC) assessed annually to inform their treatment decisions (TD).
Methods: An approach to GOC data collection was developed, including information about a patient's Substitute Decision Maker, illness understanding, code status, and if goals and values have been incorporated into a documented plan of treatment.
A data submission tool was developed to capture patient GOC and TD via regular submissions from regional renal programs. More than 500 providers were educated on GOC and TD conversations. Provider and patient education resources on GOC and their role in developing a plan of treatment were also developed.
Results: Of chronic dialysis registrants from April to June 2017 in Ontario, 33% had GOC documented within 90 days after chronic dialysis registration, which is in line with expectations. Sixty-four percent of patients had incomplete data submitted, with only 3% of records missing.
Conclusions: Many programs incorporate GOC conversations into patient care; however, a consistent and province-wide process is new. Collection of GOC data will continue quarterly, improving the accuracy of the indicator and allowing for correlations to be meaningfully explored.
Implications for Nephrology Practice: GOC conversations ensure that TD are aligned with patient wishes, values, and beliefs, and that patients are supported throughout their care journey. Providers can also introduce the concepts of palliative care and share the benefits of early integration with treatment.
9. En route vers l'autonomie : de l'adolescence a l'age adulte pour un meilleur accompagnement
Danielle Boucher, IPSN, M.SC, D.E.S.S., CNeph(C),
Liane Dumais, IPSN, M.SC, D.E.S.S., Ste-Brigitte-de-Laval, QC
L'adolescent cheminant vers l'age adulte doit relever de nombreux defis et le developpement de l'autonomie en est un de taille. L'adolescent atteint d'une maladie chronique comme l'insuffisance renale est confronte a cette meme realite. Il doit en plus composer avec les exigences de traitement de la maladie. Les enjeux developpementaux de ces derniers sont nombreux et doivent passer par la consolidation de leur identite en integrant la maladie comme une part d'eux-memes.
La non-adhesion au traitement est un probleme important chez les adolescents insuffisants renaux. Selon la litterature, elle est influencee par de nombreux facteurs dont les caracteristiques de la maladie et de son traitement, le contexte familial mais aussi par la capacite de l'adolescent a devenir autonome. Malheureusement, celui-ci progresse plus lentement vers le developpement de son autonomie.
Les infirmier(e)s ouvrant aupres de cette clientele, doivent comprendre cette realite afin de mieux les accompagner dans l'acquisition de leur autonomie, notamment lors de la transition du milieu de soins pediatrique aux soins adultes.
Dans ce contexte de recherche identitaire et de developpement de l'autonomie, le jeune majeur atteint d'insuffisance renale doit en plus apprendre a naviguer dans un systeme de soins adulte avec une dispensation de soins et de services plus fragmentee. Devrions-nous revoir nos facons de faire aupres de ces jeunes adultes dans nos cliniques? Comment faire la transition du milieu de soins pediatrique aux soins adultes?
La litterature revele des pistes de solutions afin d'ameliorer l'approche aupres de cette clientele et consequemment favoriser une meilleure adhesion au traitement.
10. The Integration of LPNs in a Hemodialysis Unit: Building on the Foundations Laid Before Us
Sheriane Cowie, BScN, RN, Montreal, QC
"It has been seen from research that patients do benefit from appropriate staff mix, as do healthcare facilities" (CNA, 2005). Centres across Canada have integrated licensed practical nurses (LPNs) in their hemodialysis (HD) centres, as a response to the declining numbers of registered nurses (RNs), and the increased acuity of patients (CNA, 2005). In our centre, the increase in patient acuity and workload for the nurses has resulted in a decrease in completed nursing assessments, nursing follow-ups, and positive patient outcomes. The desire to augment the quality of care in our centre was the impetus for adopting a collaborative practice by introducing LPNs to the staff mix.
A pilot project was initiated in February 2017. At the outset, we met with the nursing staff to get their feedback. Their responses were predominantly favourable, with a select few resistant to the change. In preparation for the project, we reviewed the literature and visited centres functioning in a mixed-skills environment. Although eight LPNs were trained, two did not meet the criteria. One month into the project, the six remaining LPNs were widely accepted and even embraced by the team. We presented our project to our nursing director on November 28, 2017, highlighting the projected improvements in nursing and patient outcomes. Consequently, we were mandated to integrate the LPNs in our department by April 2018.
Canadian Nurses Association. (2005). Nursing staff mix: A literature review. Retrieved from http://www.cna-aiic.ca
11. J'ai besoin d'un rein: comment en parler avec mes proches?
Liane Dumais, IPSN, M. Sc., D.E.S.S., Quebec, QC
Le don vivant est une option therapeutique avantageuse pour le candidat a la greffe renale. Les bienfaits sont multiples pour le receveur et ont ete largement demontre en terme de meilleur fonctionnement et de survie du greffon, de qualite de vie amelioree et la possibilite d'une greffe preemptive afin d'eviter la dialyse.
Toutefois, le patient est souvent reticent a solliciter ses proches pour un don vivant. Il ne sait pas comment aborder ce sujet ou, il ne veut tout simplement pas l'aborder.
La litterature nous apprend que la crainte de porter prejudice a la sante d'un proche, d'un refus, le manque de connaissances sur le sujet et les croyances personnelles en lien avec le don vivant constituent des barrieres frequemment evoquees par le patient.
L'infirmier(e), en raison de son lien de proximite avec le patient, peut jouer un role important dans cette demarche. L'infirmier(e) est souvent mal a l'aise a aborder cette question et ne peut ainsi aider adequatement le patient a discuter de ce sujet avec ses proches. Comment outiller les infirmier(e)s afin d'actualiser leurs connaissances et leurs competences pour en parler avec le patient et mieux le soutenir dans sa demarche aupres de ses proches?
Afin de repondre a cette question, une revue de litterature sera presentee et permettra d'identifier les interventions et les approches qui aideront l'infirmiere a outiller le receveur afin d'aborder ses proches pour ce type de don.
12. From Cannulation to Complications: Integrating a Learner-Centred Approach to Delivering Hemodialysis Nursing Orientation
Guylaine St-Cyr, MN, RN, CNeph(C), Ottawa, ON
The Ottawa Hospital's nephrology program identified the need to enhance the content and delivery of the hemodialysis nursing orientation to improve nurse retention and preparation. Practising hemodialysis skills in the clinical environment early on in orientation was found to be anxiety-provoking for the newly hired nurse, as well as for the patient. Learner and staff feedback underlined that the environment was not conducive to learning, and that teaching methods were outdated.
A literature review highlighted a gap between the status quo and best practices for adult learning. In January 2017, the nephrology program shifted the second week of hemodialysis orientation to a simulation centre to foster a safe learning environment. New hires now engage in a full week of active hands-on learning prior to practising skills in the clinical environment with the aim of increasing their self-confidence. Additionally, a three-month post-orientation workshop involving high-fidelity simulation and advanced hemodialysis skills was implemented, as part of a quality improvement project.
The simulation environment provides innovative opportunities for teaching and assessing clinical competencies in preparation for clinical practice in the hemodialysis unit. This presentation will outline the process for the development and implementation of the revised curriculum using evidence-based resources. Perceived benefits for both the new hires and the patients will be highlighted.
13. Development of an Early Hospital Readmission Risk-Prediction Model for Kidney Transplant Recipients
Olusegun F amure, MPH, MEd, CHE
April Huang, BSc, BScN,
Jayoti Rana, BSc, MPH
Franz-Marie Gumabay, BSc
PeiXuan (Rachel) Chen, BSc(c)
Robin Huizenga, BScN
S. Joseph Kim, MD, PhD, MHS, FRCPC
Sunita Singh, MD, MSc, FRCPC, Toronto, ON
Purpose: Early hospital readmissions (EHR) confer high costs to the healthcare system and are associated with suboptimal outcomes in kidney transplant recipients (KTRs). Current literature focuses on identifying explanatory factors for EHRs, and few studies provide implications for clinical practice. We aim to develop an EHR risk prediction model to use as a tool that can be integrated into clinical practice to reduce future EHRs.
Methods: We conducted a single-centre, retrospective cohort study, including adult KTRs transplanted between July 1, 2004, and December 31, 2014, at the Toronto General Hospital and followed for at least 30 days from transplantation admission discharge. EHR risk prediction models were developed using stepwise backward logistic regression and compared for predictive ability using ROC curves. Bootstrapping was used to internally validate the final EHR risk prediction model.
Results: In our cohort of 1,381 KTRs, 267 experienced at least one EHR post-transplant. Our most parsimonious model consisted of 12 variables, such as age, and resulted in a moderate predictive value (ROC=0.65). However, no recipient, donor, and transplant risk factor was highly predictive of EHR. Internal validation resulted in a lower predictive value (ROC=0.61).
Conclusions: The predictive accuracy value of our model could possibly be improved by adding variables such as patients' socioeconomic factors and surgical complications during transplant admission.
Implications for Care: The risk prediction model provides a uniform method to assess and predict EHR in Canadian KTRs. The ability to identify patients who are at higher risk of experiencing EHR will allow practitioners to deliver individually-tailored interventions and reduce future readmissions.
14. Employment Patterns After Kidney Transplantation: Rates, Contributing Factors, and Outcomes
Olusegun Famure, MPH, MEd, CHE
Jayoti Rana, BSc MPH
Monika Ashwin, BSc
Yanhong Li, BSc, MSc
S. Joseph Kim, MD, PhD, MHS, FRCPC, Toronto, ON
Background: The costs of productivity lost in transplant patients poses a concern, as a significant number of patients are of working age. Furthermore, healthcare and public health literature highlight the relationship between a lack of secure income and poor health outcomes. However, few studies have examined predictors of paid employment post-transplant and the impact of employment status on clinical outcomes.
Objectives: (1) To investigate the rates and predictors of post-transplant employment status; and (2) to examine the association between post-transplant employment status and clinical outcomes in kidney transplant recipients (KTRs).
