Quality standards for predialysis education: results from a consensus conference.

This position statement was compiled following an expert meeting in March 2013, Zurich, Switzerland. Attendees were invited from a spread of European renal units with established and respected renal replacement therapy option education programmes. Discussions centred around optimal ways of creating an education team, setting realistic and meaningful objectives for patient education, and assessing the quality of education delivered.

Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique.

BACKGROUND: The rope-ladder puncture technique, with cannulation along the whole length of the vessel traject, has been very common in haemodialysis patients with autogenous arterio-venous fistula (AVF). Today's dialysis population with AVF may exhibit difficult cannulation, because of a short vein length or a complicated cannulation route. An alternative needling possibility is the buttonhole (BH) technique, which inserts needles at exactly the same location during every dialysis session. The present study was conducted to investigate the effect of both cannulation techniques on the incidence of vascular access (VA) complications. METHODS: A total of 75 prevalent haemodialysis patients with autogenous AVF using the BH technique were compared with 70 patients using the rope-ladder technique. The following parameters were registered: haematoma occurrence, redness, swelling, aneurysm formation, the use of sharp or dull needles, miscannulations, and interventions. Needling pain and fear of puncture were assessed using a verbal rating scale (VRS). The duration of the follow-up was 9 months. RESULTS: Patients in the BH group had more unsuccessful cannulations, compared with the rope-ladder method (P < 0.0001), but the frequency of haematoma (P < 0.0001) and aneurysm formation (P < 0.0001) was less. In addition, intervention such as angioplasty (P < 0.0001) was higher in patients using the rope-ladder technique. A negative outcome of the BH technique was the higher incidence of access infections compared to the rope-ladder method. CONCLUSION: This study showed that the BH method is a valuable technique with few complications like haematoma, aneurysm formation and the need for interventions. However, the infections induced by the BH method should not be underestimated. This underlines the importance of an aseptic and correct technique of the buttonhole procedure.

Workforce development and models of care in home hemodialysis.

Creating and maintaining a successful home hemodialysis (HD) program is highly dependent on the workforce model and quality of staff. We describe the minimum staff required to start a home HD program (e.g., a clinical champion and lead nurse) and detail what additional workforce (e.g., renal technician, dietitian, psychologist, and others) may be necessary as the program evolves and expands. The goal of the program and allied staff should be to provide a seamless patient journey, a process that requires consideration of a patient recruitment strategy, a patient training pathway, thoughtful initiation of home HD, and development of support systems for routine care and emergencies at home. This module describes how care models are implemented at centers of excellence in various locations around the world, highlights the importance of an integrated care pathway, and describes workforce challenges that programs may encounter.

Buttonhole Cannulation Is Not Associated with More AVF Infections in a Low-Care Satellite Dialysis Unit: A Long-Term Longitudinal Study.

BACKGROUND: Buttonhole cannulation (BHC) has been associated with a greater risk of arteriovenous fistula (AVF)-related infections and septicemia than the rope ladder cannulation (RLC) in in-center hemodialysis (HD). Such infections have never been studied in satellite HD units. STUDY DESIGN: Retrospective single center study. SETTING AND PARTICIPANT: All patients in our satellite HD unit using a native AVF from 1 January, 1990, to 31 December, 2012. STUDY PERIOD: Two different kinds of cannulation have been used during the study period: From 1 January, 1990 to 1, January, 1998 RLC was used in the unit (period 1). After 1 January, 1998 onwards, all the patients were switched within 3 months to BHC (period 2). OUTCOMES: Three different infectious events were observed during the two periods: local AVF infection, bacteremia, and combined infection. The aim of this study was to evaluate the incidence of AVF-related infections in our low-care HD unit and to determine whether BHC is associated with an increased risk of infection in this population. RESULTS: 162 patients were analyzed; 68 patients participated to period 1 and 115 to period 2. Sixteen infectious events occurred. Incidences of AVF-related infectious events were 0.05 [95% CI, 0.02-0.16] and 0.13/1000 AVF-days [95% CI, 0.0.8-0.23], for period 1 and 2 (p = 0.44) respectively. Recurrence of AVF-related infection was observed only during period 2. Unadjusted incidence rate ratio (IRR) of all infections was 0.39 (95%CI 0.12-1.37). Two complicated infections occurred during the study period: one in period 1 and one in period 2. LIMITATIONS: Observational retrospective single centre study. CONCLUSIONS: BHC is not associated with an increased infectious incidence in our HD population from a satellite dialysis unit. In the rare patients with AVF-related infection it seems necessary to change cannulation sites as recurrence of infection might be an event more frequent with BHC.

Continuing education: preparing patients to choose a renal replacement therapy.

BACKGROUND: Patients with progressive chronic kidney disease face a series of treatment decisions that will impact the quality of life of themselves and their family. Renal replacement therapy option education (RRTOE), generally provided by nurses, is recommended by international guidelines OBJECTIVES: To provide nurses with advice and guidance on running RRTOE. DESIGN: A consensus conference. PARTICIPANTS: Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 European countries) from units that had extensive experience in RRTOE or were performing research in this field. APPROACH: Experts brainstormed and discussed quality standards for the education team, processes, content/topics, media/material/funding and quality measurements for RRTOE. RESULTS: Conclusions and recommendations from these discussions that are particularly pertinent to nurses are presented in this paper. CONCLUSIONS: Through careful planning and smooth interdisciplinary cooperation, it is possible to implement an education and support programme that helps patients choose a form of RRT that is most suited to their needs. This may result in benefits in quality of life and clinical outcomes. APPLICATION TO PRACTICE: There are large differences between renal units in terms of resources available and the demographics of the catchment area. Therefore, nurses should carefully consider how best to adapt the advice offered here to their own situation. Throughout this process, it is crucial to keep in mind the ultimate goal - providing patients with the knowledge and skill to make a modality choice that will enhance their quality of life to the greatest degree.

