Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Resultados de un modelo de organización asistencial para COVID-19 en hemodiálisis en un hospital terciario y sus centros concertados / Results of a healthcare organization model for COVID-19 on hemodialysis in a tertiary hospital and its subsidized centers

Se describe la experiencia de un hospital terciario y cuatro centros concertados de hemodiálisis adscritos al mismo durante la epidemia de COVID-19. Se resume la organización asistencial que se ha llevado a cabo y el curso clínico de los 16 casos de COVID-19 en pacientes en hemodiálisis. La aplicación conjunta de medidas que incluyen el cribado de pacientes, la investigación precoz de casos posibles, el aislamiento de los casos confirmados, en investigación o en contactos, así como la utilización de medidas de protección individuales, han permitido controlar la epidemia. Se compara el curso clínico de estos 16 pacientes con la serie publicada por el Hospital Universitario de Wuhan y con los datos del registro de infecciones COVID-19 de la Sociedad Española de Nefrología. En nuestra experiencia, y a diferencia de lo comunicado por el centro de Wuhan, la enfermedad COVID-19 en los pacientes en hemodiálisis es grave en un porcentaje importante de los casos y la letalidad, elevada, es mayormente causada por la propia infección. Las medidas de contención de la epidemia son eficaces

The experience of a tertiary hospital and four hemodialysis centers attached to it during the COVID-19 epidemic is described. The organization of care that has been carried out and the clinical course of the 16cases of COVID-19 in hemodialysis patients are summarized. The joint application of measures, including patient screening, the early investigation of possible cases, the isolation of confirmed, investigational or contact cases, as well as the use of individual protection measures, has enabled the epidemic to be controlled. The clinical course of these 16patients is compared with the series published by the Wuhan University Hospital and with the data from the COVID-19 infection registry of the Spanish Society of Nephrology. In our experience, and unlike what was reported by the Wuhan Center, COVID-19 disease in hemodialysis patients is severe in a significant percentage of cases, and high lethality is mostly caused by the infection itself. Measures to contain the epidemic are effective

Manejo de la epidemia por coronavirus SARS-CoV-2 (Covid 19) en unidades de hemodiálisis / Management of the SARS-CoV-2 (Covid 19) coronavirus epidemic in hemodialysis units

La epidemia de SARS-CoV-2 representa un riesgo especial para los pacientes renales por su condición de personas con comorbilidades y edad avanzada, y por la realización del tratamiento de hemodiálisis en salas colectivas. La información específica en el momento actual al respecto es muy limitada. El presente manuscrito recoge una propuesta de actuación para prevenir la infección en los Servicios de Nefrología, y en particular en las Unidades de Hemodiálisis, con el objetivo de identificar precozmente aquellos pacientes que cumplan con la definición de caso sospechoso de infección por el SARS-CoV-2 y proponer circuitos y mecanismos para administrarles el tratamiento con hemodiálisis. Son recomendaciones en continua revisión y podrán ser modificadas si la situación epidemiológica y las opciones diagnóstico-terapéuticas así lo requieren

The current outbreak of SARS-CoV-2 represents a special risk for renal patients due to their comorbidities and advanced age. The usual performance of hemodialysis treatments in collective rooms increases the risk. The specific information at this time in this regard is very limited. This manuscript includes a proposal for action to prevent infection in the Nephrology Services, and in particular in Hemodialysis Units, with the objective of early identification of patients who meet the definition of a suspected case of infection by SARS-CoV-2 and propose circuits and mechanisms to carry out hemodialysis treatments. They are recommendations in continuous review and can be modifiedif the epidemiological situation, the diagnostic and therapeutic options so require

Alta prevalencia de covid19 asintomático en hemodiálisis. Aprendiendo dia a dia el primer mes de pandemia de covid19 / High prevalence of asymptomatic COVID-19 in haemodialysis: learning day by day in the first month of the COVID-19 pandemic

