An education initiative modifies opinions of hemodialysis nurses towards home dialysis.

BACKGROUND: It has been shown that in-center hemodialysis (HD) nurses prefer in-center HD for patients with certain characteristics; however it is not known if their opinions can be changed. OBJECTIVE: To determine if an education initiative modified the perceptions of in-center HD nurses towards home dialysis. DESIGN: Cross-sectional survey of in-center HD nurses before and after a three hour continuing nursing education (CNE) initiative. Content of the CNE initiative included a didactic review of benefits of home dialysis, common misconceptions about patient eligibility, cost comparisons of different modalities and a home dialysis patient testimonial video. SETTING: All in-center HD nurses (including those working in satellite dialysis units) affiliated with a single academic institution. MEASUREMENTS: Survey themes included perceived barriers to home dialysis, preferred modality (home versus in-center HD), ideal modality distribution in the local program, awareness of home dialysis and patient education about home modalities. METHODS: Paired comparisons of responses before and after the CNE initiative. RESULTS: Of the 115 in-center HD nurses, 100 registered for the CNE initiative and 89 completed pre and post surveys (89% response rate). At baseline, in-center HD nurses perceived that impaired cognition, poor motor strength and poor visual acuity were barriers to peritoneal dialysis and home HD. In-center HD was preferred for availability of multidisciplinary care and medical personnel in case of catastrophic events. After the initiative, perceptions were more in favor of home dialysis for all patient characteristics, and most patient/system factors. Home dialysis was perceived to be underutilized both at baseline and after the initiative. Finally, in-center HD nurses were more aware of home dialysis, felt better informed about its benefits and were more comfortable teaching in-center HD patients about home modalities after the CNE session. LIMITATIONS: Single-center study. CONCLUSIONS: CNE initiatives can modify the opinions of in-center HD nurses towards home modalities and should complement the multitude of strategies aimed at promoting home dialysis.

CONTEXTE: Le personnel infirmier s'occupant de patients qui reçoivent leur traitement d'hémodialyse (HD) en centre hospitalier préfère cette modalité thérapeutique pour certains types de patients; nous ne savons toutefois pas si cette opinion peut être modifiée. OBJECTIFS: Déterminer si une intervention d'éducation a modifié la perception de l'hémodialyse à domicile par le personnel infirmier s'occupant des patients en HD hospitalière. TYPE D'ÉTUDE: Étude transversale auprès du personnel infirmier en HD hospitalière, avant et après la réalisation d'une intervention d'éducation en soins infirmiers de trois heures. Le contenu de la formation comprenait un examen didactique des avantages de l'hémodialyse à domicile, des idées fausses sur l'admissibilité des patients, une comparaison des coûts des différentes modalités, de même qu'une vidéo présentant des témoignages de patients en hémodialyse à domicile. CONTEXTE: Tout le personnel infirmier en HD hospitalière (qui comprend celui des services satellites de dialyse) affilié à un établissement d'enseignement unique. MÉTHODES: Les thèmes du sondage comprenaient les obstacles perçus à la dialyse à domicile, les modalités favorisées (HD hospitalière contre HD à domicile), la distribution idéale des modalités au sein du programme local, la sensibilisation à l'HD à domicile et l'éducation des patients au sujet des modalités à domicile. MÉTHODES: Comparaisons par paires des réponses obtenues avant et à la suite de la formation. RÉSULTATS: Parmi les 115 membres du personnel infirmier en HD hospitalière, 100 se sont inscrits à la formation et 89 ont rempli à la fois les sondages qui précèdent et qui suivent la formation (taux de réponse de 89 %). Au départ, le personnel infirmier en HD hospitalière a ciblé un déficit cognitif, une faible force motrice et une faible acuité visuelle comme des obstacles à la dialyse péritonéale et à l'HD à domicile. L'HD hospitalière était favorisée pour la disponibilité des soins multidisciplinaires et du personnel médical en cas d'événement catastrophique. À la suite de la formation, l'opinion était généralement favorable à l'HD à domicile sans égard aux caractéristiques des patients, et à la majorité des facteurs patient/système. L'HD à domicile a été perçue comme étant sous-utilisée, tant au départ qu'à la suite de la formation. Finalement, à la suite de la séance de formation, le personnel infirmier en HD hospitalière était plus sensibilisé à l'HD à domicile, se sentait mieux informé de ses avantages, et plus à l'aise d'informer les patients en HD hospitalière quant aux modalités à domicile. LIMITES DE L'ÉTUDE: L'étude ne touche qu'un centre. CONCLUSIONS: Les initiatives d'éducation en soins infirmiers peuvent modifier l'opinion du personnel infirmier en HD hospitalière au sujet des modalités de dialyse à domicile, et devraient constituer un complément à la multitude de stratégies visant à promouvoir l'HD à domicile.

Factors associated with access blood flow in native vessel arteriovenous fistulae.

