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Long Q, Yang M, Long J. Application of intelligent nursing system based on big data in maintenance hemodialysis patients. SLAS Technol 2024:100160. [PMID: 38901761 DOI: 10.1016/j.slast.2024.100160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/22/2024] [Accepted: 06/18/2024] [Indexed: 06/22/2024]
Abstract
Maintenance hemodialysis (MHD) is one of the most important renal replacement therapies for patients with end-stage renal disease. However, long-term and frequent treatment not only damages the physiological functions of patients but also leads to serious economic burdens and mental stress. This can easily cause a series of psychological disorders in patients, resulting in severe rejection and fear of MHD. To reduce patient resistance and improve the quality of life of MHD, this article built an intelligent nursing system based on big data and then used the constructed intelligent nursing system to research MHD. Through experiments, it has been found that compared to self-efficacy intervention, intelligent nursing systems can control the concurrent rate of MHD patients below 14 %, and self-efficacy intervention methods can control the concurrent rate of MHD patients above 13 %. Moreover, using intelligent nursing systems can improve the ability of MHD patients to self-care. At the same time, before the use of intelligent nursing systems, the nursing satisfaction of MHD patients also varied greatly, with the overall satisfaction rate after use being 70 % higher than before. Using intelligent nursing systems can improve the satisfaction of MHD patients with nursing outcomes.
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Affiliation(s)
- Qijun Long
- School of Public Health and Administration, Youjiang Medical University for Nationalities, Baise 533000, Guangxi, China; College of Innovation and Entrepreneurship, Youjiang Medical University for Nationalities, Baise 533000, Guangxi, China
| | - Meichun Yang
- Affiliated Hospital, Youjiang Medical University for Nationalities, Baise 533000, Guangxi, China; College for International Education, Philippine Christian University, Manila 1004, Philippines.
| | - Jiahui Long
- Medical College, Xinjiang University of Science & Technology, Korla 841009, Xinjiang, China
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2
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Shome-Vasanthan E, Chou S, Hemmett J, MacRae J, Ward D, Gallagher N, Al-Wahsh H, Qirjazi E. Reducing the Frequency of Surveillance Blood Work in Patients Treated With Maintenance Hemodialysis: A Local Quality Improvement Initiative. Can J Kidney Health Dis 2024; 11:20543581241255784. [PMID: 38812721 PMCID: PMC11135100 DOI: 10.1177/20543581241255784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/15/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction There is little evidence on the ideal frequency of routine blood work in maintenance dialysis patients to manage complications, including anemia, mineral bone disease (MBD), and hyperkalemia. Recent quality improvement studies from Ontario showed no negative impacts when decreasing the frequency from monthly to every 6 weeks in conventional in-center hemodialysis (ICHD) patients. In December 2020, Alberta Kidney Care-South (AKC-S) reduced the frequency of routine blood work from every 6 weeks to every 8 weeks for ICHD patients. Objective We aimed to assess the impact of reducing blood work frequency on patient outcomes. Methods We compared prevalent AKC-S ICHD patients in 2 cohorts: (1) retrospective control (October 31, 2019-October 31, 2020) and (2) prospective intervention (December 1, 2020-December 1, 2021). Primary outcomes were true frequency of routine blood work, odds of patients being within target for anemia and MBD, and proportion of lab values of hyperkalemia. Furthermore, we compared hospitalizations and mortality. Results A total of 972 patients in Calgary's ICHD program were included, 787 in each period (with 602 patients overlapping both cohorts). The frequency of routine blood work decreased from every 39.5 days in the control period to every 54.2 days in the intervention period (P < .01). There was a reduction in the odds of phosphate values in targets (P = .02), and an increase in the odds of labs with hyperkalemia (>6.0 mmol/L) during the intervention period (P = .01). There was no significant change in the odds of being within the accepted targets during the intervention period compared with the control period for hemoglobin, Tsat, calcium, or parathyroid hormone (PTH). Fewer patients were hospitalized during the intervention period and the risk of death decreased as well, although additional factors such as the COVID-19 pandemic may have affected this. A cost-savings of $32 962 occurred from the reduced anemia and MBD blood work during the intervention period. Conclusions When ICHD units in Calgary reduced routine blood work frequency from every 6 weeks to 8 weeks, there were no negative impacts on hospitalizations or deaths. A slightly lower proportion of phosphate values were within target, and a 0.7% increase in potassium values greater than 6 mmol/L was demonstrated. Our study suggests that blood work frequency in ICHD dialysis patients may be further reduced to every 8 weeks safely. Ultimately, additional pragmatic trials are needed to identify the optimal frequency of routine blood work.