Los pacientes en diálisis son un grupo de riesgo de sufrir la infección por el SARS-CoV2 y posiblemente de tener más complicaciones, pero la información con la que contamos es escasa. El objetivo de este trabajo es describir la experiencia del primer mes de pandemia por SARS-Cov2 en una unidad hospitalaria de hemodiálisis (HD) que atiende al 2º distrito madrileño con más en incidencia de COVID19 (casi 1000 pacientes en 100000 h). Se presenta mediante un diario las acciones llevadas a cabo, la incidencia de COVID19 en pacientes y en el personal sanitario, algunas características clínicas y el resultado de un cribado entre todos los pacientes de la unidad. Al inicio, teníamos 90 pacientes en HD: 37(41,1%) han tenido COVID19, de los que 17 (45,9%) fueron diagnosticado spor síntomas detectados en el triaje o durante la sesión y 15 (40,5%) en un cribado realizado a posteriori en los que no se había hecho test diagnóstico por PCR-SARS-Cov2 hasta ese momento. El síntoma más frecuente fue la fiebre, el 50% presentó linfopenia y el 18,4% saturación de O2 < 95%. Precisaron ingreso hospitalario 16 (43,2%) y 6 fallecieron (16,2%). Encontramos un agrupamiento de contagio por turnos y también en aquellos que usaban transporte colectivo. En cuanto al personal, de las 44 personas involucradas, 15 (34%) presentaron sintomatología compatible y 4 (9%) tuvieron PCR SARS-Cov-2 positiva determinada por Salud Laboral y 9 (20%) precisaron algún periodo de Incapacidad Laboral Transitoria (ILT), y 5 fueron considerados casos probables

Dialysis patients are a risk group for SARS-CoV2 infection and possibly further complications, but we have little information. The aim of this paper is to describe the experience of the first month of the SARS-Cov2 pandemic in a hospital haemodialysis (HD) unit serving the district of Madrid with the second highest incidence of COVID19 (almost 1000 patients in 100000 h). In the form of a diary, we present the actions undertaken, the incidence of COVID19 in patients and health staff, some clinical characteristics and the results of screening all the patients in the unit.We started with 90 patients on HD: 37 (41.1%) had COVID19, of whom 17 (45.9%) were diagnosed through symptoms detected in triage or during the session, and 15 (40.5%) through subsequent screening of those who, until that time, had not undergone SARS-CoV2 PCR testing. Fever was the most frequent symptom, 50% had lymphopenia and 18.4% < 95% O2 saturation. Sixteen (43.2%) patients required hospital admission and 6 (16.2%) died. We found a cluster of infection per shift and also among those using public transport. In terms of staff, of the 44 people involved, 15 (34%) had compatible symptoms, 4 (9%) were confirmed as SARS-Cov2 PCR cases by occupational health,9 (20%) required some period of sick leave, temporary disability to work (ILT), and 5 were considered likely cases. CONCLUSIONS: We detected a high prevalence of COVID19 with a high percentage detected byscreening; hence the need for proactive diagnosis to stop the pandemic. Most cases are managed as outpatients, however severe symptoms are also appearing and mortality to date is 16.2%. In terms of staff, 20% have required sick leave in relation to COVID19

Targeting Zero Infections in the Outpatient Dialysis Unit: Core Curriculum 2020.

Although overall mortality rates in dialysis patients have improved during the last decade or so, infections remain a leading cause of death, second only to cardiovascular disease. In addition, infections account for a major share of hospitalizations in this patient population. Receiving hemodialysis treatments in an outpatient dialysis facility significantly contributes to patients' risks for infection. In dialysis units, patient-to-patient transmission of viral pathogens such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus can occur; proper screening and vaccination of patients can decrease the risk for transmission. Strict adherence to hand hygiene, use of appropriate personal protective equipment, transmission-based precautions, and maintaining aseptic technique while connecting the access to the hemodialysis machine can substantially decrease the likelihood of bacterial infections. With an effective infection control program in place, infection prevention becomes part of the dialysis facility's culture and results in improved patient safety. In this installment of the Core Curriculum series, we highlight best practices that should be followed by health care workers in the dialysis unit and discuss the role of the medical director in promoting initiatives to reduce infection rates.

Arteriovenous Fistula Use in the United States and Dialysis Facility-Level Comorbidity Burden.

