Urgent-Start Peritoneal Dialysis
Cathy Wilson-Bates, RN, CDN, CPDN
Objectives
Define Urgent Start Peritoneal Dialysis (PD)
What it is and what it’s not.
Compare several centers and the outcomes they were able to
achieve with Urgent Start PD – Drop Out Rates
– Peritonitis Rates
– Adequacy
Comparison of the benefits of PD to In center Hemodialysis
(ICHD) and Home Hemodialysis (HHD)
Changes in PD Therapy
•
•
•
•
First recorded date - 1877 with studies on animals
In 1978 - FDA approved the use of polyvinyl bags
In 1980’s - new systems were developed (Y Sets)
In 1990’s - increased emphasis on adequacy,
nutrition and individualized prescriptions
• Late 1990 to early 2000- Computer data collection
via memory cards, lock mechanisms
• Present time – Buried and Pre-sternal catheter
placement and Urgent start PD
Review - Advantages of PD
•
•
•
•
•
Initial survival benefit
Preservation of residual kidney function
Lower risk of infections (bacteremia, hepatitis)
Preservation of vascular access sites
Improved quality of life
– Patients feel in control of their life and schedule
– More time at home with family
– Less dietary restriction
– Fewer medical interactions
Definition of
Urgent Start PD
Urgent Start PD
Any patient who has been without the benefit of
planning for Chronic Kidney Disease (CKD) who will
need therapy within two weeks of placement of the
PD catheter.
A structured initiation of PD therapy for identified
“stable” CKD patients who are without a plan for
initiating dialysis.
Therapy is initiated with low fill volumes for a period of
two weeks until the membrane is well healed.
Patient position during initial two weeks of therapy is
supine with any volume of dwell.
Urgent  Emergent
Dialysis centers are not equipped to deal with acute patients who:
– Are overtly uremic
– Are severely volume overloaded (i.e. dyspnea)
– Have severe metabolic disturbances
– Have limited or no support system in place
– Have multiple other co-morbid conditions that may require
supplies and skill related to;
– Wound Vacs, Trachs, Feeding Tubes
Center specific criteria and supporting paperwork for Urgent Start
PD should be established by the Core Team. Selecting the right
patients is imperative to the overall success of the program.
Question to Consider
How many have performed small volume
exchanges on an adult or pediatric patient
using a PD catheter that was less that two
weeks old?
Benefits of Urgent-Start PD
• Avoids the placement and use of a central venous
catheter (CVC) at all
• Allows for initiation of PD with an immature PD
catheter (<2 weeks after PD catheter placement)
• Provided in the outpatient setting if patient is
clinically stable
• Training is concurrent with dialysis
• Possibly limits the need for future medical leave and
time off work
How is this Possible?
TEAM- A group of people with different skills
and tasks, who collaborate on a common
project, service, or goal, with a blending of
functions and mutual support.
Together
Everyone
Achieves
More
Core Team
Dialysis venue will affect the members of team. Are you a stand
alone, hospital based or training center?
Core Team Includes:
•
•
•
•
•
Patient and Family
Medical Director
Nephrologist
Operator – Surgeon, Interventional Radiologist, Nephrologist
Nurse, Dieticians & Social Workers
Other Core Team Members:
•
•
•
•
Transportation
Primary Care MD’s, Hospitalists and Specialists
Pastoral Care
Nutrition Services
Nephrologist : Patient
Nephrologist is first to evaluate if Urgent-Start PD is an appropriate
modality for the patient. The Nephrologist:
• Establishes open communication and trust
• Objectively assesses suitability for home therapy
• Provides Medical/Psychosocial evaluations as needed
• Provide introduction of other disciplines
• Educator and resource for Operator - expertise varies, need to
use catheter within days, potential for complications etc.
• Liaison to other disciplines in the healthcare continuum
 Case Managers and Discharge Planners
 Primary Care Providers, Specialists, Hospitalists, Emergency Room
 Hospital Administration
Nephrologist : Operator
Perhaps the most essential relationship of any Urgent Start
PD program is between the Nephrologist and Operator.
Vital to the success of the program is the general
agreement upon procedures, practice and need for
patient education related to:
– Pre-op care – bowel prep, night before shower
– Surgical – placement, titanium adapter, transfer sets, sutures
– post-op care – parameters for first dressing change, first flush,
when is it ok to shower, lifting and general things to avoid
– Pain expectation, treatment and preventing complications
Nephrologist : Medical Director
• Criteria should dictate that all referrals must
be reviewed by the Medical Director.
• Medical Director will either approve or deny
the request.
– Any denial will be verbally communicated with the
referring nephrologist with reasons detailing the
area(s) of concern
Nephrologist : Nurse
This relationship is the most fundamental to the overall
success of the patient experience and outcomes
related to Urgent Start PD.