Methods: A retrospective cohort study was conducted in adult patients undergoing a kidney transplant between January 1, 2007, and December 31, 2014, with follow-up until December 31, 2015, at the Toronto General Hospital. Employment status and clinical data were obtained from paper and electronic charts. The Kaplan-Meier product limit method was used to assess time to return to work and time to total graft loss from the transplant date. Multivariable Cox proportional hazards models were fitted to examine independent predictors of post-transplant employment, and the association between employment status and total graft loss.
Results: Among the 1,069 KTRs in the study cohort, the mean age was 50.7 years ([+ or -] 13.6) and 60.2% were male. A total of 319 KTRs returned to work over the first year post-transplant (cumulative probability 30.4%). Significant independent predictors of employment within the first year post-transplant included pre-transplant employment status, age at transplant, length of stay in hospital after transplant, physical disability, and private drug coverage. After adjusting for relevant covariates (including comorbid conditions), being employed (versus not employed) post transplant was associated with a significantly lower risk of total graft loss (HR 0.29 [95% CI: 0.17, 0.50]).
Conclusions: Although transplantation improves working capacity in patients with end stage renal disease, post-transplant employment status was impacted by other factors, including pre-employment status. These findings support the need for pre- and/or post-transplant interventions to improve participation in paid work following kidney transplantation.
15. Quality of Life in Kidney Transplant Patients: A Five-Year Review
Olusegun Famure, MPH, MEd, CHE
Jaya Manjunath, BSc(c)
Anastasia Kalantarova, BSc(c)
Jayoti Rana, BSc, MPH
S. Joseph Kim, MD, PhD, MHS, FRCPC, Toronto, ON
Background: Transplantation success is evaluated by graft and patient survival. Quality of life, (QoL), which assesses overall health by evaluating physical, emotional, and social well-being, is potentially another useful metric to assess successful transplantation.
Objectives: To assess changes in QoL in kidney transplant recipients (KTRs) post-transplantation.
Methods: A QoL Assessment Survey comprising the Kidney Disease and QoL Short Form, End-Stage Renal Disease (ESRD)-Symptom Checklist and an adherence questionnaire were offered to all adult KTRs at Toronto General Hospital transplanted between 2007 and 2016 at baseline and one year post-transplant. Survey responses were used to calculate mean scores for six categories of QoL: Physical Functioning (PF), Role-Physical (RP), General Health (GH), Social Functioning (SF), Role-Emotional (RE), and Emotional Well-being (EW). We used paired student's t-test to compare QoL mean scores at baseline and one year post-transplant and unpaired student's t-test to compare QoL mean scores one year post-transplant to the general Canadian and ESRD populations.
Results: Of 879 KTRs, 343 patients completed a baseline and a one-year post-transplant QoL Assessment Survey. Compared to baseline, the PF, RP, EW and SF QoL mean scores significantly decreased at one year post-transplant. In comparison to the general Canadian population, KTRs at one year post-transplant had significantly lower mean scores for all QoL categories except for EW (p<0.0001), but significantly higher mean scores for all QoL categories in comparison to ESRD patients (p<0.0001).
Implications in Nephrology Care: The QoL Assessment Survey evaluates overall health of KTRs and demonstrates the ability to assess transplant success beyond graft and patient survival.
16. Home Dialysis Training Videos
Rachel Tong, RN
Sukhjeet Samra, RN, Toronto, ON
Purpose: The purpose of this project is to provide educational videos to supplement peritoneal dialysis training at the home dialysis unit.
Introduction: Our program serves patients from diverse cultural backgrounds, socioeconomic status, information retention ability and literacy levels. Current teaching methods are patient-specific, and include the use of a written manual, hands-on-practice, and demonstrations. We believe the addition of step-by-step instructional videos will enhance learning and can provide visual repetition that patients can access at their own convenience.
Description: We will start this project by creating two instructional videos on exit site care and carrying out a continuous ambulatory peritoneal dialysis (CAPD) exchange. Patients and their caregivers will be able to access these videos through the St. Michael's Hospital Home Dialysis website, or these can be given to them in a DVD or USB format.
Outcomes: By implementing the use of these videos, we aim to increase patient satisfaction and comfort, as well as to ensure patients follow proper technique in doing their peritoneal dialysis routine. We hope to achieve this by providing material to supplement hospital training and for patients to review procedures at home.
Implications for Nephrology Education: Exit site infections can lead to peritonitis (infection of the peritoneal membrane). Repeated peritonitis leaves the peritoneal membrane scarred, which then negatively impacts the efficacy of peritoneal dialysis. Infections remain a frequent cause of peritoneal dialysis failure. Developing methods to maintain optimal technique in doing peritoneal dialysis will improve patient outcomes.
17. Assessing the Delivery of Integrated Care to Patients with Chronic Kidney Disease in Ontario: Patient and Provider Perspectives
Saurabh Sati, MBA, Ontario Renal Network
Jenna M Evans, PhD, BHS, Cancer Care Ontario
Sharon Gradin, PMP, BScN, RN Ontario Renal Network
Marnie MacKinnon, BPE, Ontario Renal Network, Toronto, ON
Peter Blake, MD, FRCPC, Ontario Renal Network, London, ON
Area of Focus: History and future directions of CKD and treatment.
Purpose of Study: Patients with chronic kidney disease (CKD) have complex health needs, and thus require care that is integrated across professionals and organizations. The extent to which patients with CKD in Ontario receive integrated care is unclear. This study assessed integrated care delivery across Ontario from provider and patient perspectives.
Methods: A five-item survey for providers was developed and administered via the web by the Ontario Renal Network (ORN) to 596 purposefully selected providers, including nephrologists, nurses, and social workers. Four items from the Patient Assessment of Chronic Illness Care (PACIC-26) survey were used to capture the patient perspective. The patient survey was administered to a random sample of 14,257 patients with CKD.
Results: A total of 314 providers, including 144 nurses, and 2,447 patients responded to the surveys. Key findings include that 36% of providers reported their patients' care was well-coordinated across settings; 51% of providers reported they are aware of appropriate home and community services to support their patients; 20% of patients reported they were encouraged to attend programs in the community; and 38% of patients were asked how their visits with other doctors were going (% reporting 'always' or 'most of the time').
Conclusion: The survey results suggest that patients with CKD in Ontario are not consistently receiving integrated care.
Implications for Nephrology Care: Key areas for future improvement include linkages to community-based services and patient-provider communication. Standardized measurement of integrated care delivery over time, using surveys similar to the instruments utilized in this research study can support local quality improvement and broader system transformation.
18. Development of a 44-Hour Ambulatory Blood Pressure Monitor Training Program
Cheryl Ralph, BScN, RN, CNephC
Cindy Cockram, RN, CNeph(C)
Barbara Drodge, RN
Swapnil Hiremath, MD, MPH
Marcel Ruzicka, MD, PhD, FRCPC, Ottawa, ON
Purpose: Hypertension is widely prevalent in the hemodialysis population and the leading modifiable factor for cardiovascular outcomes. Unlike blood pressure (BP) measured during dialysis, ambulatory BP represents superior measurement of true BP load.
Description: We started 44-hour ambulatory blood pressure measurement at our tertiary care dialysis unit in 2012. Herein, we describe our five-year experience with 44-hour ABPM in regard to patient acceptance and nursing implications.
Outcomes: Forty-four-hour ambulatory blood pressure monitoring (ABPM) was pioneered at a tertiary care in-centre hemodialysis unit. It is well tolerated by patients, with an overall completion rate around 70%. In many cases, this assessment improved overall BP control, and has led to the avoidance of unnecessary escalation of BP-lowering medications, thereby preventing potentially dangerous hypotensive episodes during and in between HD treatments. It has also allowed for up-titration of BP-lowering drugs for patients with identified sustained high BP load.
The Ottawa Civic Campus hemodialysis unit serves as the centre for ABPM for our regional program. Forty-four-hour ABPM requires sophisticated equipment, which was provided by the nephrology program, as well as trained personnel to administer this test. Lack of well-trained professional personnel is the major limiting factor to administering this test at any given dialysis shift on any given day.
Implications: This presentation addresses this gap with the lack of trained nurses and focuses on the development of a pragmatically structured training program for ABPM for a core group of dialysis nurses in our dialysis unit and making ABPM widely available to hemodialysis patients within our regional program.
19. Using a Telehome Monitoring and Communication Platform to Enhance Nursing Support and Practice for Home-Based Renal Replacement Therapy
Jo-Anne McMullen, RN, CNeph (C), London, ON
As the use of home-based therapies increases, nursing practice struggles to find ways to support the growing number of patients. The CONNECT Trial, a multi-centre randomized controlled trial, aims to leverage past research and clinical expertise to seamlessly integrate modern technology into peritoneal dialysis care delivery, optimizing nursing practice and enhancing patient care. In June 2016, we began to evaluate the impact of a mobile and browser-based home dialysis management platform on patient engagement, clinical outcomes, and operational efficiency in peritoneal dialysis clinics. Interim results of this trial demonstrate that the integration of the platform has greatly improved quality of care delivered to patients by enabling healthcare team members to identify and intervene early in clinical situations through real time access to data from the home, as well as improved communication methods, including messaging and picture sharing. In addition, we will explore how the use of the platform has identified opportunities for patient re-education, increased patient confidence, and reduced feelings of isolation to empower patients to better manage their self-care. This study explores the significant positive impact that a home dialysis management platform can have on patient health outcomes and confidence by establishing a new and innovative way of providing care to patients.