RATIONALE & OBJECTIVE: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. PREDICTORS: Facility-level burden of patient comorbid conditions; patient characteristics. OUTCOMES: Odds of AVFs versus other access types; facility-level use of AVFs. ANALYTICAL APPROACH: Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. RESULTS: Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. LIMITATIONS: Limited to Medicare dialysis-dependent patients treated for 1 year or more. CONCLUSIONS: After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

Crisis por COVID-19: aplicando los principios de la manufactura esbelta dentro de una Unidad de Hemodiálisis / COVID-19 crisis: Applying the principles of lean manufacture within a Hemodialysis Unit

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Establishing an evidenced-based dietetic model of care in haemodialysis using implementation science.

AIM: To establish an evidence-based dietetics service in an in-centre haemodialysis unit utilising implementation science. METHODS: The service was developed through the Knowledge-to-Action Framework. The steps of the Action Cycle were addressed through a literature review, identification of evidence-based guidelines, benchmarking and local staff engagement. The theoretical domains framework (TDF) was used to identify barriers/enablers, and behaviour change wheel to determine appropriate interventions. To monitor, evaluate outcomes and assess sustained knowledge use we employed multidisciplinary team engagement and database use. Audit data were collected at baseline, 6 and 12 months on nutrition assessment (Patient-Generated Subjective Global Assessment), intervention timeliness and alignment to dietetic workforce recommendations. Descriptive statistics, McNemar tests and a linear mixed model were applied. RESULTS: Barriers existed in the knowledge, skills, environmental context and resources TDF domains. Suitable interventions were identified with training on nutritional management of haemodialysis patients delivered to 148 nurses, and nutrition management recommendations summarised into local procedural resources. A database to prompt and monitor outcome measures was created and indicated that over 18 months post-service commencement, eligible patients received nutrition assessment at least 6-monthly, aligning with recommendations. Prevalence of malnutrition was 28% (n = 9/32) at baseline, 23% (n = 5/22) at 6 months and 20% (n = 4/20) at 12 months (P = 0.50). CONCLUSIONS: We demonstrated benefits to service development and implementation with implementation science providing a structured and methodical approach to translating guidelines into practice. Development of training, resources and prompts for outcome measures has supported the establishment of an evidence-based dietetics service in a haemodialysis unit.

Análisis de las medidas correctoras para la disminución de los eventos adversos en una unidad de hemodiálisis hospitalaria / Analysis of corrective measures for reducing adverse events in a hospital dialysis unit

Los pacientes en hemodiálisis son una población susceptible de padecer eventos adversos por fallos en el proceso asistencial. Objetivo: Evaluar la eficacia de las medidas correctoras en un plan de seguridad del paciente en hemodiálisis para disminuir los eventos adversos. Material y Método: Estudio descriptivo y retrospectivo del registro de hemodiálisis de una unidad hospitalaria. Como método de evaluación se utilizó la metodología propia de nuestro centro (MIDEA) basado en el método Global Trigger Tools. Se revisaron todas las sesiones de hemodiálisis de marzo, mayo y julio de 2016: 2.080 sesiones; y los mismos meses en 2017: 1953 sesiones. Después del análisis de 2016, se implantaron las siguientes medidas correctoras: revisión del procedimiento de anticoagulación del circuito extracorpóreo, actualización del manejo de los accesos vasculares y actualización del procedimiento ante hipotensiones. Resultados: En el año 2016, se revisaron las gráficas de 208 pacientes. Se detectaron 255 eventos adversos (11,8% de las sesiones), siendo los más frecuentes: 85 hipotensiones, 74 coagulaciones del circuito sanguíneo, 31 problemas del acceso vascular y 65 otros eventos adversos. En el año 2017, se revisaron las gráficas de 258 pacientes. Se detectaron 155 eventos adversos (7,9% de las sesiones), siendo los más frecuentes: 60 hipotensiones, 36 coagulaciones del circuito, 30 problemas del acceso vascular y 29 otros eventos adversos. Conclusiones: Los eventos adversos disminuyeron un 39,2% en 2017, y aunque siguen siendo las hipotensiones, coagulaciones del circuito sanguíneo y los problemas derivados del acceso vascular los más frecuentes, pensamos que las medidas correctoras están siendo eficaces