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Affiliation(s)
| | - Sophia Chou
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Juliya Hemmett
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Jennifer MacRae
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - David Ward
- Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Huda Al-Wahsh
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Elena Qirjazi
- Cumming School of Medicine, University of Calgary, AB, Canada
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3
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Kim DH, Cho AJ, Park HC, Kim BY, Lee M, Kim GO, Kim J, Lee YK. Regular laboratory testing and patient survival among patients undergoing maintenance hemodialysis: a Korean nationwide cohort study. Sci Rep 2023; 13:18360. [PMID: 37884647 PMCID: PMC10603026 DOI: 10.1038/s41598-023-45502-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/20/2023] [Indexed: 10/28/2023] Open
Abstract
Routine laboratory tests are regularly performed in patients undergoing maintenance hemodialysis (HD) to detect anemia, chronic kidney disease-mineral bone disorders, and cardiovascular disease. More frequent laboratory tests may be associated with better outcomes. However, there is little evidence supporting a specific monitoring interval. This study evaluated the impact of regular laboratory testing on mortality in Korean patients undergoing maintenance HD. We used HD quality assessments, and National Health Insurance Service claims data from October to December 2015. In HD quality assessment, 22 tests are recommended every 1-6 months. A total of 34,950 patients were divided into two groups based on the regularity of laboratory testing. A Cox proportional hazards model was used to assess the effects of regular laboratory tests on patient mortality during a mean follow-up duration of 53.7 months. The proportion of patients with and without regular laboratory testing was 85.6% (n = 29,914) and 14.4% (n = 5036), respectively. Patients who underwent regular laboratory testing had a longer dialysis duration, lower serum phosphorus levels and diastolic blood pressure, and higher hemoglobin and single-pool Kt/V levels than those who did not. After adjusting for demographic and clinical parameters, regular laboratory testing independently reduced mortality risk (hazard ratio, 0.90; 95% confidence interval 0.85-0.95; P < 0.001). Regular laboratory testing was associated with a decreased mortality risk among patients undergoing HD. Management of end-stage kidney disease-related complications based on laboratory tests can improve survival.
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Affiliation(s)
- Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Korea
- Hallym University Kidney Research Institute, Seoul, Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Korea
- Hallym University Kidney Research Institute, Seoul, Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Korea
- Hallym University Kidney Research Institute, Seoul, Korea
| | - Bo Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Miri Lee
- Division of Quality Assessment 1, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Gui Ok Kim
- Division of Quality Assessment Management, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Jinseog Kim
- Department of Bigdata and Applied Statistics, Dongguk University, Gyeongju, Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Korea.
- Hallym University Kidney Research Institute, Seoul, Korea.
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4
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Hamidi S, Auguste BL. Continuous quality improvement in peritoneal dialysis: Your questions answered. Perit Dial Int 2023:8968608231156924. [PMID: 36843355 DOI: 10.1177/08968608231156924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.