20. Dying with Dignity: A Hemodialysis Medical Assistance in Dying (MAID) Case
Primrose Mharapara, MScN, PHC-NP, RN(EC), CNeph(C), Toronto, ON
The goal of patient care in nephrology is to achieve good quality of life for patients with chronic life-limiting illness. End-stage renal disease (ESRD) is associated with limited life expectancy, high morbidity, and burden of symptoms. Dialysis is often burdensome and, increasingly, patients, families, and healthcare teams express doubts about the quality of life of individuals with multiple other health problems (Brown, Chambers, & Eggeling, 2008). Among patients on dialysis, survival rates and complexity of comorbidities are increasing; in addition, withdrawal from dialysis is becoming a more common cause of death in these patients. The prognosis and outcome of this patient population can be difficult to predict. This unknown aspect in health care can be emotionally taxing to the patient and his/her family and presents unique medical and ethical challenges (Rak et al., 2017). End-of-life care is multifaceted and may include palliative care, psychological support, spiritual care, and medical assistance in dying (MAID). MAID is available for patients meeting specific eligibility requirements to decrease suffering from grievous and irremediable medical conditions of the right to life, liberty, and security of the person. This case of a vintage hemodialysis patient will exhibit patients' perspectives of suffering and inability to cope, demonstrate the UHN MAID process and role of an interdisciplinary team, and provide an ethical framework for decision-making during end-of-life care.
Brown, E.A., Chambers, E.J., & Eggeling, C. (2008). Palliative care in nephrology. Nephrology Dialysis Transplantation, 23(3), 789-791.
Rak, A., Raina, R., Suh, T.T., Krishnappa, V., Darusz, D., Sidoti, C.W., & Gupta, M. (2017). Palliative care for patients with end stage renal disease: Approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses. Clinical Kidney Journal, 10(1), 68-73.
21. La perception du Sentiment de Bien-etre des Patients Recevant des Traitements d'Hemodiafiltration
Roch Beauchemin, MScN, Inf, IPSN
Nancy Filteau, MScA. BScN, Inf
Andrea Laizner, PhD, MScA, BScN
Daniel Nagel, PhD, MScN, BScN, Montreal, QC
Introduction: L'hemodiafiltration (HDF) est un traitement qui associe hemodialyse et hemofiltration. Ce traitement permet de filtrer davantage de toxines uremiques que la dialyse traditionnelle. Cette association peut ainsi diminuer certains des effets negatifs de l'hemodialyse, comme l'amyloidose. La perception du sentiment de bien-etre chez les patients recevant les traitements d'HDF est peu connue ni bien documentee.
Les objectifs de la presentation: Nous presenterons les donnees d'une etude qualitative descriptive qui avait pour but d'explore la perception de bienetre des patients recevant des traitements d'hemodiafiltration.
Methodologie: Des entrevues d'une duree de 60 minutes ont etes conduits aupres de 10 patients ages entre 42 et 75 ans. L'echantillon comprend trois femmes et sept hommes, parmi lesquels cinq etaient francophones et cinq etaient anglophones. Ensuite, les entrevues furent transcrites et les membres de l'equipe de recherche ont analyse les donnees et ressorti les themes principaux des entrevues.
Resultats: Espoir, but de fonctionner normalement, attentes non-realisees, croyance et destinee, et influence des soignants sur les pensees et perceptions sont les cinq themes principalement abordes par les participants. Un cadre conceptuel emergea de l'analyse. Il met en relation les differentes dimensions de la signification du bienetre avec les themes pour illustrer les diverses perceptions et ainsi comprendre le sentiment de bienetre chez les patients sous traitement d'HDR
Conclusion: Les resultats de l'etude demontrent la complexite de ce sujet. Le bienetre est multidimensionnel. Ceci indique que l'approche infirmiere aux personnes recevant des traitements d'HDF doit etre individualisee et la recherche doit continuer.
22. La litteratie en nephrologie: une approche pour se reinventer : resultats d'une etude clinique
Julie Dupont, IPS nephrologie, M. Sc., DESS, Quebec, QC
Le but de l'etude etait d'evaluer le niveau de litteratie en sante des patients adultes atteints d'insuffisance renale chronique au CHU de Quebec-Universite Laval.
Cette etude de cohorte unicentrique transversale avait un echantillon de 353 patients : 152 en pre-dialyse, 157 en hemodialyse hospitaliere, 32 en dialyse peritoneale et 12 en hemodialyse a domicile. Deux outils auto-administres ont ete utilises : le Brief Health Literacy Screen (BHLS), librement traduit et le Health Literacy Questionaire (HLQ) en version francaise validee (9 domaines de la litteratie etudies).
Selon le BHLS, les patients dialyses a domicile ont un niveau de litteratie plus eleve compare aux 2 autres groupes (p <0.001). Pour le HLQ, les patients dialyses a domicile, compares aux autres groupes, se sentent plus soutenus et compris par les professionnels de la sante (p <0.001), evaluent mieux l'information sur leur sante (p < 0.001) et la comprennent mieux leur permettant de savoir agir (p <0.001).
Les patients en dialyse a domicile ont un niveau de litteratie plus eleve. La majorite de la population autochtone n'a pas pu participer a l'etude par limitation du francais parle ou ecrit.
Prendre conscience du niveau de litteratie des patients permettra d'adapter les interventions et le materiel d'enseignement afin de mieux repondre aux besoins des patients, d'augmenter leur capacite d'auto-soins et de favoriser l'acces a la dialyse autonome. Une attention particuliere devra etre apportee a la clientele autochtone afin de cerner leur niveau de litteratie et de s'adapter a leur realite.
23. Augmenter l'acces a la dialyse peritoneale par l'ajout d'un nouveau mode d'installation des catheters en angioradiologie: resultats d'une etude retrospective
Julie Dupont, IPS nephrologie, M. Sc., DESS, Quebec, QC
L'etude decrit les resultats cliniques et complications associes a l'installation des catheters de dialyse peritoneale (DP) en angioradiologie au CHU de Quebec-Universite Laval.
Cette etude retrospective unicentrique regroupe tous les patients ayant eu un catheter de DP en angioradiologie entre janvier 2014 et aout 2016 (n = 27). L'incidence cumulative des complications immediates (<24h), precoces (<7 jours) et a 3 mois sont repertoriees pour les hemorragies, infections, fuites, catheters dysfonctionnels et mal positionnes.
Aucune complication immediate serieuse ni hemorragie n'ont ete observees. Il y a eu 4 infections de site d'emergence du catheter. Trois patients ont fait une peritonite plus d'un mois apres l'insertion du catheter et traitees efficacement par antibiotiques. Quatre patients ont eu un mauvais positionnement du catheter : 3 cas resolus par laxatifs et un par repositionnement en angioradiologie. Les patients ont debute la DP un mois apres l'installation du catheter. A 3 mois, 3 patients ont eu des fuites (peri-catheter, scrotale, pleurale). A 3 mois, 25 patients (sur 27) etaient en DP active.
L'etude demontre donc un haut taux de succes et un faible taux de complications avec l'installation des catheters de DP en angioradiologie.
L'introduction de cette technique a probablement contribue a l'augmentation de la prevalence en DP dans notre centre passant de 60 a 70 patients. Puisque cette technique est plus economique et moins invasive que la chirurgie, elle devrait etre utilisee pour l'installation des catheters de DP chez les patients non-compliques.
24. S'adapter a nos patients, de la litteratie a l'enseignement : une avenue se conjuguant au present et au futur pour ameliorer les soins!
Julie Dupont, IPS nephrologie, M. Sc., DESS, Quebec, QC
Cette presentation repose sur une revue de litterature et presente les concepts de litteratie en sante dans le domaine de la nephrologie ainsi que la pedagogie de l'adulte (andragogie) dans le but d'ameliorer les soins offerts aux patients par des enseignements adaptes.
Plusieurs etudes rapportent differents niveaux de litteratie dans les diverses clienteles nephrologiques. Les concepts generaux, les donnees probantes en nephrologie ainsi que des pistes d'action concretes pour inclure les concepts de litteratie au quotidien seront presentes.
L'androgogie est une science comprenant plusieurs theories d'apprentissage. Certaines d'entre elles sont a la base de guides de pratique clinique pour la formation des patients en dialyse peritoneale comme celui de l'International Society of Peritoneal Dialysis (ISPD). Des types et theories d'apprentissage seront exposes en lien avec les patients insuffisants renaux en plus des nouvelles lignes directrices pour l'enseignement en dialyse peritoneale. Des outils facilement integrables au quotidien seront aussi decrits pour determiner les types d'apprentissage des patients.
Cliniquement, comprendre la capacite des patients a obtenir, decoder et utiliser l'information permet d'ajuster les soins pour ameliorer la capacite d'auto-soins des patients. L'enseignement aux patients fait partie du quotidien des infirmier(e)s en nephrologie. Connaitre des notions d'apprentissages chez les adultes permet d'adapter le materiel et d'individualiser les methodes d'enseignement utilisees en identifiant le type d'apprentissage des patients.
La recette du futur : s'adapter, integrer la litteratie et individualiser nos approches pour mieux repondre aux besoins des patients dans le present.
25. Le role de l'eau pour l'hemodialyse
Leo Sauriol, Technologue en Genie Biomedical
Rochelle Stiven, Technologue en Genie Biomedical
Mohammed Amri, Technologue en Genie Biomedical, Lachine, QC
D'hier a aujourd'hui ; l'eau utilisee pour les therapies d'hemodialyse et d'hemodiafiltration. Au debut de l'hemodialyse, on a utilise l'eau potable de concert avec le concentre acide et bicarbonate pour fabriquer le dialysat. Au fil du temps, on s'est rendu compte que l'eau potable etait inadequate pour effectuer ces traitements. En effet, les patients devenaient malades pendant et apres leurs traitements. Une relation fut faite entre l'eau utilise et les maux des patients dialyses. Par exemple, une eau qui contenait 0,25mg/L ou plus de chlore cree l'anemie et l'hemolyse chez plusieurs patients. De meme, pour l'aluminium qui est utilise comme coagulant dans la majorite des usines d'eau potable, le seuil de toxicite est de 200 mg/L qui lorsqu'atteint, cause la << demence de dialyse ou encephalopathie >>. Neanmoins, ces 2 substances ne sont pas reglementees pour l'eau potable ou tres peu. En effet, selon Sante Canada, le chlore dans les reseaux d'eaux potables au Canada est entre 0,04 mg/L et 2,0 mg/L et il n'y a pas de recommandation pour la quantite de chlore dans l'eau potable. En ce qui concerne l'aluminium, Sante Canada recommande que la moyenne annuelle soit en bas de 0,2 mg/L. Ce qui signifie qu'une municipalite peu ponctuellement utilise de tres grande quantite d'aluminium sans pour autant sortir de la recommandation de Sante Canada. Par consequent, il y a une correlation a faire entre la quantite d'eau utilise dans un traitement et le besoin d'utiliser une eau de plus en plus pure. C'est la raison de privilegier les systemes d'osmose double passe pour les traitements d'hemodiafiltration. Enfin l'utilisation d'eau purifiee a permis de diminuer la mortalite des patients qui necessitent des traitements d'hemodialyse.