Patients on hemodialysis (HD) are a population susceptible to suffering adverse events (AD) due to failures in the healthcare process. Objective: To evaluate the efficacy of corrective measures in a HD patient safety plan to reduce AD. Material and Method: Descriptive and retrospective study of the HD records of a hospital unit. As an evaluation method, we used the methodology of our center (MIDEA) based on the Global Trigger Tools method. All the HD sessions of March, May and July 2016 were reviewed: 2,080 sessions; and the same months in 2017: 1953 sessions. After the 2016 analysis, the following corrective measures were implemented: revision of the anticoagulation procedure of the extracorporeal circuit, updating of the vascular access management and updating of the procedure before hypotension. Results: In 2016, the clinical records of 208 patients were reviewed. 255 EA were detected (11.8% of the sessions). The most frequent AEs were: 85 hypotension, 74 blood circuit coagulations, 31 vascular access problems and 65 other AD. In 2017, the clinical records of 258 patients were reviewed. 155 AE were detected (in 7.9% of the sessions). The most frequent AEs were: 60 hypotension, 36 circuit coagulations, 30 vascular access problems and 29 other AE. Conclusions: Adverse events decreased by 39.2% in 2017, and although hypotension, blood circuit coagulation and vascular access problems are the most frequent, we consider that corrective measures are being effective

Factores asociados al desarrollo de eventos adversos en pacientes con hemodiálisis en Guerrero, México / Factors associated with the development of adverse events in hemodialysis patients in Guerrero, Mexico

Objetivo: Determinar los eventos adversos más prevalentes y los factores asociados a su desarrollo en el paciente que se somete a hemodiálisis en el estado de Guerrero, México. Material y Método: Estudio observacional, longitudinal, retrospectivo en 157 pacientes en hemodiálisis afiliados al Instituto Mexicano del Seguro Social en Guerrero, atendidos en 5 unidades privadas y 2 públicas. Se recolectaron variables socio-demográficas, mediciones de laboratorio, evolución de la enfermedad, complicaciones propias de la enfermedad y del tratamiento dialítico. Resultados: Los eventos adversos se presentaron en el 73% de la población estudiada, la principal causa etiológica fue Diabetes mellitus tipo 2 (DM2) e hipertensión arterial. Los eventos adversos más frecuentes fueron: hipotensión (35,5%) infección de angioacceso (24%), cefalea (22,3%), crisis hipertensiva (14,5%), mareos (9,9%), escalofríos (9,9%), y trombosis de fístula arteriovenosa (9,9%). Los factores que se asociaron a su desarrollo fueron: pacientes mayores de 65 años, (OR=6,859IC 95%;1,55-30,35), ser obeso, (OR=1,70, IC95%:1,60-4,81), e hipoalbuminemia (OR=0,251, IC 95%: 0,160-0,593). Conclusión: Los pacientes mayores de 65 años, obesos, con hipertensión diastólica e hipoalbuminemia tienen mayor probabilidad de desarrollar eventos adversos durante el periodo de hemodiálisis

Objective: To determine the most prevalent adverse events and the risk factors associated in the patient undergoing hemodialysis in the state of Guerrero, Mexico. Material and Method: Observational, longitudinal, retrospective study in 157 hemodialysis patients affiliated to the Mexican Institute of Social Security in Guerrero, assisted in 5 private and 2 public units. Socio-demographic variables, laboratory measurements, evolution of the disease, complications of the disease and dialysis treatment were collected. Results: Adverse events occurred in 73% of the studied population, the main etiological cause was Diabetes mellitus type 2 (DM2) and arterial hypertension. The most frequent adverse events were: hypotension (35.5%) angioaccess infection (24.0%), headache (22.3%), hypertensive crisis (14.5%), dizziness (9.9%), chills (9.9%), and thrombosis of arteriovenous fistula (9.9%). The associated risk factors: patients over 65, (OR=6.859, 95% CI:1.55-30.35) being obese, (OR=1.70, 95% CI: 1.60-4.81), and hypoalbuminemia (OR=0.251, 95% CI:0.160-0.593). Conclusion: Patients over 65, obese, with diastolic hypertension and hypoalbuminemia are more likely to develop adverse events during the hemodialysis

Managing creativity and compliance in the pursuit of patient safety.