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Affiliation(s)
- Shabnam Hamidi
- Department of Medicine, University of Toronto, ON, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bourne L Auguste
- Department of Medicine, University of Toronto, ON, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, ON, Canada
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5
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Detection of Hyponatremia Development in Hemodialysis Patients by Routine Automated Conductivity-Based Monitoring. ASAIO J 2023; 69:239-246. [PMID: 35438654 DOI: 10.1097/mat.0000000000001737] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Predialytic hyponatremia is associated with poor outcome in hemodialysis patients. Hypotonic hyponatremia is the most frequently encountered disorder reflecting mixed disorders combining extracellular fluid overload and free water excess, resulting from the interplay of intermittency of dialysis and diet observance, and likely precipitated by an acute or subacute illness. In this context, hyponatremia requires to be detected and worked up to identify and cure the cause. In this clinical case report, we describe preliminary results of using an online biosensor on a dialysis machine that provides automated predialysis plasma sodium concentration derived from dialysate conductivity measurements. Based on this biosensor, within a 5 year time frame, 11 patients out of more than 130 maintenance hemodialysis patients and over 40,000 dialysis sessions were identified with episodes of predialysis hyponatremia (≤135 mmol/l). In all patients, hyponatremic episodes were indicative of a severe underlying illness associated with fluid overload leading to plasma hypotonicity. Automated online predialysis plasma sodium concentration measurement offers an innovative, reliable, and cost-free tool that permits to detect hyponatremia as marker of an underlying illness development in dialysis patients. The value of this tool in supporting clinical decision-making deserves further studies in a large dialysis population.
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6
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Chidiac C, Chelala D, Nassar D, Beaini C, Azar H, Finianos S, Boueri C, Hawi J, Abdo I, Aoun M. Routine laboratory testing in hemodialysis: how frequently is it needed? BMC Nephrol 2022; 23:344. [PMID: 36303122 PMCID: PMC9615394 DOI: 10.1186/s12882-022-02971-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/07/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background: Hemodialysis patients are followed by routine laboratory testing. There is uncertainty whether these tests always lead to a change in decision-making. This study aims to discover the number of yearly interventions/changes in prescription based on these tests and depict the group of patients who would benefit from reduced or increased laboratory blood tests. Methods: This is a multi-center retrospective study that included patients on hemodialysis for more than one year. Laboratory data collected included yearly average of hemoglobin, urea reduction ratio (URR), serum phosphate, calcium, potassium, parathormone (PTH), ferritin and transferrin saturation (TSAT); changes in prescription of erythropoietin-stimulating agents (ESAs), intravenous (IV) iron, alfacalcidol, phosphate binders and dialysis parameters were retrieved from medical records. A multivariate regression analysis assessed factors associated with high number of interventions. Results: A total of 210 hemodialysis patients were included: 62.4% males, 47.1% diabetics. Their median age was 72 (62,78.5) years. Their laboratory parameters were within KDIGO targets. The median number of yearly interventions was 5 (3,7) for ESAs, 4 (2,6) for IV iron, 1 (0,2.25) for phosphate binders, 0 (0,1) for alfacalcidol. Based on the multivariate analysis, patients with higher ferritin, frequent changes in ESA, more changes in alfacalcidol and higher PTH had higher number of prescription’s changes in ESA, IV iron, phosphate binders and alfacalcidol respectively. Conclusion: While maintaining KDIGO targets, therapeutic interventions following routine laboratory testing did not exceed six times yearly for all parameters. This suggests that a reduced testing frequency in hemodialysis patients is possible without any impact on quality of care. A personalized approach remains safe for hemodialysis patients while reducing the cost. This is very relevant in low-resource settings and during economic crises and needs to be evaluated in prospective studies.