The role of a nurse is to provide quality care based on
protocols, guidelines and current patient assessment
concurrent to the role of liaison between all
supportive core team members.
California Board of Registered Nursing. (2011)
Other members of Core Team
Dieticians and Social Workers have demanding yet varying roles
– Social Worker:
• Crisis management related to lack of planning for life altering event
• Insurance and Education
• Transportation Services
– Dietician:
• Frequent monitoring of labs given risk of hypokalemia & malnutrition
• Patient and family education on diet while in training and when they
go home
• Intake and output – what should their intake be?
What’s Next?
Infrastructure Considerations
Whether you are a Hospital based, In Center – Stand
Alone or Training Center, your infrastructure will
determine your process and practice.
•
•
•
•
•
Do you have more than one training room?
Do you have chairs that have the capability of being flat?
Do you have additional comfortable chairs for family?
Do you have a call system in place?
Do you have regularly scheduled clinics that require the use of all
your training rooms?
• Do you have a bathroom in your training room?
Referral Process
• Policy to support the referral process
• Protocols that supports critical thinking
• Completed forms returned in a timely manner with
applicable information:
– ICD 9 codes, co-morbid conditions, past and current
medical history, labs, medications, allergies etc.
Without a paper or electronic process that starts the
referral properly, you will have a chaotic start that
could lead to an unpleasant patient and or staff
experience.
Considerations
Before scheduling a patient for Urgent Start PD consideration
must be given to evaluate for the following:
• Staffing / census – consider not starting a patient on a Friday
or a holiday
• Logistics – comfortable chair that will maintain supine
position, communication, nourishment, medications, blanket
and pillow. Plan for things to not always go as planned.
• Other commitments - MD clinics, PD or HHD training, Nurse
clinic visits, home visits
To accommodate Urgent Start PD, you may need to get
creative with your staffing and real estate!
Ready to Start
•
•
•
•
•
•
•
Initial Prescription for Urgent Start PD
Solution: 1.5% dextrose, modify based upon nursing
assessment for UF needs
Fill volume: 500ml originally, now 1 L for two weeks
# Exchanges: 4 – 6 (short dwells)
Treatment time: 5 - 7 hours
5 days per week
No last fill – patient goes home dry
Patient maintains supine position throughout therapy. It is
imperative to drain the patient before sitting up
Patient
Centered
Care
“The basis for urgent-start PD should always be patient
centered and not enterprise driven”
Arramreddy (2103)
WB Pre-op: Patient Education
WB Post-op: Patient Education
Bowel Care Guidelines
Expected Initial
Prescription Results
Likely poor clearance, but sufficient given the
residual renal function (RRF) and imminent
transition to higher volumes.
However, move forward cautiously for those
without RRF who may or may not be
exhibiting signs of fluid overload.
Comparing
Urgent Start PD
Outcomes
Urgent-Start PD publications
Povlsen
2006
1980
1990
2000
Ghaffari
2012
2010
Lobbedez
2008
Casaretto
2012
Koch
2012
Rioux
2011
Arramreddy
2013
Urgent-Start PD Outcomes
Povlsen (NDT 2006)
• More mechanical complications among acute PD vs.
planned PD starts
• No difference in technique survival
• No difference in infection rates
Lobbedez (NDT 2008)
• No difference in peritonitis rates between acute and
delayed PD starts
Ghaffari (AJKD 2012)
• Similar outcomes (Kt/V, Hgb, Iron, Albumin)
• PD program grew 37.5% in first year of program
Comparison of Urgent-Start PD Regimens
Ghaffari
WellBound
Standard protocol Yes
Yes
Operator
IR
Variable
Governance
Single group
Variable
Starting volumes
0.5-1.25 L
0.5-1L
Time
5-8 hours
5-7 hours
Frequency
3 x week
3-5 x week
Exclusion
< 48 hours
< 48 hours
34
Comparison of the benefits of PD
to In-Center Hemodialysis (ICHD)
and Home Hemodialysis (HHD)
PD vs. In Center HD
• Potential risk of infection
• More control over schedule,
diet and lifestyle
• Ability to travel with limited
preparation
• Care provided in the comfort
of home
• Access protrudes
• Maintain RRF
• May see a decrease B/P
meds
• IV meds during clinic visits
•
•
•
•
•
•
•
•
Potential risk of infection
In center with care providers
Travel to and from center
Less liberal diet and fluids
Depressing atmosphere
Potential for blood loss
Access protrudes
Limited control over schedule
and time away from home
• IV meds
• Equal survival rates
• After effects of therapy
PD to HHD
• Training is 5-10 days
• Rarely nothing is seen as
emergent in PD
• Closet full of supplies
• Machine smaller, less
invasive of real estate
• Fluid removal more gradual
• Machine can be swapped
out within 24 hours
• Green factor
• Data card
• Training ranges from 4 to 14
weeks or “as long as it takes”
• Constant risk of blood loss
• Supplies consume greater real
estate than a closet
• Therapy consumes time of
loved ones at home
• Results of UF seen
immediately
• Higher costs with supplies,
machines and training at
initiation of therapy
“If I have to do this, I would
rather be at home.”