* La norme de qualite d'eau a respecter aujourd'hui pour l'hemodialyse.
* La norme de qualite d'eau a respecter aujourd'hui pour l'hemodiafiltration.
** Theorie versus realite de la norme pour l'hemodiafiltration
** Les etapes pour se rendre a la realite
* Etude de cas : L'implantation d'un systeme de purification qui respecte les normes d'aujourd'hui quant a la qualite de construction et d'eau produite (hemodiafiltration) a l'hopital General de Montreal.
* Le devis technique
** L'evaluation des besoins
** L'etude des normes en vigueur
** S'informer sur les certifications detenues telles que Building Owners and Managers Association (BOMA), Leadership in Energy and Environmental Design (LEED) ou Hospitals for a Healthy Environment (H2E)
** Observation des nouvelles tendances par exemple en Europe
** L'art de boucher les << trous >> lors de l'ecriture
* Problemes rencontres
** Choix du soumissionnaire
** Renovations de la salle (retards)
** Erreur d'analyse lors de la certification du nouveau systeme d'eau
* Mise en route du nouveau systeme de traitement d'eau sur la vieille boucle de distribution d'eau comme plan de contingence apres qu'il ait ete certifie
* L'installation d'un systeme temporaire dans la nouvelle salle d'eau renovee afin de certifie la nouvelle boucle
* Le transfert des generateurs de dialyse sur la nouvelle boucle
* Le transfert du systeme d'eau dans la salle renovee et son branchement sur la nouvelle boucle
26. Le role du technicien de Genie Biomedical en Dialyse
Leo Sauriol, Technologue en Genie Biomedical
Rochelle Stiven, Technologue en Genie Biomedical
Mohammed Amri, Technologue en Genie Biomedical, Lachine, QC
* Entretiens preventifs et correctifs des generateurs de dialyse, du systeme de purification d'eau et des chaises utilisees par les patients. Effectuer les entretiens correctifs des hemodialyseurs en atelier ou dans l'unite?
** Les entretiens preventifs servent a prevenir une multitude de bris en plus de permettre une restauration des performances d'origine.
** Les entretiens correctifs eux seront de 2 ordres, simple et complexe a solutionner. Pour les entretiens correctifs simples, nous pourrons souvent intervenir dans l'unite de dialyse entre 2 patients. Par consequent, les entretiens correctifs complexes iront dans l'atelier. Toutes les reparations impliquant d'ouvrir le circuit hydraulique et necessitant une desinfection s'effectueront en atelier.
** Les entretiens preventifs... pourquoi?
** Les entretiens correctifs et preventifs du systeme de purification d'eau
* Relation avec les infirmiers(eres), les preposes(es) et les patients
** Une bonne communication est essentielle car le personnel soignant connait les patients et peuvent nous fournir d'importantes informations.
*** Fuite de sang
*** Presence d'une maladie infectieuse
*** Quel est exactement le probleme qu'elles ont observe
*** De notre cote, il est primordial de tenir les infirmieres et preposees au courant des problemes qui ont un impact sur leur travail et des solutions mises en place.
* Plusieurs fois par semaine voir par jour nous sommes appeles dans l'unite de dialyse pour repondre a diverses questions :
** Que signifie cette alarme qui est affiche sur l'hemodialyseurs?
*** Erreurs de debit
** Module BVM (blood volume monitoring) qui ne demarre pas
** Module de pression arterielle qui reste grise et ne prend aucune pression arterielle
** Fonctionnalites possibles des hemodialyseur
** Communication du logiciel de collection de donnees patients (pression arterielles, concentres, temps de traitements,... )
* Dans le cas des patients, il faut etre a l'ecoute et expliquer ce qu'on fait lorsqu'on travail pres d'eux ou s'ils nous le demande.
* Acquisition de materiels
** Recherches afin d'obtenir la meilleure proposition qui comble le besoin au meilleur prix
* Renouvellement des equipements
** Faire connaitre les besoins de renouvellement des equipements (desuetudes, bris frequents et autres raisons)
** De concert avec l'ingenieur Biomedical ou le Specialiste
*** Ecrire le devis technique
*** Evaluer les soumissions recues
*** Repondre aux questions techniques des soumissionnaires recues lors d'appel d'offre Telle que pourquoi vous avez demande l'hemodiafiltration? Ou pourquoi vous demandez la capacite neonatal? Ou pourquoi vous avez demande l'amorcage en ligne? Ou pourquoi vous avez demande des roues d'une grandeur minimum?
27. Can Nursing Procedures Have an Influence on Improved Anemia Control?
Maria-Teresa Parisotto, RN, Bad Homburg, Germany
Introduction: Most patients who require hemodialysis have a variety of serious health problems, one of them anemia, a common complication of both renal failure and hemodialysis. Dietary restrictions and poor absorption or removal of iron and vitamins by hemodialysis can contribute to anemia. The hemodialysis procedure itself leads to a loss of 300 to 600 grams of hemoglobin (Hb) per year due to blood retention in the dialysis lines and filters.
Objectives: To maintain an adequate level of hemoglobin and a high quality of care by optimizing the blood reinfusion at the end of treatment.
Methods: 840 hemodialysis patients were followed up from December 2011 to September 2013. Results on hemoglobin level and erythropoiesis stimulating agents (ESA) consumption were compared before and after the blood reinfusion optimization.
Results: At baseline (December 2011), with ESA and iron doses of 1.87 [+ or -] 1.87 mcg/kg/month, 2.21 [+ or -] 2.42 mg/kg/month, respectively, the hemoglobin level was 11.25 [+ or -] 1.24 g/dL. In December 2012, with ESA and iron doses of 1.21 [+ or -] 1.31 mcg/kg/month and 3.18 [+ or -] 2.17 mg/kg/month, respectively, the hemoglobin level was 11.34 [+ or -] 1.22 g/dL. In September 2013, with ESA and iron doses of 1.39 [+ or -] 1.43 mcg/kg/month and 1.98 [+ or -] 2.13 mg/kg/month, respectively, the hemoglobin level was 11.22 [+ or -] 1.18 g/dL (p=0.57 NS).
Conclusion: The analysis demonstrated that, by performing a proper reinfusion procedure, it is possible to reduce the quantity of residual blood in the extracorporeal circuit, thereby reducing anemia risks and increasing safety while optimizing costs.
28. Creating Meaningful Experiences for Grieving Family Members in Adult Critical Care Areas
Wendy Sherry, Nurse Clinician, Montreal, QC
Hospital end-of-life care (EOL) rituals and the creation of keepsakes are often completed in neonatal and pediatric critical care units (Kobler, Limbo, & Kavanaugh, 2007). However, EOL needs in adult critical care units are scarce despite the 2001 recommendations by the Society of Critical Medicine (Troug, et al., 2001). At the MUHC, the nurse clinicians for organ and tissue donation create keepsakes through interactive family activities such as making handprints, drawing pictures, writing letters/poems, etc. The presentation will demonstrate a need for research on EOL care practices in adult critical care units as anecdotal evidence demonstrates a positive effect on the grieving process. Utilizing Wright and Bell's Belief and Illness Model (2009), cultural values, religious beliefs and family needs are explored in order to develop tailored therapeutic interventions to create a meaningful bedside experience for family members.
1. To provide an overview of MUHC Nurse Clinician Organ & Tissue Donation EOL bedside practices
2. To compare current adult critical care EOL care standards with the interactive family activities practised by nurses working in organ and tissue donation
3. To promote reflection on the usual standard of adult EOL care in critical care areas
Kobler, K., Limbo, R., & Kavanaugh, K. (2007). Meaningful moments: The use of ritual in perinatal and pediatric death. MCN: The American Journal of Maternal Child Nursing, 32, 288-297. doi:10.1097/01.NMC.0000287998.80005.79
Troug, R.D., Cist, A.F.M., Brackett, S.E., Burns, IP., Curley, M.A.Q., Danis, M.,... Hurford, W.E. (2001). Recommendations for end-of-life care in the intensive care unit: The ethics committee of the society of critical care medicine. Critical Care Medicine, 29(12), 2332-48. Retrieved from http://www.learnicu.org/Docs/Guidelines/End-of-LifeCare.pdf
Wright, L M. & Bell, J.M. (2009). Beliefs and illness: A model for healing. Calgary, AB: 4th Floor Press Inc.
29. Supporting Culturally Diverse Families Involved in the Deceased Donation Process
Wendy Sherry, Nurse Clinician, Montreal, QC
Many people assume they are culturally sensitive because they are polite and respectful to people with different ethno-cultural backgrounds; or they get along well at work with colleagues who are members of a different ethno-cultural community. However, providing culturally congruent care to patients and families with diverse cultural backgrounds and who are involved in the deceased organ and tissue donation (OTD) process can be challenging (Guido, et al., 2009; H0ye & Severinsson, 2008; Pearson et al., 2001). In 2010, the Expert Panel on Global Nursing created a set of universal transcultural standards to guide nursing care practice. These standards, Leininger's (1988) Theory of Culture Care Diversity and Universality, discussions with members of key ethno-cultural communities, nurses, and expert clinicians in the field of OTD, informed the creation of a nursing resource manual for critical care nurses caring for culturally diverse families involved in the OTD process. Participants' cultural self-knowledge will be evaluated with a self-assessment checklist (available in English and French), and the contents of the critical care nursing resource manual will be presented. The manual was created in partial fulfilment of a graduate degree in nursing (Sherry, 2014).