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Affiliation(s)
- Claudia Chidiac
- Department of Internal Medicine, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Dania Chelala
- Nephrology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Nephrology Department, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Dany Nassar
- Department of Internal Medicine, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Chadia Beaini
- Nephrology Department, Bellevue Medical Center, Mansourieh, Lebanon
| | - Hiba Azar
- Nephrology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Nephrology Department, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Serge Finianos
- Nephrology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Nephrology Department, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Celine Boueri
- Nephrology Department, Saint-George Hospital, Ajaltoun, Lebanon
| | - Jenny Hawi
- Nephrology Department, Saint-George Hospital, Ajaltoun, Lebanon
| | - Ibrahim Abdo
- Nephrology Department, Bellevue Medical Center, Mansourieh, Lebanon
| | - Mabel Aoun
- Nephrology Department, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
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7
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AOUN M. A cost-saving hemodialysis scheme in limited-resource settings. Kidney Int Rep 2022; 7:1437-1438. [PMID: 35685326 PMCID: PMC9171704 DOI: 10.1016/j.ekir.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 11/07/2022] Open
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More KM, Levin A, Silver SA. A National Vision for Quality Improvement in Canadian Nephrology-The Canadian Nephrology Quality Improvement and Implementation Science Collaborative (CN-QUIS): An Opinion Piece. Can J Kidney Health Dis 2020; 7:2054358120969298. [PMID: 33224511 PMCID: PMC7656874 DOI: 10.1177/2054358120969298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Keigan M. More
- Division of Nephrology, QEII Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Adeera Levin
- BC Renal Agency, Vancouver, Canada
- The University of British Columbia, Vancouver, Canada
| | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen’s University, Kingston, ON, Canada
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9
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Holden RM, Mustafa RA, Alexander RT, Battistella M, Bevilacqua MU, Knoll G, Mac-Way F, Reslerova M, Wald R, Acott PD, Feltmate P, Grill A, Jindal KK, Karsanji M, Kiberd BA, Mahdavi S, McCarron K, Molnar AO, Pinsk M, Rodd C, Soroka SD, Vinson AJ, Zimmerman D, Clase CM. Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. Can J Kidney Health Dis 2020; 7:2054358120944271. [PMID: 32821415 PMCID: PMC7412914 DOI: 10.1177/2054358120944271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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Affiliation(s)
- Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, USA.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - R Todd Alexander
- Department of Pediatrics and Physiology, University of Alberta, Edmonton, Canada
| | - Marisa Battistella
- University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Micheli U Bevilacqua
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Greg Knoll
- Division of Nephrology, The Ottawa Hospital, ON, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, CHU de Québec, Hôtel-Dieu de Québec Hospital, Université Laval, Québec City, QC, Canada
| | - Martina Reslerova
- Nephrology Section, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip D Acott
- Division of Nephrology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Patrick Feltmate
- Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, ON, Canada
| | - Kailash K Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meena Karsanji
- Professional Practice, Vancouver Coastal Health, Richmond, BC, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Mahdavi
- Department of Nutritional Sciences, University of Toronto, ON, Canada.,Department of Nephrology, Scarborough Health Network, ON, Canada
| | - Kailee McCarron
- Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Canada
| | - Amber O Molnar
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Maury Pinsk
- Division of Nephrology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Celia Rodd
- Division of Diabetes & Endocrinology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, NSHA Renal Program and Pharmacy Services, Halifax, NS, Canada
| | - Amanda J Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Catherine M Clase
- Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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McCoy IE, Shieh L, Fatehi P. Reducing Phlebotomy in Hemodialysis Patients: A Quality Improvement Study. Kidney Med 2020; 2:432-436. [PMID: 32775983 PMCID: PMC7406848 DOI: 10.1016/j.xkme.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Hospitalized patients receiving hemodialysis frequently have routine, daily laboratory studies drawn by peripheral venipuncture-a painful process that damages peripheral veins that may be needed for future dialysis access. Some of these peripheral venipunctures are likely preventable by drawing blood samples off the hemodialysis machine circuit. We describe an initiative to allow and encourage blood to be drawn “with dialysis.” Study Design Quality improvement study. Setting & Participants Non–critically ill adult patients treated with hemodialysis at Stanford Health Care between September 2018 and September 2019. Quality Improvement Activities We modified the electronic health record to allow providers to order laboratory studies with the frequency “with dialysis.” Use of the “with dialysis” frequency was promoted through educational efforts aimed at primary medical teams, nephrology consult staff, and nephrology advanced practice providers. Outcomes We tracked the number of “with dialysis” blood draws and the number of eligible patients per week during the first year of implementation. Analytical Approach The number of “with dialysis” blood draws and eligible patients per week were measured over time. Cost savings were estimated by multiplying the difference in cost between peripheral venipuncture and “with dialysis” blood draw by the number of “with dialysis” blood draws performed. Results Uptake during the first year of implementation was an average of 6.3 “with dialysis” draws per 100 eligible patients per week. Estimated savings exceeded $7,000 in the first year of the program. Limitations Our single-center study may not be generalizable to other institutions, especially those without dialysis ordering and laboratory ordering housed within the same electronic system. We were unable to track additional outcomes, including the number of peripheral venipunctures and delays in laboratory results. Conclusions The prevention of unnecessary peripheral venipuncture in hospitalized patients receiving hemodialysis is a promising and valuable quality improvement target, which may be aided by the electronic health record. Future work is needed to increase recognition and use of “with dialysis”blood work options.