BACKGROUND: Are creativity and compliance mutually exclusive? In clinical settings, this question is increasingly relevant. Hospitals and clinics seek the creative input of their employees to help solve persistent patient safety issues, such as the prevention of bloodstream infections, while simultaneously striving for greater adherence to evidence-based guidelines and protocols. Extant research provides few answers about how creativity works in such contexts. METHODS: Cross-sectional survey data were collected from employees in 24 different U.S.-based outpatient hemodialysis clinics. Linear mixed-effects models were utilized to test study hypotheses. Professional status, clinic climate variables, and interaction terms were modeled as fixed effects, with a random effect for clinic included in all models. RESULTS: Our results show that high status employees contributed more creative patient safety improvement ideas compared to low status employees. However, when high status employees were part of clinics with a stronger safety climate of compliance, they contributed fewer creative ideas compared to their counterparts working in clinics with a reduced compliance orientation. We also predicted low status employees working in less punitive clinics would contribute more creative ideas, but this hypothesis was not fully supported. CONCLUSIONS: This study suggests that in hospitals and clinics that rely on strict protocols and formal hierarchies to meet their goals, the factors that promote creativity may be distinctively context-dependent. Implications for theory, practice, as well as future directions for research examining creativity in healthcare and safety critical contexts are discussed.

Kidney Health Australia - Caring for Australasians with Renal Impairment guideline recommendations for infection control for haemodialysis units.

AIM: There is no national consensus on infection control in haemodialysis units in Australia and New Zealand. The primary aim of this guideline was to provide recommendations on screening for blood-borne viruses and multi-resistant organisms for dialysis units based on the available evidence. METHODS: The Kidney Health Australia Caring for Australasians with Renal Impairment guidelines, overall approach to guideline development follows the GRADE framework. A facilitated workshop was conducted to ensure that patient and caregiver concerns were considered. The evidence from relevant medical databases on the impact of screening on detection and transmission rates, hospitalization, mortality and psychosocial care, was reviewed and critically appraised. The guideline group made recommendations from the evidence available. RESULTS: The main guideline recommendations are: Dialysis units adopt a comprehensive approach that encompasses standard infection control precautions. Conduct routine surveillance for key blood-borne viruses and methicillin-resistant Staphylococcus aureus. Conduct routine surveillance of individual levels of protection against hepatitis B for patients on haemodialysis. Use dedicated dialysis machines for HBV-infected patients. The evidence in totality was not found to support routine surveillance of vancomycin-resistant Enterococci . Enhanced surveillance in light of the local risk of transmittable infectious agents should be considered by dialysis units. Very few studies have reported on the potential adverse effects of screening and associated practices. CONCLUSIONS: Future research should focus on the potential benefits and adverse effects of screening and associated practices on clinical outcomes including infections prevented and health service delivery, and psychosocial domains for patients. Given the results of trials in the critical setting, the effectiveness of methicillin-resistant Staphylococcus aureus decolonization in people receiving dialysis therapy warrants further research.

Análisis de la cultura de seguridad del paciente en unidades extra-hospitalarias de hemodiálisis. Evolución tras la implantación de medidas / Analysis of the safety culture of the patient in out-of-hospital hemodialysis units. Evolution after the implementation of measures

