care coordination in ckd patients undergoing haemodialysis 34 ana lino.pdf · ana lino, rn,...

Care coordination in CKD patients undergoing haemodialysis

Ana Lino, RN, Fresenius Medical Care, NephroCare Covilhã, Portugal

46th EDTNA/ERCA International Conference | Krakow | Poland | 9-12 September 2017

EDTNA/ERCA 09-12.09.2017 Care coordination in CKD patients undergoing haemodialysis, Ana Lino © FMC-P

Presentation outline

Summmary 1

Introduction 2

Objectives 3

Results 4

Discussion / Conclusions 5


Introduction

Care coordination is defined as “the deliberate organization of

patient care activities between two or more participants

(including the patient) involved in a patient’s care to facilitate

the appropriate delivery of health care services”. (McDonald, et al., 2010)


“The best coordination model is one in which a patient

experiences primary care as delivered by an integrated,

multidisciplinary team that includes at least one care

coordinator staff person”. (Craig, Eby, and Whittington, 2011)

Introduction


The main goal of care coordination is: To meet patient’s needs and preferences;

Delivery of high-quality and high-value health care.

Objectives


Methods

Patient needs and education

Vascular access

Treatment efficiency

Hydration status

Nursing Coordination Model


Results

Patient needs and education - Evidence

32 29

12 14

28

0

5

10

15

20

25

30

35

Host in the dialysis

unit

Vascular Access Intradialytic

Complications

Diet and Nutrition Hand Hygiene

Nu

mb

er o

f sessio

ns

Educational dimensions

Figure 1 – Different dimensions of patient and family

education – Oct. 2014 to Oct. 2016


Results

Patient needs and education - Interventions

• Implementation of an educational programme about the clinic, chronic

kidney disease, treatment, health risks, and the active role in care;

• Evaluation of the patient’s general condition using the Modified

Barthel Index Stage, nursing assessment at each treatment session, and

the Charlson Comorbidity Index;

• Classification of the fall risk;

• Documentation of all educational interventions carried out, in order

to reassess them regularly.


Results

65.8 69.2 71.6

14.1 13.5 12.1

17.1 17.3 16.3

0

10

20

30

40

50

60

70

80

2014 2015 2016

%

Year

Figure 2 - Prevalence of vascular access between 2014-2016

AVF

AVG

Catheter

70 78

83

42 45 44

0

20

40

60

80

100

2014 2015 2016

%

Year

Figure 3 - Secondary patency of patients with AVF

Secondary Patency

Prevalence Diabetic

Patients

Vascular access - Evidence


Results

Vascular access - Interventions

• Implement a pre-emptive evaluation of the AVF to define the appropriate

puncture technique for each patient;

• Our dialysis staff performs routine physical examination of the VA at

every dialysis session;

• Changes established during the physical examination, problems with

dialysis, or any unclear persistent decrease in the substitution volume

and/or dialysis dose delivered (Kt/V), the Coordinator of the VA is

informed accordingly.

• Flow monitoring according to the VA protocol;

• Referral to endovascular intervention.


Results

Treatment efficiency - Evidence

92.1 95.4

98.4

88

90

92

94

96

98

100

Year 2014 Year 2015 Year 2016

Kt/

V

Figure 4 - Average Kt/V between Oct. 2014 and Oct. 2016

22.46

23.46 23.68

20 20,5

21 21,5

22 22,5

23 23,5

24

Year 2014 Year 2015 Year 2016

Su

bs.

vo

lum

e (

L)

Figure 5 - Average substitution volume


Results

Treatment efficiency - Interventions

• Optimisation of blood pump volume according to the venous and

arterial pressure;

• Evaluation of the blood clot on the dialyser and venous chamber

(at every treatment session);


Results

Hydration status – Evidence / Interventions

• 83% of the patients reached the hydration status targets vs 62% at the

beginning of the programme

(including targets for hydration status assessed by bioimpedance spectroscopy, for pre-

dialysis blood pressure and for anti-hypertensive medication)

• Monthly bioimpedence spectroscopy;

• Monitoring of hydration status targets as normohydration weight and

relative OH;

• Clinical evaluation of symptoms of respiratory distress and the presence of

oedema.


Conclusions

• Close patient monitoring was identified as an important component of the daily

care of CKD patients on haemodialysis in order to improve patient outcomes.

• Routine assessment of coordination needs and outcomes for patients with

CKD may provide an opportunity to proactively address a special need

and avoid potential problems, major clinical events, and hospitalisations.


Acknowledgments

Hélder Araújo Head Nurse Fresenius Medical Care, NephroCare Covilhã Covilhã - Portugal Ricardo Peralta Nursing Coordinator Fresenius Medical Care, NephroCare Portugal Porto - Portugal Bruno Pinto Nursing Coordinator Fresenius Medical Care, NephroCare Portugal Porto - Portugal João Fazendeiro Matos Country Nursing Director Fresenius Medical Care, NephroCare Portugal Porto - Portugal

care coordination in ckd patients undergoing haemodialysis 34 ana lino.pdf · ana lino, rn,...

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