Synopsis: The objective of this workshop is to promote reflection of cultural awareness and to demonstrate how nursing care is impacted when supporting culturally diverse families involved in the deceased organ and tissue donation process. A review of the developed nursing resource manual for critical care nurses caring for ethno-cultural families involved in the donation process will be presented. In addition, a checklist designed to measure cultural competence (English and French) will be provided to promote discussion.
Expert Panel on Global Nursing and Health. (2010). Standards of practice for culturally competent nursing care: Executive summary. Retrieved from http://www.tcns.org/files/Standards_of_Practice_for_Culturally_Compt_Nsg_Care-Revised_.pdf
Guido, L.D.A., Linch, G.F.D.C, Andolhe, R., Conegatto, C.C., & Tonini, C.C. (2009). Stressors in the nursing care delivered to potential organ donors. Revista Latino-Americana de Enfermagem, 17, 1023-1029.
Hoye, S., & Severinsson, E. (2008). Intensive care nurses' encounters with multicultural families in Norway: An exploratory study. Intensive and Critical Care Nursing, 24, 338-348. doi10.1016/j.iccn.2008.03.007
Leininger, M.M. (1988). Leininger's Theory of Nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1, 152-160. doi:10.1177/089431848800100408
Pearson, A., Robertson-Malt, S., Walsh, K., & Fitzgerald, M. (2001). Intensive care nurses' experiences of caring for brain dead organ donor patients. Journal of Clinical Nursing, 10, 132-139. doi:10.1046/j.1365-2702.2001.00447.x
Sherry, W. (2014). Development of a resource manual for critical care nurses caring for culturally diverse families involved in the organ and tissue donation process--A practicum report submitted to the School of Nursing in partial fulfillment of the requirements for the degree of Master of Nursing. St. John's, NL: Memorial University of Newfoundland.
30. Clinical Outcomes of Home Hemodialysis with Low Dialysate Volume
Julien Gautier, Engineer, NxStage Medical, Inc.
Sharon Fairclough, BN, MN(c), RN, CNeph(C), Clinical
Educator, NxStage Medical Canada, Inc.
Sharon Joy Dubiel, BScN, M.A.(ed), Clinical Educator, NxStage Medical Canada, Inc.
Eric Weinhandl, Clinical Epidemiologist and Statistician, NxStage Medical, Inc.
Purpose: The Canadian Agency for Drugs and Technologies in Health recommends self-care home-based dialysis in patients diagnosed with end-stage kidney disease, either with home hemodialysis (HHD) or peritoneal dialysis. We evaluated outcomes on HHD with a transportable device that employs low dialysate volume (LDV).
Methods: We collected data from HHD patients at nine centres in Western Europe. We recorded hemodialysis prescription, biochemical, and medication data at HHD initiation, and at six and 12 months thereafter.
Results: The cohort comprised 182 patients. Ranges of age, body mass index, and Charlson score were 15 to 84 years, 13.3-50.8 kg/[m.sup.2], and 2-11 points, respectively. Mean training duration was 18.9 sessions. Most (93.4%) patients were prescribed five or six sessions/week, and session duration was commonly 2.0-3.5 hours; mean dialysate volume was 23.9 L/session. Mean ultrafiltration (UFR) rate declined from 6.9 to 6.6 mL/hour/kg between HHD initiation and 12 months, with a halving of patients with UFR [greater than or equal to]10 mL/hour/kg. Mean standardized Kt/V was 1.6 at all times; the majority of patients had standardized Kt/V between 2.4 and 3.0 at 12 months. Serum concentrations of bicarbonate, potassium, calcium, phosphorus, albumin, and hemoglobin were stable. The percentage of patients using no antihypertensive medications steadily increased from 27% at HHD initiation to 36% at six months and 42% at 12 months.
Conclusions: HHD with LDV is viable for a wide array of patients. Increased treatment frequency, low ultra-filtration intensity, stable biochemistry, and reduced medication use are observed.
Implications: HHD with LDV presents features likely to lead to better clinical outcomes.
31. Conservative Kidney Management: An Alternative Care Pathway to Dialysis
Betty Ann Wasylynuk, BScN, RN
Janice McKenzie, MScN, RN
Sara N. Davison, MD, MSc, Edmonton, AB
The prevalence of advanced chronic kidney disease for patients 75 years and older continues to climb worldwide with dialysis often being the default modality option. Unfortunately, many of these older patients suffer from functional disability, cognitive impairment, and/or high levels of comorbidity, and dialysis may not provide them with either a survival or quality of life advantage. Alberta's Kidney Health Strategic Clinical Network[TM] (KHSCN) strives to optimize kidney care and outcomes across all ages and stages of kidney health. As a result, in partnership with the KHSCN, and using state of the art implementation science, we developed a provincial Conservative Kidney Management (CKM) pathway aimed at providing sustainable, high-quality and evidence-based care for patients who are unlikely to benefit from dialysis and have chosen a conservative approach to care. The purpose of this presentation will be to describe Alberta's CKM pathway: its purpose, development, implementation, and evaluation, including feedback from CKM patients and renal staff providing CKM care. Lastly, participants will receive a guided tour of the publicly accessible and interactive CKM website (www.ckmcare.com). Upon completion of the presentation, participants will learn that CKM is an alternative care pathway for patients who are unlikely to benefit from dialysis.
32. Are We There Yet... Challenges of Transition to Adult Care
Paule Comtois, BScN, Montreal, QC
According to the Canadian Pediatric Society, 15% of youth in North America have a chronic condition. Although there has been active research on the transition to adult care in the past 20 years that has contributed to better understanding of the transition process, the search for improvements in this process continues. Clinicians continue to strive to achieve a process that minimizes the time and resources required for effective transition from the pediatric to the adult environment. The real challenge, however, remains fostering independence in these young adults in order for them to assume responsibility for their care at large. Chronic illness should not deter these patients from becoming young adults who have fulfilling lives and control over their illness.
In this presentation, we will explore the barriers to transition to adult care, and the impact it has on the family and the care team at large (pediatric and adult). Different transition models have been developed to support these teenagers acquiring milestones required to become responsible for their health such as pediatric transition clinics, joint adult-pediatric transition clinics, or a novel approach utilizing technology and long-term follow-up for young adults.
The challenge lies in what approach to take with these patients, as a one-size-fits-all approach may not address their unique needs.
This presentation underscores the importance of the pediatric and adult care team and family members working closely together toward the common goal of a successful transition for our patients.
Let's make it happen.
33. Le donneur vivant non compatible: quelles sont les options?
Liane Dumais, IPSN, M. Sc., D.E.S.S., Quebec, QC
Pour une majorite des personnes qui souffrent d'insuffisantes renales chroniques au stade terminal de la maladie, la greffe renale est le mode de suppleance qui ameliore considerablement leur qualite de vie.
Selon la litterature, la transplantation renale a partir d'un donneur vivant presente de nombreux avantages dont la diminution de la duree d'attente pour un rein, la possibilite d'une greffe preemptive afin d'eviter la dialyse et un meilleur fonctionnement et survie du greffon. En outre, la promotion du don vivant s'inscrit dans une volonte provinciale d'augmenter le nombre de transplantation en provenance de ce type de donneur. (Projet don vivant de rein, Ministere de la sante et des services sociaux, 2016). Quelles sont les options du receveur lorsque le donneur vivant potentiel qui s'est manifeste est incompatible?
Cette presentation abordera les themes suivants afin de d'informer et de sensibiliser les infirmieres en regard des options possibles, qui a son tour pourra renseigner le receveur et ses proches:
* L'augmentation de la sensibilite des techniques d'identification des anticorps
* Le test de compatibilite croise virtuel (<< cross match virtuel >>)
* Les antigenes permis en presence d'anticorps pour faciliter l'acces a la transplantation chez les receveurs sensibilises
* La greffe ABO incompatible et la desensibilisation HLA
* Le programme canadien de << don croise de rein >>.
L'infirmier(e) en nephrologie pourra ensuite renseigner le receveur.
Oral and Poster Presentations
1. Creating an Opportunity to Improve Outcomes through a Joint Initiative to Develop a Standardized Preceptor/Mentor Workshop for Hemodialysis (HD) Nurses
Lezlie Lambert-Burd, B.Ad.Ed, BScN, RN, CNeph(C), St. Catharines, ON
Can a joint initiative between two partner organizations develop a standard learning opportunity for HD nurses that will improve outcomes for mentors and mentees?
The literature shows that a successful orientation has the capacity to empower nurses, increase retention rates, ensure patient safety, and improve positive patient outcomes (Bally, 2007). Training for preceptors or mentors will support and improve instruction and confidence during orientation for both the preceptor and preceptee (Squillaci, 2015). Furthermore, effective orientation may increase overall job satisfaction, thus improving retention and, ultimately, reducing program costs (Grindel, 2004).
An opportunity was seized, and an integrated project to develop and deliver a preceptor to mentor full-day workshop for HD nurses at both partner organizations using a standardized approach was achieved. The aim was to provide nurse preceptors/ mentors with the opportunity to cultivate their knowledge, skills, and attitudes/abilities to support new learners and further develop a toolbox of usable resources to support knowledge translation in their preceptor roles. A priority goal was to utilize the RNAO Practice Education in Nursing (2016) in the development and implementation of the preceptor/ mentor workshop.
Data were captured at both pre and post workshop with a follow-up survey at six months to assess the impact and implementation of new knowledge into practice. Data demonstrated measurable improvement with learning outcomes and staff satisfaction with an integrated workshop experience.
Creating an opportunity for professional development within a program may positively impact healthcare organizations, cultivate collegial learning environments, and ultimately improve nursing care.
Bally, J.M.G. (2007). The role of nursing leadership in creating a mentoring culture in acute care environments. Nursing Economics, 25(3), 143-147.
Grindel, C.G. (2004). Mentorship: A key to retention and recruitment. Medsurg Nursing, 13(1), 36-37.