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Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
- Address for Correspondence: Ian E. McCoy, MD, MS, Division of Nephrology, Stanford University School of Medicine, 777 Welch Rd, Ste DE, Palo Alto, CA 94304.
| | - Lisa Shieh
- Division of Hospital Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Pedram Fatehi
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
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11
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Thomas A, Silver SA, Perl J, Freeman M, Slater JJ, Nash DM, Vinegar M, McArthur E, Garg AX, Harel Z, Chanchlani R, Zappitelli M, Iliescu E, Kitchlu A, Blum D, Beaubien-Souligny W, Wald R. The Frequency of Routine Blood Sampling and Patient Outcomes Among Maintenance Hemodialysis Recipients. Am J Kidney Dis 2019; 75:471-479. [PMID: 31732233 DOI: 10.1053/j.ajkd.2019.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/20/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval. STUDY DESIGN Retrospective population-based cohort study. SETTING & PARTICIPANTS All prevalent HD recipients in Ontario, Canada, as of April 1, 2011, and a cohort of incident patients commencing maintenance HD in Ontario, Canada, between April 1, 2011, and March 31, 2016. EXPOSURE Frequency of surveillance blood work, monthly versus every 6 weeks. OUTCOMES The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiovascular events, all-cause hospitalization, and episodes of hyperkalemia. ANALYTICAL APPROACH Cox proportional hazards with adjustment for demographic and clinical characteristics was used to evaluate the association between blood testing frequency and all-cause mortality. Secondary outcomes were evaluated using the Andersen-Gill extension of the Cox model to allow for potential recurrent events. RESULTS 7,454 prevalent patients received care at 17 HD programs with monthly blood sampling protocols (n=5,335 patients) and at 8 programs with blood sampling every 6 weeks (n=2,119 patients). More frequent monitoring was not associated with a lower risk for all-cause mortality compared to blood sampling every 6 weeks (adjusted HR, 1.16; 95% CI, 0.99-1.38). Monthly monitoring was not associated with a lower risk for any of the secondary outcomes. Results were consistent among incident HD recipients. LIMITATIONS Unmeasured confounding; limited data for center practices unrelated to blood sampling frequency; no information on frequency of unscheduled blood work performed outside the prescribed sampling interval. CONCLUSIONS Monthly routine blood testing in HD recipients was not associated with a lower risk for death, cardiovascular events, or hospitalizations as compared with testing every 6 weeks. Given the health resource implications, the frequency of routine blood sampling in HD recipients deserves careful reassessment.
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Affiliation(s)
- Alison Thomas
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada; ICES, London, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Megan Freeman
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | | | | | - Amit X Garg
- ICES, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; ICES, London, Ontario, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Michael Zappitelli
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eduard Iliescu
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Daniel Blum
- Division of Nephrology, Sir Mortimer B Davis Jewish General Hospital, Quebec, Canada
| | | | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; ICES, London, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Sherman RA. Briefly Noted. Semin Dial 2019. [DOI: 10.1111/sdi.12830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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