Potential Benefits of
Urgent-Start PD
•
•
•
•
•
•
•
•
Avoids use of CVC in selected patients
Reduces obligatory discharge with CVC to in-center HD
Reduces risk related to responsibility of care for CVC
Reduces number of RN order entries requiring MD signature
Reduces duration of exposure to CVC
Reduces hospitalization days for acute PD starts
Increases PD incidence and prevalence
Reduces overall healthcare costs related to hospitalizations for
access placement
43
Barriers to Urgent-Start PD
• Overall inexperience
• Lack of appropriate infrastructure
– Integrated system involving nephrologist, operator,
hospital, provider and patient
• Lack of common goal and buy in amongst the core team
• Lack of policies and procedures that define the common goal
and purpose of urgent start
• Myth that there is a 2-4 week waiting period before the PD
catheter can be used
• Hesitance to treat patients that are severely uremic, volume
overloaded or have severe electrolyte disturbances with PD
– Would require in-patient Urgent-Start PD
Frequent Question to Wellbound
Why not offer Urgent-Start PD at all home
centers?
• Answer:
– Every center has its own set of challenges and
barriers, making standardization technically
difficult.
– We need more data on quality metrics from
centers participating in Urgent-Start PD pilots to
determine feasibility, outcomes, technique
survival.
What have we learned?
1. Urgent-Start PD programs require clear
communication and agreement of care plan
by all stakeholders.
2. Barriers to success may vary by region but can
be minimized with a strong infrastructure
and education.
The people we serve are just like us.
They are someone’s Mother, Father, Sister or
Brother, they have responsibilities, challenges,
dreams and desires in addition to managing to
live with kidney disease.
Never underestimate how the education we
provide and care we deliver adds to their
ability to live more productive lives.
Role of Nurse
• The Standards of Competent Performance, California Code of
Regulations, Title 16, section 1443.5 speaks to the role of
nurses and how we demonstrate the ability to transfer
scientific knowledge and apply that knowledge to our nursing
process.
This practice is demonstrated by our actions when we “act as a
client’s advocate, as circumstances require by initiating action
to improve health care or to change decisions or activities
which are against the interests or wishes of the client, and by
giving the client, the opportunity to make informed decisions
about health care before it is delivered.”
(California Board of Registered Nursing website, 2011)
Acknowledgements
Dr. Rohini Arramreddy graciously provided her time, unique
perspective and consultation as well as the structure and
supportive documents for this presentation.
Sheree Piccinini - Clinical Manager of WellBound of Modesto
provided her time, insight and wisdom to make this
presentation a reflection of what Urgent-Start PD looks like in
real life.
Satellite Healthcare for their continued vision and innovation while
delivering effective and compassionate care to those in need.
Contact Us
Please email any questions/comments to
Dr. Rohini Arramreddy
arramreddyr@satellitehealth.com
Cathy Wilson-Bates, RN
wilson-batesc@satellitehealth.com
There’s No Place Like Home
I am blessed to be a part of a wonderful
organization that supports a “One size does
not fit all philosophy.”
Thank you for being here today and taking part
in this presentation.
Thank you for all you do to help those we serve.
References
Povlsen, J. (2006) How to start the late referred ESRD patient
urgently on chronic apd. Nephrology Dialysis Transplantation,
21, [Suppl 2] ii56-ii59.
Lobbedez, T. (2008) Is rapid initiation of peritoneal dialysis
feasible in unplanned dialysis patients? A single-center
experience. Nephrology Dialysis Transplantation, 23, 3290-4.
Rioux, J.P. (2011) Effect of an in-hospital chronic kidney disease
education program among patients with unplanned urgentstart dialysis. Clinical Journal American Society Nephrology,
Apr. 6(4), 799-804
References
Arramreddy-, R., (2013). Urgent start peritoneal dialysis: a chance
for a new beginning. American Journal Kidney Disease 2013
Casaretto, A., (2012) Urgent start peritoneal dialysis: report from a
u. s. private nephrology practice. Advances in Peritoneal
Dialysis, Vol. 28, 2012
Ghaffari, A. (2012). Urgent start peritoneal dialysis: A quality
improvement report, American Journal Kidney Disease, 59(3),
400-408.
Koch, M. (2011) - Comparable outcome of acute unplanned
peritoneal dialysis and haemodialysis. Nephrology Dialysis
Transplantation 0, 1–6