Registered Nurses' Association of Ontario (RNAO). (2016). Practice Education in Nursing. Toronto, ON: Author.
Squillaci, L. (2015). Preceptor training and nurse retention. Project study in partial fulfillment for degree of doctorate of nursing practice. Retrieved from ScholarWorks http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=1302&context=dissertations
2. Interprofessional Shadowing Between the Hemodialysis Unit and Laboratory
Billie Hilborn, MHSc, BScN, RN, CNeph(C)
Jhanvi Solanki, MScN, MBA, RN
Elizabeth McLaney, BA, MEd, BScOT, OT Reg. (Ont)
Anne Marie Phillips, BSc, ART (Hematology), MLT
Neil Lund-Walker, MLA,
Irene Alao, BScN, RN
Melissa Adamson, BScN, RN, Toronto ON
Successful collaborative practice between disciplines relies on quality working relationships (Laflamme, 2017). The purpose of this project was to foster high quality, person-centred care by learning together across professions. The two main goals included enhancing the culture of collaboration and interprofessional competencies between the laboratories and nursing with attention to role clarification and interprofessional conflict resolution while supporting ongoing quality improvement.
A shadowing experience was designed for nursing and laboratory services in four dyad pairs, with one pair being from Specimen Management in the lab and the hemodialysis unit. One member from each department spent 2.5 hours shadowing in the other department. Sets of questions were prepared for participant reflection before, during, and after the shadowing experience.
Anticipated outcomes included improved ability for dyads to describe common work flow tasks and priorities, identify challenges and competing demands for their partner's profession, and relate the impact of their profession's work on their partners. This will improve existing relationships and promote interprofessional collaboration between the laboratories and hemodialysis unit.
Implications for Nephrology Practice/Education:
When collaboration between the laboratories and hemodialysis unit is not optimal, there can be negative impact on patient experience such as having repeated specimens drawn for testing, inefficiencies due to repeating work processes and reporting of critical results, wasted resources such as test tubes and reagents, and siloed work that limits improvement opportunities. This project will hopefully promote a positive impact.
Laflamme, L. (2017). Enhancing perioperative patient safety: A collective responsibility. Operating Room Nurses Association of Canada (ORNAC) Journal, December, 13-33.
1. Role of the Regional Resource Nurse From Teacher to Mentor
Mary Touzel, RN, CNeph(C), London, ON
There are many facets to the Regional Resource Nurse role. We are highly involved with all aspects of mentoring due to the distance locations of our satellites. We teach, empower, and develop critical thinking skills within our satellite units from the novice to the experienced nurse.
This presentation will utilize a poster display board reflecting how we utilize different teaching styles to suit the learner's needs especially in the changing hospital environment. By sharing my experience, I hope to help other hemodialysis units overcome teaching hurdles and help ensure student success.
1. Distinguish between different learning styles
2. Distinguish pros & cons of being a novice nurse
3. Distinguish pros & cons of being an experienced nurse
4. Identify education process for RN and RPN
5. Continuing education within satellite units
6. Comparison of students with or without simulation experience.
2. Addressing Healthcare Gaps: The Person-Centred Decision-Making Initiative
Elizabeth Carmelina del Rosso, BA, Honours Psychology, Kitchener, ON
Purpose: To provide an overview of the development and implementation of the Person-Centred Decision-Making (PCDM) initiative, in Grand River Hospital's Renal Program.
Description: PCDM conversations ensure that patients receive treatment in accordance with their values, wishes, and goals. Unfortunately, data show that PCDM conversations often do not take place, or occur late in a patient's illness trajectory, essentially compromising the standard of care received.
In 2017, the Nephrology department at Grand River Hospital established an interdisciplinary team responsible for the implementation of PCDM conversations into routine care. Briefly, this process included: (1) each patient identifying a Substitute Decision-Maker(s) (SDM); (2) healthcare providers prompting interaction regarding patient values and Goals of Care (GOC) in alignment with the Plan of Care (POC); and (3) obtaining informed consent from patients for treatment decisions.
Evaluations/Outcomes: Qualitative and quantitative data from the development and implementation processes of this initiative will be discussed.
Implications: Incorporating PCDM conversations into routine care will ensure that patients are better equipped to make decisions about their healthcare and that healthcare providers are delivering a higher standard of care.
3. Improved Identification of Hemodialysis Patients at Risk for Falls to Increase Preventative Action Strategies and Patient Safety
Anuradha Sawant, PhD, PT
Sarah Spence, MN, NP-PHC
Trisha Slinger, BScN, BAHons, RN, CMSN(C), London, ON
Purpose: To compare the Renal Fall Risk Assessment Tool (RFRAT), an evidence-based fall risk assessment tool developed for people on maintenance hemodialysis (HD), to the Morse Fall Scale (MFS) that is currently used in the outpatient HD units at London Health Science Centre (LHSC) in London, Ontario.
Method: The RFRAT and MFS were administered by RNs to participants on HD at the University Hospital (UH) HD Unit. The total scores were compared using a one-sample t test.
Results: The RFRAT was completed on 28 participants (n=28). The MFS was completed on 25 of the same participants. The results indicate seven of the 28 participants who were rated at "no risk" or "low risk" for falls on the MFS were either "at risk" or "medium risk" for falls on the RFRAT. The MFS (mean [M] = 2.8, standard deviation (SD) = 2.1, n = 25) and RFRAT (M = 9.5, SD = 2.7, n = 28) scores were significantly different (p<0.001).
Conclusion: The RFRAT is more likely to detect subtle changes in the mobility of people on HD and identify the risk for falls more accurately than the MFS.
Implications: The RFRAT is more sensitive to detect falls in people on HD and should be routinely used to identify people at risk for falls in LHSC's HD units. Improving fall risk assessments can lead to increased use of appropriate fall prevention services.
4. Vascular Access Link Nurse's Initiative: A Bold Commitment With Exemplary Results
Bincy Varghese, BSN, RN, CNeph(C)
Maricar Vergara, RN, Surrey, BC
Depending on one's outlook, experience is, indeed, the best coach in life.
In 2016, the Link Nurses group was formed by 10 frontline staff to mitigate the lack of having a vascular access RN on site. The primary aim was to promote a common understanding in the care and management of arteriovenous fistulas and grafts.
The endeavour has proven to be of vital significance in addressing commonly encountered issues in the unit and in influencing the way our staff treat a patient's lifeline. In 2017, an additional 25 frontline staff found inspiration with the achievements of the first group and, thus, voluntarily committed themselves to learn from each other's experiences to enrich their knowledge, harness valuable skills, and improve the overall perception of and approach to vascular access-related issues.
To promote active participation, each member was asked to select a topic to research on and to share their findings through weekly meetings, which eventually facilitated the presentations of current access-related issues. The theoretical and practical components of vascular access care (including sonography) were covered within a span of one year. Opportunities to practise on ultrasound guided-cannulation and access mapping were provided with the support of pioneer vascular link nurses.
Overall, the group has gained the respect and recognition from patients and their families, the multidisciplinary team, and other members of the healthcare team in different units within Fraser Health.
5. Prevalence of Cardiac Events in Patients With Chronic Kidney Disease
Leonor Cercena, BScN, RN, Montreal, QC
Purpose: To determine the prevalence of previous or current cardiac events in patients with chronic kidney disease (CKD) as this is a common cause of mortality in those patients.
Methods: This retrospective study included 199 patients (118 males and 81 females, mean age 64, range 26 to 95 years) with CKD currently on dialysis in our institution. We looked at these patients' charts for prior history of cardiac events as defined by previous hospitalization with a discharge diagnosis of myocardial infarction or previous elevation of troponin levels. We also looked at the presence or absence of diabetes.
Results: Eighty-six (43.2%) of the 199 patients had prior cardiac events. One hundred seven patients (53.8%) had diabetes. The study indicated that 53 patients with diabetes of 107 (49.5%) had prior cardiac events. Among those without diabetes, 33 of 92 (35.9%) had prior cardiac events.
Conclusion: A substantial proportion of patients with CKD, particularly if they have diabetes, on hemodialysis had a cardiac event in our study population. Our study suggests that these patients are at high risk for future cardiac events.
Implications for Nephrology Care: Patients with CKD should be screened for coronary artery disease. They should be encouraged to implement a lifestyle including exercise and diet to reduce the risk of future cardiac events.
6. Enhanced Sliding Short Axis (ESSAX) Technique: An Innovation for a 100% Cannulation Accuracy
Neil A. Penalosa, BSN(Ph), RN, CNeph(C), Surrey, BC
Precision with needle placement has been a long-standing challenge. With conventional assessment, nursing skills are limited to creating merely an impression or an imagination of the depth, size, and direction of the vein.
The Enhanced Sliding Short Axis (ESSAX) technique is an ultrasound-guided method that facilitates monitoring of the needle tip, upon insertion into the arterio-venous fistula or graft. ESSAX had revolutionized the way we carry out cannulation, as we treat each vascular lifeline with great importance and respect. The innovation was conceived with the earnest desire to resolve the dilemma on miscannulation.
7. NephroTalk: an Interdepartmental Nursing Communication Tool
Michelle Brazier, BScN, RN, CNeph(C) Anne Pilon, BScN
Elizabeth Carvalho, RN, CNeph(C), Montreal, QC
NephroTalk is an interdepartmental nursing communication tool developed to provide the admitted dialysis patient with a safe transfer of care between the inpatient units and the dialysis department.
The Registered Nurses' Association of Ontario (RNAO) Best Practice Guidelines (2014) stipulate that using streamlined and standardized communication tools will ensure a clear and accurate transfer of care, and prevent omission or duplication of critical information. Furthermore, effective communication is fundamental to the safety and the quality of services rendered within the care continuum. A patient handoff must occur each time there is a nurse or patient transition, and must occur in a structured and formal process.
According to recent literature, 80% of serious medical errors involve miscommunication during the hand-off (Starmer et al., 2014; Huang et al., 2010). Thus, clear and accurate communication regarding the patients' condition is essential for safe continuity of care.