INTRODUCCIÓN: El fomento de la cultura de seguridad del paciente es recomendado para una atención más segura. OBJETIVOS:· Conocer la frecuencia de percepciones y actitudes de los profesionales de los centros de hemodiálisis en relación con la seguridad del paciente.·Identificar puntos fuertes y oportunidades de mejora en el ámbito de la seguridad del paciente.·Comparar los resultados obtenidos, tras la implantación de medidas, con los del estudio de 2014. Material y MÉTODO: Estudio cuantitativo, descriptivo, transversal y comparativo, para medir la cultura de seguridad del paciente en seis centros periféricos de hemodiálisis mediante un cuestionario anónimo autoapli-ado (Cuestionario sobre la seguridad de los pacientes, versión española del Hospital Survey on Patient Safe-ty) en agosto-2014 y marzo-2017. En ese trascurso de tiempo se puso en marcha un sistema de notificación de eventos dversos y se realizó formación en seguridad del paciente. RESULTADOS: La media de la valoración del grado de seguridad percibido por todos los profesionales, fue de 8.02 (±1.42). Se ha incrementado notablemente el grado de notificación manifestada por los profesionales (62.5%). Se identificaron como fortalezas: el trabajo en equipo (86.2%), el feed back sobre errores (75.5%) y las expectativas en la dirección/supervisión (75.1%). Siete de las doce dimensiones presentaron mejoría significativa con respecto a los resultados del 2014. CONCLUSIONES: Podría atribuirse el incremento significativo de los porcentajes de respuesta positiva a la formación realizada en los centros y a la implantación del sistema de notificación y los informes publicados

INTRODUCTION: Developing patient safety culture is recommended for safer care. OBJECTIVES: • Knowing the frequency of staff perceptions and attitudes of health-care workers in hemodialysis centers concerning patient safety.• Identifying strengths and improvement areas in relation to patient safety.• Contrasting the results obtained, after the implementation of measures, with those of the 2014 study. Material and METHOD: A quantitative, descriptive, cross sectional and comparative study to evaluate patient safety culture in six hemodialysis centers through an anonymous self-administered questionnaire (Patient Safety Questionnaire, Spanish version of the Hospital Survey on Patient Safety) in August 2014 and March 2017. An adverse event notification system was implemented during this period, as well as a patient safety training. RESULTS: The average rating of staff security perception was 8.02 (± 1.42). The notification expressed by professionals has increased significantly (62.5%). Teamwork (86.2%), error feedback (75.5%) and management/supervision expectations (75.1%) were identified as strengths. Seven out of the twelve dimensions studied showed a significant improvement in relation to the 2014 results. CONCLUSIONS: A significant increase in positive response ratio could be attributed to the training programs carried out in the centers and to the implementation of the notification system, as well as to the reports already published

Necessidades de ações educativas-terapêuticas em um serviço de diálise renal no Brasil / Needs of Educational-Therapeutic actions in a renal dialysis service in Brazi

Introdução: As ações educativas frequentemente são subestimadas pelos profissionais atuantes em serviços de hemodiálise (HD), mesmo sabendo que elas são imprescindíveis no processo terapêutico. Objetivo: investigar as dúvidas e/ou necessidades das pessoas com DRC e a existência de um programa educacional em um serviço de HD. Método: estudo descritivo e exploratório, com abordagem qualitativa desenvolvido em uma Unidade de Terapia Dialítica, no Brasil. Participaram 30 pessoas com DRC em tratamento HD. Os dados e as elocuções foram coletados por meio de entrevistas individuais, com roteiro semiestruturado e analisado, através de categorias temáticas. Resultado: não se evidenciou predominância para categoria sexo, sendo 15 (50%) para ambos, a faixa etária variou entre 40 a 93 anos. Em relação ao tempo que realiza a HD predomínio foi entre 1 e 5 anos (53%). Os participantes revelaram a ausência (20%) e/ou conhecimento imitado (80%) sobre as questões que envolvem a DRC, identificaram-se através dos discursos, nove necessidades de esclarecimentos, principalmente sobre como se desenvolve (23%), diagnóstico precoce (8%), prevenção (8%) e tratamentos (33%). Apontaram (40%) que, o profissional de enfermagem foi o precursor na prestação de informação relativo à doença e autocuidado. Conclusão: A função de educador é um dos domínios fundamentais dos cuidados de enfermagem, porém, é sabido das dificuldades que tais profissionais enfrentam para viabilizar tal competência. Faz se necessária uma reorientação da prática educacional neste serviço, com o objetivo de ofertar melhor esclarecimentos sobre a DRC, e consequentemente, uma melhor qualidade de vida a estas pessoas (AU)