Information and counselling for patients approaching end-stage renal failure in selected centres across Europe.

The EDTNA/ERCA survey of the provision of pre-ESRF information, education and counselling in renal care was the third project organised through the Collaborative Research Programme (CRP). Data was collected from 35 participating centres in 10 countries. The majority of participating centres had a structured pre-ESRF programme. Advice and education received by patients in these centres was usually provided by a multidisciplinary team and was coordinated by nurses in half of the centres. Programmes in all countries had similar content in that normal kidney function, medication, diet, haemodialysis, peritoneal dialysis and transplantation were routinely discussed and that issues such as employment, importance of leisure activities, holidays and Kidney Patient Associations were also on the agenda for discussion. Educational material produced by companies was widely used. Policy differences did emerge in attitudes to discussing the "no-treatment" option with patients accepted for dialysis and in the treatment that would be offered to patients with specific co-morbidities and life-style.

Predialysis education in practice: a questionnaire survey of centres with established programmes.

BACKGROUND: There is growing evidence that renal replacement therapy option education (RRTOE) can result in enhanced quality of life, improved clinical outcomes, and reduced health care costs. However, there is still no detailed guidance on the optimal way to run such programmes. To help address this knowledge gap, an expert meeting was held in March 2013 to formulate a position statement on optimal ways to run RRTOE. Experts were selected from units that had extensive experience in RRTOE or were performing research in this field. Before the meeting, experts completed a pilot questionnaire on RRTOE in their own units. They also prepared feedback on how to modify this questionnaire for a large-scale study. METHODS: A pilot, web-based questionnaire was used to obtain information on: the renal unit and patients, the education team, RRTOE processes and content, how quality is assessed, and funding. RESULTS: Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 EU countries) participated. Nurses were almost always responsible for organising RRTOE. Nephrologists spent 7.5% (median) of their time on RRTOE. Education for the patient and family began several months before dialysis or according to disease progression. Key topics such as the 'impact of the disease' were covered by every unit, but only a few units described all dialysis modalities. Visits to the unit were almost always arranged. Materials came in a wide variety of forms and from a wide range of sources. Group education sessions were used in 3/9 centres. Expectations on the timing of patients' decisions on modality and permanent access differed substantially between centres. Common quality assurance measures were: patient satisfaction, course attendance, updated materials. Only 1 unit had a dedicated budget. CONCLUSIONS: There were substantial variations in how RRTOE is run between the units. A modified version of this questionnaire will be used to assess RRTOE at a European level.

Pre-dialysis education and patient choice.

The discussion was initiated by a paper on the influence of a pre-dialysis education programme on the mode of renal replacement therapy by Goovaerts et al (NDT 2005). Barriers to the uptake of self-care treatment modalities, including late referral, limited availability of treatment options, reimbursement, support from staff and families, the requirement for a helper and the length of the training programmes for home haemodialysis (HD) were discussed by 21 participants from 12 countries. The 'take-home' messages from the discussion were that to optimise the uptake of self-care modalities, renal units should try to ensure the all patients who are able to choose are fully informed before starting dialysis, even if they are referred to the unit very late. Offering a wide range of treatment options to new patients, and allowing (or encouraging) home HD without a helper, may also increase the number of patients who start and stay on a self-care modality. It should be possible to provide an acceptable level of training, without compromising on safety, within 3 weeks if the patient is confident with needling.

Influence of a pre-dialysis education programme (PDEP) on the mode of renal replacement therapy.

BACKGROUND: The distribution of renal replacement therapy (RRT) modalities among patients varies from country to country, and is often influenced by non-medical factors. In our department, patients progressing towards end-stage renal disease (ESRD) go through a structured Pre-Dialysis Education Programme (PDEP). The goals of the programme, based on both individualized information session(s) given by an experienced nurse to the patient and family and the use of in-house audio-visual tapes, are to inform on all modalities of RRT, in order to decrease anxiety and promote self-care RRT modalities. METHODS: To evaluate the influence of our PDEP on the choice of RRT modalities, we retrospectively reviewed the modalities chosen by all consecutive patients starting a first RRT in our institution between December 1994 and March 2000. RESULTS: Two hundred and forty-two patients started a first RRT during the study period. Fifty-seven patients, median age 66 (24-80) years, were directed towards in-centre haemodialysis (HD) for medical or psycho-social reasons (seven of whom were not involved in the PDEP); the remaining 185 patients, median age 53 (7-81) years, with no major medical complications, went through our PDEP. Eight of them (4%) received a pre-emptive renal transplantation. The therapeutic options of the other 177 patients were as follows: 75 (40%) patients, median age 65 (20-81) years opted for in-centre HD, while 102 patients opted for a self-care modality; 55 (31%) patients, median age 56 (7-77) years, chose peritoneal dialysis, 30 (16%) patients, median age 49 (21-68) years, chose to perform self-care HD in our satellite unit, and 17 (9%) patients, median age 46 (19-70) years, opted for home HD. Interestingly, in the whole cohort of patients, the cause of ESRD was associated with the RRT modality: the proportion of patients with chronic glomerulonephritis or chronic interstitial nephritis on self-care therapy was significantly higher than that of patients with nephrosclerosis, diabetic nephropathy or unknown cause of ESRD. CONCLUSION: In our centre offering all treatment RRT modalities, a high percentage of patients exposed to a structured PDEP start with a self-care RRT modality. This leaves in-centre HD for patients needing medical and nursing care, or for patients refusing to participate in their treatment. Additional large studies, preferably with a randomized design, should delineate the cost-benefit of such a PDEP on the final choice of a RRT modality.