Our poster will detail the communication tool and its three segments, the purpose, and implications of nephrology practice, as well as describe the collaborative method demonstrated during the introductory process of the tool in the clinical setting.
Lastly, we will present the evolution of this initiative and future plans to evaluate its effectiveness, with hopes to standardize this practice across our organization, the centre integre universitaire de sante et de services sociaux de l'Ouest-de-1'ile-de-Montreal (CIUSSS ODIM).
Starmer, A.J., Spector, N.D., Srivastava, R., West, D.C., Rosenbluth, G., Allen, A.D.,... Landrigan, C.P. et al., for the I-PASS Study Group. (2014). Changes in medical errors after implementation of a handoff program. NEJM, 371, 1803-1812. doi: 10.1056/NEJMsa1405556
8. Visual Education--CVAD (Central Venous Access Device) Video
Linda M. Mills, RN, CNeph(C)
Kelly Sutherland, RN, CNeph(C), Hamilton, ON
The overall purpose of our project was to decrease or maintain the low catheter-related blood stream infection (CRBSI) rates in our hemodialysis population. Our regional program encompasses 521 hemodialysis (HD) patients across four different sites. One hundred and fifty-two nursing staff access 282 CVADs routinely.
Given such a large group of staff, our goal was to identify the educational need related to CVAD care and create an educational tool that was easily accessible without the need for face-to-face education.
An audit tool was developed to assess current practice, and random audits were performed. The evaluation indicated gaps in practice. Educational videos focusing on policy review and updates grounded in recent evidence were developed. Practice points that prevent contamination during initiation and discontinuation procedures were emphasized. Once complete, staff were instructed to review the videos and complete a short post-test to indicate completion and new learning.
Post education audits were held in February 2018. A review of both adherence to policy and actual CRBSI rates four months prior and four months post education were examined.
The result is a self-directed, timely, accessible, and efficient method of providing education to a large group of both new and experienced nurses in multiple practice settings to positively impact patient clinical outcomes. This education provided in a visual and auditory format supports adult learning needs and can provide a more effective use of resources to provide education. With proven success, next steps include further educational video development.
9. Enhancing Quality of Life: Advance Care Planning for Patients with End-Stage Renal Disease
Jennifer Nguyen, BScN, RN, Brampton, ON
The purpose of this quality improvement (QI) project is to initiate and implement Advance Care Planning (ACP) for patients with end-stage renal disease (ESRD) who are currently receiving hemodialysis (HD) treatments at the Toronto General Hospital (TGH). In order to implement this QI project, it is also imperative to educate the healthcare staff to increase their knowledge and comfort level in having the ACP conversations with their patients. This QI project was started by conducting a pre-survey to the hemodialysis staff at TGH to determine the knowledge and comfort level of the HD nurses on the topic of ACP.
ACP is a process in which individuals make decisions about the care they would want to receive if they become unable to speak for themselves (Brinkman-Stoppelenburg, Rietjens, & Van der Heide, 2014). It is a way for these patients to document their wishes for end-of-life care, and will greatly comfort them and their caregivers, knowing that their wishes will be respected. ACP also includes individuals having a discussion about their personal values with their loved ones and designating their power of attorney/substitute decision maker.
Life is unpredictable, therefore it is crucial for one to think and share what is important to them. From September 2017 to the present, education and awareness have been ongoing for patients and staff through educational tools such as in-services, meetings, newsletters, posters, and informational brochures. This project will then be sustained and become part of the admission process when new patients start HD treatments (including kardex rounds) and align with the Ontario Renal Network's mandate for ACP.
Brinkman-Stoppelenburg, A., Rietjens, J.A., & Van der Heide, A. (2014). The effects of advance care planning on end-of-life care: A systematic review. Palliative Medicine, 28(8), 1000-1025.
10. Clinical Use of a Body Composition Monitor to Establish and Troubleshoot Ideal Body Weight in Hemodialysis Patients
Christine Morton, BScN, RN, CNEPH(UK)(NI), Toronto ON
This presentation looks at the body composition monitor (BCM) at St. Michael's Hospital, as a beneficial tool in helping to optimize the ideal body weight targets for our patient population in hemodialysis. Optimal volume control can be elusive and is in need of more precision. We focused on two groups of patients: incident patients and those with hard to determine fluctuation in body weight. A routine BCM testing schedule was established for new patients on hemodialysis to accurately establish their target weight in the initial three months on HD, typically a time when there are weight and also potential over-hydration issues. The second group included HD patients whose ideal body weights were difficult to determine due to other comorbidities.
Hemodialysis nurses at St. Michael's Hospital have been managing BCM testing for both groups of patients, which included data interpretation. Results show a smooth transition onto dialysis and helpful advantage when it comes to targeting the ideal body weight for our patients. Implications for nephrology care are significant. Establishing accurate ideal body weight is, by its nature, a moving target that greatly impacts the health and quality of life for patients on hemodialysis. BCM is an important tool that provides information to the physician and multidisciplinary team about a patient's ideal target weight. Routine testing of body composition enables the healthcare team to monitor the accuracy of the target weight and provide a high-quality fluid management strategy.
11. Development and Implementation of a Hemodialysis Unit in a Rehab/Complex Care Setting
Lisa Wolfs, MPH, BScN, RN
Joanne Lawnicak, RN
Julia Gordon, RPN, London, ON
Purpose: The purpose of this presentation is to describe the unique planning, development and implementation of a hemodialysis (HD) service at St Joseph's Health Care, Parkwood Institute in cooperation with London Health Sciences Centre (LHSC) for patients currently requiring travel to and from hospital sites. This project was informed and implemented in cooperation with patients and families receiving care through the renal program.
Description: LHSC's dialysis units currently provide HD treatments to inpatients from Parkwood Institute, a neighbouring rehabilitative and long-term care facility. The total number of trips between LHSC and Parkwood Institute is significant in numbers and costs, and has a significant effect on a patient's quality of life.
Undergoing HD treatments can affect a patient's energy level, which, in turn, can affect their ability to fully participate and complete rehabilitative therapies. Travelling to and from hospital sites for HD can further contribute to a patient's fatigue levels, making it challenging for them to achieve their goals for rehabilitation and recovery.
Evaluation/Outcomes: The goal of this project is to create efficiency and reduce travel costs, improve the patient experience and satisfaction through the reduction of transportation from site to site, and improve patient outcomes in terms of their rehabilitative goals at Parkwood Institute. A formal evaluation of this service is planned.
Implications: The implications of this project are universal to all renal care centres across Canada experiencing similar challenges with providing efficient, cost effective and patient-centred care resulting in inter-facility travel for HD.
12. Technological Advancements in APD With Remote Patient Monitoring and User-Friendly Peritoneal Dialysis Cycler: Impact on Patient Confidence and Clinical Decision-Making
Arden Gibson, RN, St. Catharines, ON
Home therapy dialysis options for patients living with chronic kidney disease (CKD) in Canada have recently experienced great enhancements using new technology. Our program recently adopted a new ADP cycler that provides home patients with a user-friendly, step-by-step experience. This cycler comes with a two-way web-based remote monitoring connection between the patient and the clinic.
This poster will describe two case studies of patients who have utilized this new PD technology. The new technology uses two-way web-based remote monitoring to provide data from daily treatments to the PD clinic. Clinic staff can view all aspects of patient treatments and make changes to therapy remotely. The device is also voice-guided, and provides step-by-step animated guidance for therapy set-up and alarm conditions.
Patients express their satisfaction and increased confidence with the improved simplicity, ease of use, and enhanced comfort level in knowing a nurse can observe their daily treatment and intervene if issues arise.
Hospital PD programs receive information allowing them to observe data and make prescription changes when required and in a timely manner. This timely availability of information allows for more informed clinical decision-making. In addition, training time of community nurses supporting PD patients has decreased.
13. Supporting Best Practice Dialysis Through the Case Management Model
Janett Black, MHS, BScN, RN, CNeph(C), Alliston, ON
Serena Chan, BN, RN, CNephC, Toronto, ON
The lack of integrated frameworks and a systematic approach to patient care delivery has resulted in inconsistent patient care in many organizations. Hemodialysis (HD) programs require processes and care delivery models reflective of patient and family engagement through self-management, care continuity, and collaborative partnerships, to ensure continuous improvement and positive care outcomes. The Case Management (CM) model was introduced at Scarborough and Rouge Hospital's (SRH) Regional HD program in response to an identified need to improve patient and family engagement and self-management as partners in their care, and the need to establish consistency and standardization in the delivery of dialysis best practices and care among our patients on HD.
The overall goals of the implementation of the CM model were to:
* Improve patient engagement and partnership through patient identified goal-setting and self-management practices
* Sustain consistency in best practice and standards of HD care
* Improve staff accountability for patient care through interprofessional collaboration and peer mentorship.
Evaluation of the CM model demonstrated:
* Significant improvement in nurses' adherence to completing CM deliverables in support of the CM goals
* Improvements in patient and family engagement and motivation towards patient-directed goal-setting and goal attainment
* Improvement in staff satisfaction related to practice and performance.
The program's experiences in the development and implementation of this model provides proof of concept and demonstrated successes that can be adopted in other HD or health service programs.
14. A First User Experience of New Remote Monitoring Technology in Peritoneal Dialysis-Leveraging Timely Sharesource Data to Effectively Manage Patients at Home and Ease Their Transition Into PD
Karen Eyolfson, RN, CNeph(C)
Kim Bomak, BSN, RN, Winnipeg, MB
There are many considerations and steps involved when starting a patient on peritoneal dialysis. A few big considerations include smoothening the transition, increasing patience confidence in self-management of disease, and effectively troubleshooting any clinical or technique issues through the first three months on PD.
Our program was the first in Manitoba to evaluate a new technology in APD cyclers that allows for two-way web-based remote monitoring connection between the patient and the clinic. This remote monitoring software allows for daily overview of patients' treatments to be visible to the clinic, flag alerts when deviation occurs to the prescribed treatment regime, and for remote patient cycler programming.
