Strategies For Improvement
Debra Evans, RN, BSN
Quality Improvement Nurse Specialist
&
Leighann Sauls RN, CDN
Director, Quality Improvement
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Inadequate dialysis has long been identified
as a contributor to increased mortality in
hemodialysis patients.
The percent of patients being adequately
dialyzed in the USA, as measured by urea
reduction ratio (URR) in the Core Indicators
Project and subsequently the Clinical
Performance Measures Project, has increased
from 43% in 1993 to 91.3% Q4 2010.
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The 2010 Q4 Elab reports Network 6 URR of 90.7%
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The Network 6 MRB reviewed facility specific data
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Focus on facilities presenting the optimal opportunity
for facility-specific improvement as well as overall
Network improvement in hemodialysis adequacy.
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Facilities were ranked from highest to lowest % of
patients with URR <65%
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Chose all facilities with >40 patients and < than 80%
of the patients with a URR>65%.
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To develop strategies for improving adequacy
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To promote ongoing education to staff and
patients
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To review importance of patient assessment and
patient monitoring
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To establish proper techniques for lab sampling
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Understand project requirements
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To improve the QOL and
decrease mortality of ESRD
patients by providing an
adequate dose of dialysis
every treatment.
90% of hemodialysis
patients will have a URR of
> 65%
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Provide ongoing education to staff and
patients
Know your adequacy numbers
◦ URR > 65%, KT/V > 1.2
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Know what can have an effect on these
numbers
Know when to intervene
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Teach patients the importance of completing
the prescribed RUN times.
Teach patients the medical consequences of
“underdialysis” at an appropriate grade level
and culturally appropriate manner
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Teach each patient their prescribed blood
flow rate and their prescribed dialysate flow
rate.
Patients should understand the Importance of
assessments: pre, during, post and home
assessment. (check thrill, Signs & Symptoms
to report)
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Why fistulas are the best choice for access
 last longer
 Fewer infections

Disadvantages of Central Venous Catheters
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Higher risk for Infections
Slower blood flow rates
Vessel damage
Designed for short term use only
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Review patient issues:
◦ symptoms of uremia – Nausea, vomiting, poor
appetite , yellow skin color, weakness, infections,
bleeding
◦ Avoid hypotensive episodes that decrease dialysis
delivery
 Avoid excessive ultrafiltration-Does the patient gain
more than 4.0 kgs between treatments?
 Does the patient need a new estimated dry weight?
 Does the staff actually watch the patients weigh pre
and post treatment?
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Review machine maintenance issues
◦ Are the machines kept up to date on all PM”s per
manufacturer’s recommendations?
◦ Are the scales calibrated routinely?
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Review Heparin usage
◦ Document condition of dialyzer to determine if
heparin adjustment needed.
◦ Does staff wait 3-5 minutes after Heparin Bolus to
initiate treatment?
◦ Do you conduct clinical audits to verify that Heparin
policy is followed?
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Do skills check and retraining for cannulation
competency. (technique, needle placement)
Always verify direction of blood flow
Limit cannulation attempts. If unsuccessful
on 2nd attempt seek assist from “identified
unit expert”
Monitor pressure @ prescribed blood flow.
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Review lab results immediately upon receipt
Repeat adequacy lab draws, with Dr. order, If
results appear incorrect
Verify dialysis prescription is followed each
treatment.
◦ Correct dialyzer
◦ Correct blood flow
◦ Correct dialysate flow
Notify physician if unable to follow dialysis
prescription Every treatment until access problems
are resolved.
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Make treatment prescription changes to improve
adequacy
Implement new physician treatment orders for next
treatment.
◦ Increase blood and/or dialysate flow rates
◦ Change dialyzer to increase surface area
◦ Increase treatment time
Refer patient for evaluation of access if needed
Ensure that staff follows correct blood draw
procedures.
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
Single pool variable volume model is
recommended by K/DOQI
 Calculates KT/V using pre and post BUN samples

Pre & post dialysis BUN samples must be drawn
correctly (on the same day) to ensure adequacy
results
 Pre – BUN sample:
 Should be drawn immediately prior to treatment initiation
 Avoid dilution of pre BUN sample with Heparin or saline
 To avoid BUN sample dilution with Heparin from CVC line
withdraw 10 ml of blood from arterial CVC port prior to
taking the blood sample
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Drawing post BUN sample
Collect sample using the Slow flow or Stop
pump technique to prevent dilution of
post BUN sample with recirculating blood
and minimize effects of urea rebound.
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 Stop flow sampling
Stop the blood pump. Clamp arterial and venous
blood lines. Clamp arterial needle tubing. Draw the
post BUN sample from the arterial port closest to
the patient
 Slow flow sampling
 With blood pump still running, draw post BUN
sample from the arterial sample port closest to
the patient
 Discontinue treatment as usual
.
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Promote AV fistula use
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Decrease venous catheter use
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Assess access status before each treatment
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Utilize the “ Sleeves up” protocol for
converting AV grafts to AV fistulas
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Include medical director, charge nurse, social
worker, dietitian and other team members
that impact care
Schedule regular monthly Adequacy team QI
meetings with dates and times
Evaluate your current process for improving
adequacy your QI plan
Identify barriers in your process that
contribute to poor adequacy and their root
causes.
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Evaluate the actions already implemented to
improve adequacy
◦ Were they effective? Did they work? If not, why not?
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Implement new action steps and strategies to
address root causes
Review monthly Adequacy lab data, Identify
patients not meeting Adequacy goals and
reasons why
Develop a patient specific care plan for all
patients not meeting adequacy goals to address
barriers and issues impacting their adequacy
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Review this care plan with patients and the
patient’s caregivers
Update and evaluate your current adequacy
QI plan as needed.
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Patient Education is KEY to maintaining
adequate treatment
Teach Your Patient About Adequacy
It’s About Quality of life !
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Free CEU:
◦ Visit continuing education website at
http://learning5.flqio.org/
◦ Click on ESRD; Go to the course titled
◦ IMPROVING ADEQUACY OF HEMODIALYSIS
Other tools:
◦ Adequacy improvement flowchart
◦ Hemodialysis Adequacy tracking tool
◦ Hemodialysis Adequacy QAPI Tip sheet
 www.esrdnetwork6.org
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1. Submit Monthly Spreadsheet via email to info@nw6.esrd.net by the 10th day
of the month for information from the previous month. The monthly sheet
will be emailed to you at the end of the month for submission.
2. Participate in an Adequacy Webinar on November 29, 2011
3. Send Adequacy QAPI (action plan) to the Network office via email to
info@nw6.esrd.net by December 10, 2011
4. Participate in facility-specific conference call(s) with Network staff to review
QAPI information if requested.
5. Conduct an adequacy learning session for patients and staff at the facility.
6. Complete the learning session summary sheet and return to the Network
office via email to info@nw6.esrd.net by December 15, 2011.
7. All resources and templates are available on the Network 6 website at
http://www.esrdnetwork6.org/improving-care/
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Verification of participation and post survey
information
http://www.surveymonkey.com/s/AdequacyWebinar
by Friday, December 2, 2011
QUESTIONS?
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