BACKGROUND: Access blood flow (Qa) identifies stenosis in patients with native vessel AV fistulae (AVF), but data on factors that are associated with Qa in normally functioning accesses are sparse. Such factors could be used in conjunction with Qa to improve the diagnostic performance of screening. We examined the relationship between Qa and certain clinical characteristics in a large group of patients with AVF. METHODS: This was a retrospective study of incident and prevalent haemodialysis patients treated at a single institution, all of whom had a functioning AVF during the study period. Qa was measured bimonthly using ultrasound dilution in all subjects. Mixed models were used to explore the relationship between Qa and a group of independent variables, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), diabetes mellitus, patient age, sex, height, body mass index (BMI) and AVF location (forearm vs upper arm). RESULTS: A total of 4084 Qa measurements was made in 294 patients. Univariate analysis found that younger patient age, non-diabetic status, higher blood pressure (SBP, DBP, MAP, all at the time of Qa measurement), upper arm AVF location and overweight status (BMI >/=25) were significantly associated with Qa. SBP appeared to be more strongly associated with Qa than either DBP or MAP. Patient sex, height and interval between access creation and Qa measurement were not significantly associated with Qa. Tests for interaction suggested that the association between SBP and age and Qa varied significantly by access location. In a multivariate model, SBP, overweight status and diabetic status were independently associated with Qa. The strength of the association between these characteristics and Qa appeared to be clinically relevant. CONCLUSIONS: Our findings suggest that a single Qa threshold for angiography in all patients may be simplistic, and that the optimal threshold might vary by patient subgroup. The strong association between SBP and Qa suggests that adjusting Qa for SBP may improve the specificity of access screening. Further work is required to determine whether such modifications to current practice would improve the predictive power of Qa measurements for detection of stenosis in AVF.

Best threshold for diagnosis of stenosis or thrombosis within six months of access flow measurement in arteriovenous fistulae.

Canadian clinical practice guidelines recommend performing angiography when access blood flow (Qa) is <500 ml/min in native vessel arteriovenous fistulae (AVF), but data on the value of Qa that best predicts stenosis are sparse. Because correction of stenosis in AVF improves patency rates, this issue seems worthy of investigation. Receiver-operating characteristic curves were constructed to examine the relationship between different threshold values of Qa and stenosis in 340 patients with AVF. Stenosis was defined by the composite outcome of access failure or angiographic stenosis occurring within 6 mo of the first Qa measurement. The Qa value was then classified as true negative, true positive, false negative, or false positive for stenosis. An additional analysis was performed in which Qa was corrected for systolic BP before assigning it to one of the four diagnostic categories. The area under the curve for the composite definition of stenosis was 0.86. Graphically, Qa thresholds of <500 and <600 ml/min had similar efficacy for detecting stenosis or access failure within 6 mo, and both seemed superior to <400 ml/min. However, the frequency of the composite definition of stenosis among AVF with Qa between 500 and 600 ml/min was only 6 (25%) of 24, as compared with 58 (76%) of 76 when Qa was <500 ml/min. This suggests that most lesions that would be found using a threshold of <600 ml/min occurred in AVF with Qa <500 ml/min and that the small gain in sensitivity associated with the <600-ml/min threshold would be outweighed by the reduced specificity compared with <500 ml/min. Correcting Qa for BP did not improve diagnostic performance or change these results, which were consistent in several sensitivity analyses. Qa measurements seemed to predict stenosis or incipient access failure equally well in groups defined by diabetic status, gender, and AVF location. In conclusion, it was found that Qa <500 ml/min seems to be the most appropriate threshold for performing angiography in patients with native vessel AVF. It is recommended that clinicians arrange angiography when Qa is <500 ml/min in AVF.

Access flow monitoring of patients with native vessel arteriovenous fistulae and previous angioplasty.

Screening strategies based on measurement of access blood flow (Qa) allow detection and angioplasty of subclinical stenosis in native vessel arteriovenous (AV) fistulae. However, little is known about the efficacy of Qa measurements for detecting recurrent stenoses in fistulae and that of angioplasty for correcting them. A total of 303 patients were studied over 30 mo; 69 (23%) of these had stenoses, of whom 53 underwent angioplasty. Of those undergoing angioplasty, 30 patients had 46 episodes of recurrent positive studies and underwent repeat fistulography. In 31 of these episodes (19 patients), stenosis was again identified and treated successfully with angioplasty. Overall positive predictive values for stenosis were similar in first and subsequent episodes of stenosis (71% versus 67%), and angioplasty was associated with sustained increases in Qa for both first and subsequent episodes. Assisted patency in fistulae that required repeat angioplasty was 87% (median follow-up 10 mo after the second angioplasty). In conclusion, Qa is effective for detecting first and subsequent lesions in patients with AV fistulae, and angioplasty of first or subsequent lesions is associated with sustained increments in Qa. Continued screening after correction of first stenoses appears reasonable, because of both the frequency of recurrent stenosis and the success of repeat intervention.