Introduction: Educational actions are often underestimated by professionals working in hemodialysis (HD) units, even though they are essential in the therapeutic process. Objective: To determine the doubts and/or needs of people with chronic kidney disease (CKD) and the implementation of an educational program in a HD unit. Method: A descriptive and exploratory study with a qualitative approach developed in a Dialysis Therapy Unit in Brazil. Thirty people with CKD on HD treatment were enrolled. Data and elocutions were collected through individual interviews, with a semi-structured questionnaire and analyzed through thematic categories. Results: No predominance was found for the sex category, 15 (50%) for both. The age range ranged from 40 to 93 years. Regarding HD time, the prevalence was between 1 and 5 years (53%). Participants revealed the absence (20%) and / or limited knowledge (80%) on the issues involving CKD. Nine needs for clarification were identified through the speeches: mainly about how it develops (23%), early diagnosis (8%), prevention (8%) and treatments (33%). They pointed out (40%) hat the nursing professional was the forerunner in providing information regarding the disease and self-care. onclusion: One of the fundamental domains of nursing care is the role of educator. However, these professionals face many difficulties to enable such competence. A reorientation of the educational practice in this service is required, with the purpose of offering better clarifications on the CKD, and consequently, a better quality of life to these people (AU)

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Center Effects and Peritoneal Dialysis Peritonitis Outcomes: Analysis of a National Registry.

BACKGROUND: Peritonitis is a common cause of technique failure in peritoneal dialysis (PD). Dialysis center-level characteristics may influence PD peritonitis outcomes independent of patient-level characteristics. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data, all incident Australian PD patients who had peritonitis from 2004 through 2014 were included. PREDICTORS: Patient- (including demographic data, causal organisms, and comorbid conditions) and center- (including center size, proportion of patients treated with PD, and summary measures related to type, cause, and outcome of peritonitis episodes) level predictors. OUTCOMES & MEASUREMENT: The primary outcome was cure of peritonitis with antibiotics. Secondary outcomes were peritonitis-related catheter removal, hemodialysis therapy transfer, peritonitis relapse/recurrence, hospitalization, and mortality. Outcomes were analyzed using multilevel mixed logistic regression. RESULTS: The study included 9,100 episodes of peritonitis among 4,428 patients across 51 centers. Cure with antibiotics was achieved in 6,285 (69%) peritonitis episodes and varied between 38% and 86% across centers. Centers with higher proportions of dialysis patients treated with PD (>29%) had significantly higher odds of peritonitis cure (adjusted OR, 1.21; 95% CI, 1.04-1.40) and lower odds of catheter removal (OR, 0.78; 95% CI, 0.62-0.97), hemodialysis therapy transfer (OR, 0.78; 95% CI, 0.62-0.97), and peritonitis relapse/recurrence (OR, 0.68; 95% CI, 0.48-0.98). Centers with higher proportions of peritonitis episodes receiving empirical antibiotics covering both Gram-positive and Gram-negative organisms had higher odds of cure with antibiotics (OR, 1.22; 95% CI, 1.06-1.42). Patient-level characteristics associated with higher odds of cure were younger age and less virulent causative organisms (coagulase-negative staphylococci, streptococci, and culture negative). The variation in odds of cure across centers was 9% higher after adjustment for patient-level characteristics, but 66% lower after adjustment for center-level characteristics. LIMITATIONS: Retrospective study design using registry data. CONCLUSIONS: These results suggest that center effects contribute substantially to the appreciable variation in PD peritonitis outcomes that exist across PD centers within Australia.

Nivel de seguridad percibida por el paciente de hemodiálisis crónica / Perceived safety level by the patient on chronic hemodialysis