Currently we have approximately 12 patients on PD using this new cycler. The initial experience that we would like to outline include: increased visibility to treatment data, timely identification of potential problems such as low drain alerts, and effective troubleshooting of issues by leveraging the Sharesource data.
The poster will also include some case studies showing the benefits of Sharesource in effectively managing patients at home and easing their transition to PD.
15. Renal-Friendly Interactive Cooking Demonstration for Hemodialysis Patients
Kelly Gardner, RD, CDE
Rommana Captain, RD, CDE
Allyson Babb, RD, CDE
Yassamin Gharai, RD, CDE
Queenie Cheung, RD, CDE, Oshawa, ON
Description: Hemodialysis patients face many dietary restrictions, and are often challenged with preparing meals that are safe and meet their dietary needs. Additional barriers that they encounter are financial and time constraints due to regular dialysis treatments. As a result, they often rely on processed/premade meals, which are high in sodium and/or phosphorus. The aim of a renal-friendly cooking demonstration is to help increase patients' confidence in managing a renal diet. This class is two hours in length, and includes an interactive cooking demonstration of a three-course meal led by a chef and an optional 30-minute RD-led grocery store tour, which focuses on reading nutritional information on labels. Participants enjoy the meal together and are able to ask questions to the chef and Registered Dietitians (RDs). The recipes are chosen by the chef, given the dietary restrictions (low phosphorus, low sodium), and approved by the RDs. The RDs provide additional food substitution suggestions throughout the class to accommodate high or low potassium diets. This initiative is sponsored by industry donors. With a minimal cost to attend (in order to ensure attendance), the money collected is used to purchase door prizes, such as renal cookbooks and grocery store gift cards.
Results: Thirteen hemodialysis patients and six family members/care providers attended. Participants completed an anonymous post-class evaluation. All participants indicated the class was "helpful" or "useful" or "somewhat useful", and that the information was "easy to understand." Almost all participants agreed that it helped them increase their confidence in managing the renal diet. The RDs who attended felt it improved the collaborative relationship with the patients, especially to have contact in a non-clinical setting, and helped foster a sense of community within the hemodialysis unit.
Next steps: Engage patients by having them select and approve recipes prior to class.
16. Clinical Effectiveness and Safety Of 4% Tetrasodium EDTA as a Routine Non-Antibiotic Antimicrobial Lock Solution in Central Venous Access Devices Of Hemodialysis Patients Against the Triplethreat : A 15-Month Canadian Experience
Chantal Lainesse, DVM, PhD, DACVCP, Markham, ON
Karen Kelln, CEO SterileCare
Introduction: The ideal catheter lock solution should be able to prevent the occurrence of the TripleThreat[TM] of clot, bacterial colonization, and biofilm. Providing an effective barrier for the inside of central venous access devices (CVADs) must be part of the multimodal approach to decrease the risk of catheter-related complications such as catheter-related bloodstream infections (CRBSI) and occlusions. However, this lock solution should not contribute to increasing the risk of antimicrobial resistance (AMR), higher catheter maintenance cost, and/or bleeding episodes. The in vitro effectiveness of a novel non-antibiotic antimicrobial solution of 4% tetrasodium ethylene diamine tetraacetic acid (T-EDTA) was confirmed against biofilms formed by clinically relevant bacteria and fungi. The anticoagulant property of EDTA is well known and trusted. Therefore, the objective was to collect post approval safety and efficacy data from the use of this T-EDTA catheter lock solution in Canadian hemodialysis patients compared to the standard of care.
Methods: Hemodialysis patients were selected across Canada based on their (high, medium or low) risk of CRBSI and alteplase use. Clinical endpoints included reduction of alteplase use, CRBSI, and safety. A return on investment (ROI) model was also used to evaluate cost effectiveness of T-EDTA.
Results: Canadian data collected over the last 15 months show both a clinically relevant decrease in CRBSI and alteplase use when the standard lock solution was replaced by 4% T-EDTA. The ROI model also detected a cost saving in favour of T-EDTA. No hypocalcemia was reported.
Discussion/Conclusion: Results highlight the ability of 4% T-EDTA to reduce bacterial burden and biofilms in CVADs as well as provide well-established anticoagulant activities by significantly reducing the use of alteplase. T-EDTA is a safe and effective catheter lock solution for hemodialysis patients offering cost savings.
17. Evaluating Expanded Hemodialysis (HDx) Therapy in Comparison to Conventional HD Therapy in Clinical and Patient Outcomes Aspects
Sandra Lagace, Resource Nurse, CNeph(C)
Chantal Leblanc, RN, Moncton, NB
1. Review middle large molecules clearance and its importance.
2. Discuss six-month evaluation of HDx therapy at Dr. Georges L. Dumont Hospital.
3. Review the results and the implications of HDx therapy on clinical outcomes.
Uremic solutes include middle-large molecules (MMs) that are poorly removed by conventional high-flux hemodialysis (HD) due to their size (> 15 kiloDaltons [kDa]). Such solutes are associated with inflammation and immune system disorders, as well as poor outcomes in dialysis patients (Assi et al., 2015; Hutchinson et al., 2014; Cohen et al., 1995; Cohen et al., 2001; Desjardins et al., 2013).
Recently, expanded hemodialysis (HDx) therapy has been introduced to the market. This therapy uses the medium cut-off membrane, which has greater effective pore sizes than conventional high-flux membranes, allowing permeability closer to the natural kidney's glomerular membrane and middle-large molecule removal.
The presentation will cover the unmet need of middle-large molecules clearance using a conventional HD treatment, the new HDx technology introduction at Dr. Georges L. Dumont Hospital, and its evaluation on 10 patients for six months. We will review the methods and results, and share our conclusions comparing HDx therapy to conventional HD.
Assi, L.K., McIntyre, N., Fraser, S., Harris, S., Hutchison, C.A., McIntyre, C.W.,... Taal, M. (2015). The association between polyclonal combined serum free light chain concentration and mortality in individuals with early chronic kidney disease. PLOS ONE, 10(7): e0129980. https://doi.org/10.1371/journal.pone.0129980
Cohen, G., Haag-Weber, M., Mai, B., Deicher, R., & Horl, W.H. (1995). Effect of immunoglobulin light chains from hemodialysis and continuous ambulatory peritoneal dialysis patients on polymorphonuclear leukocyte functions. Journal of the American Society of Nephrology, 6,1592-1599.
Cohen, G., Rudnicki, M., & Horl, W.H. (2001). Uremic toxins modulate the spontaneous apoptotic cell death and essential functions of neutrophils. Kidney International Supplement, 78, S48-S52.
Desjardins, L., Liabeuf, S., Lenglet, A., Lemke, H.D., Vanholder, R., Choukron, G.,... European Toxin (EU Tox) Work Group. (2013). Association between free light chain levels, and disease progression and mortality in chronic kidney disease. Toxins, 5(11), 2058-2073.
Hutchinson, C.A., Burmeister, A., Harding, S.J., Basnayake, K., Church, H., Jesky, M.D.,... Cockwell, P. (2014). Serum polyclonal immunoglobulin free light chain levels predict mortality in people with chronic kidney disease. Mayo Clinic Proceedings, 89(5), 615-622.
18. Electronic Medical Record for the Renal Program--The Road to Success
Michelle Hughes, RN
Krista hovering, MBA, BScN, RN
Lisa Dale, Project Manager, Orillia, ON
Introduction: The Regional Simcoe Muskoka Kidney Care Program endeavoured to achieve a standardized, computerized patient information system across the program that could support patients throughout their CKD journey from the Multi-Care Kidney Clinic (MCKC) to their chosen modality at home, or at any of the six in-facility sites.
Purpose: To achieve a computerized documentation system that is fully integrated throughout the RSMKCP that would ensure that all care teams could coordinate and access the most up-to-date information in the patients' chart in real time.
Method: A phased approach to "go-live" was decided upon to support staff training. Our team incorporated computerized documentation across the program, including connecting and sharing information with different hospital information systems (HIS), and integrating with in-centre dialysis machines, laboratory results, and the Ontario Renal Reporting System (ORRS). We utilized a pilot approach in training staff, i.e., parallel paper and computer documentation.
Results: The first "go-live" launch of the new computerized documentation system occurred at Orillia Soldiers Memorial Hospital in January 2018, and at a second site in March 2018. Future launches are anticipated in June and October 2018 at the remaining in-facility sites.
Conclusion/implications: Our program has successfully developed a standardized, more visible, consistent, and accessible patient information system and data across sites. Challenges to the initiative have been incorporated into future applications of the computerized documentation system; these include MCKC clinic flow, scheduling medications, time allotted for retrospective patient data entry, and resources required to support the frontline staff.
19. Support in the Home for Peritoneal Dialysis: Implementation and Evaluation of Integrated Services
Barbara Wilson, NP, CNeph(C), London, ON
There is overwhelming evidence that "support" is a common factor that enables people to do peritoneal dialysis (PD) successfully in the home. Supportive interventions in the home, despite being almost universally recommended, can be inconsistent, poorly defined, articulated, and researched. London Health Sciences Centre (LHSC) has been designated as an early adopter of the Ontario Renal Network (ORN) Integrated Dialysis Care (IDC) initiative. The goal of the program is to reduce care gaps in the delivery of health services and improve equity in home care services provided for PD. The model will enlist the use of personal support workers (PSWs) who will be hired by one community agency and trained by the LHSC PD staff to support patients on PD in their home.
This presentation will review the processes involved in the design and implementation of the program and the preliminary evaluation. A multi-method evaluation of the program is planned. First, patients and their caregivers will be interviewed and asked about their experiences receiving support for their PD. The PD staff will participate in one focus group exploring their experiences in providing dialysis care using the IDC model. In-home PSWs will complete a survey both before and after their orientation in regards to their knowledge and training in supporting people at home on PD. These findings are of particular interest to PD programs looking to find creative ways to support their patients, improve the patient experience, decrease gaps in care, and attract and retain people on a home therapy.
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|Date:||Apr 1, 2018|
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