[Quality control systems implementation in the Spanish Dialysis Units]

OBJECTIVE

The aim of this study was to evaluate and analyze the implementation of a Quality Management Systems (QMS) and the use of Clinical Performance measures by the Nephrology Services and Hemodialysis Units in Spain.

METHOD

The Quality Management Work Group of the Spanish Society of Nephrology (SEN) realized a survey that was directed to all the Spanish Nephrology Services and Hemodialysis Units. No exclusion criteria were defined for the study. The survey was based on a multichotomous self completing "Ad Hoc" questionnaire.

RESULTS

The survey was answered by 46.7% of the polled centers (44.5% were public hospitals and 55.5% private centers). Of those replying the survey 70 % had a QMS, with a higher implementation in the area of Hemodialysis (HD). The ISO 9001-2000 was the prefer QMS model chosen by 76.4% of the centers. 68.6% of the centers with a QMS were certified by an external Auditing Group. 91.7% of the Nephrology Services and Hemodialysis units were using some clinical practice guideline. A high percentage of the centers had medical protocols and nursing plans (> 90%). A significantly higher implementation of QMS was observed in Private Hospitals and Hemodialysis Units (88.8 %) when compared to public Hospitals (46.1%) (X2: 31.5; p < 0.001). The ISO 9000 Standard certification was selected by 78,3% of the private centers and by 21,7% of the public centers (X2: 37.3; p < 0.001). The certification or accreditation were done by an external auditing group in 68. 1% of the private centers compared to 31.9% for the public Hospitals (X2: 24.8; p < 0.001). Although the rate of answers prevents from extracting definitive conclusions, the result seems to indicate that in the Spanish Nephrology Community a clear trend exists towards the use QMS. This tendency suggests, that in the near future, there will be a progressive implementation and routine use of QMS in the Nephrology Community in Spain.

[Functional dependency evaluation of hemodialysis patients: a multicentric study]

BACKGROUND

There has been a change in the hemodialysis population characteristics over the last years with a progressive increase in patient,s age and associated comorbility and mortality. This older hemodialysis population are more functionally and medically dependent increasing the time taken to perform nursing work. The objective of this study was to evaluate the degree of functional dependency on hemodialysis patients and the need of care by nursing workload.

METHODS

A transversal descriptive study was done during 1 month (april 2005) on 586 patients from 10 HD Units in Spain. No exclusion criteria were used. The Delta Test, who was used to evaluate the patients dependency needs, is a workload measure instrument base on three subscales: dependency, Physical Deficiency and mental deficiency. The indicators are measure on a scale of one to three with each level representing an increasing demand on nursing time. The results obtained from the Delta Test were analyzed taking into account the following variables: age, average time in dialysis, Charlson comorbidity Index, geographic location and HD unit.

RESULTS

46% of the patients show some degree of dependency, of these 12.8% were moderated and 8.1% severe; the subscale analysis showed that 19.6% and 6.7% had, respectively, a moderate to severe physical and mental health deficiency. The dependency degree varied significantly between HD Units and geographic location with a range of 0% to 59.8%. The degree of dependency were statistically associated with age and CCI. The higher CCI (r: 0,21; p < 0.001) and age (r: 0,26; p < 0.001) the higher was the Delta Test Score for dependency level. Patients times of initiation on dialysis were not associated with an increase in the degree of dependency. The aspects evaluated by the Delta Test that showed a higher score were those related to patients mobility. The patients assistance requirements during the HD session are basically related to a lack of mobility due to musculoskeletal disease and to a lesser extent to behavior alterations.

CONCLUSIONS

HD units are attending patients with an important degree of dependency which impose and added workload to the healthcare personnel. In occasions, it is very difficult to attend and give proper care with the current legally established nurse to patient ratio which. This suggests the need to implement a better staffing policy. The Delta Test provides an objective, adaptable and standardized instrument for measuring degree of dependency of HD patients.