Introducción: Son múltiples las publicaciones que abordan los riesgos hospitalarios, sin embargo escasas las investigaciones que estudian eventos adversos en las unidades de diálisis desde la percepción de los pacientes. Objetivo: Evaluar el nivel de seguridad percibido por el paciente durante la sesión hemodiálisis. Material y métodos: Estudio descriptivo, donde participaron 44 pacientes. Al no encontrar ninguna escala validada se autodiseño una a partir de 3 escalas validadas que miden calidad, satisfacción y factores de estrés, elaborando un instrumento de 40 ítems. Resultados: Se realizó un análisis descriptivo y estratificado por edad y años en hemodiálisis. El 100% de los encuestados se sienten seguros durante la sesión de hemodiálisis. En relación con la calidad de los cuidados y la percepción de los mismos todos los ítems consiguen una puntuación superior al tres sobre cinco. En cuanto a la educación un 63% le gustaría recibir más educación aunque un 70% afirma saber actuar ante las complicaciones. En el listado de factores de estrés, obtienen puntuaciones mayores las complicaciones del acceso vascular, el tiempo conectado a la máquina, el transporte y temperatura de la sala. Conclusión: La calidad de los cuidados enfermeros percibidos obtiene una buena satisfacción. En cuanto a los factores estresantes creemos que se podría llevar a cabo intervenciones enfermeras para disminuirlos, realizando actividades educativas y lúdicas intradiálisis, todo ello para aumentar la seguridad, y la calidad de los cuidados (AU)

Introduction: There are multiple publications addressing hospital risks, however, manuscripts studying adverse events in dialysis units from the perception of patients are scarce. Objective: To assess the perceived safety level by the patient during hemodialysis session. Material and Methods: A descriptive study in which 44 patients participated. Not finding in the literature any validated scale, a scale from 3 others validated, which measured the quality, satisfaction and stress factors, was elaborated, obtaining an instrument of 40 items. Results: A descriptive analysis was performed and stratified by age and years on hemodialysis. 100% of respondents feel safe during hemodialysis session. Regarding to the quality of care and the perception of them, all items get a superior three out of five score. With respect to education, 63% of patients would like more education while 70% claimed to know to act before complications. In the list of stressors, they get higher scores on vascular access complications, time connected to the machine, transportation and room temperature. Conclusion: The perceived quality of nursing care gets a good satisfaction. With respect to the obtained stressors, we believe that nursing interventions could carry out to reduce them, conducting intradialytic educational and recreational activities with the aim of increasing safety and quality of care (AU)

Diálisis peritoneal de flujo continuo en una unidad de cuidados intensivos pediátricos / Continuous flow peritoneal dialysis in a paediatric intensive care unit

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Impact of European medicines agency recommendations for hypersensitivity reactions on intravenous iron prescription in haemodialysis centres of the Lombardy region.

BACKGROUND: The European Medicines Agency (EMA) has recommended measures to minimize the risk of hypersensitivity reactions (HSRs) to intravenous iron (IVFe). We analysed the effects of these recommendations on IVFe clinical management among haemodialysis centres (HDCs) in Lombardy, Italy. MATERIALS AND METHODS: A questionnaire was sent to all 117 HDCs to collect information on centre characteristics, e.g. HDC type [hospital centre (HC) vs. centre with limited assistance (CAL)], presence/absence of intensive care unit (ICU) and/or emergency trained staff, IVFe therapy regarding molecules, administration modalities, side effects, and percentage variations in iron prescription between 2014 and 2013 (outcome, Δ-IVFe%). A linear regression model was applied to evaluate the focus effect (ß) of HDC type on the outcome, controlling for possible confounding effects of the other characteristics. RESULTS: Response rate was 73.5 %. IVFe therapy was used in 69.1 % (HDC range 11-100) of patients. Following EMA recommendations, prescription was reduced by 12.6 %, with the largest reduction observed in CALs. No severe HSRs were reported. HCs had more frequently an ICU [97.2 vs. 20 %, odds ratio (OR) = 63.6 (95 % confidence interval 15.56; 537.47), p < 0.001], emergency trained staff [97.2 vs. 61.2 %, OR = 10.7 (2.68; 85.33), p < 0.001] and instrumental facilities (91.7 vs. 58 %, OR = 5.8 (2.03; 23.55), p < 0.001] than CALs. Linear regression demonstrated a significant raw effect of HDC type on Δ- IVFe% [ß =  19.6 (9.82; 30.63), p < 0.001]. No association was found when HDC type was adjusted for ICU-presence [ß = 6.7 (-2.32; 18.30), p = 0.199] or for all-confounding factors [ß = 5.6 (-5.50; 17.08), p = 0.337]. CONCLUSIONS: This survey shows a disparity in IVFe therapy prescription following EMA recommendations, which is largely influenced by the presence/absence of ICUs in HD centres.