Use of Electronic Patient-Reported Outcomes in the Care of Patients with Kidney Failure.

This article in the "Exploring the Evidence" series provides nephrology nurses and clinicians with a description of what electronic patient-reported outcomes (ePROs) and patient-reported outcome measures (PROMs) entail, as well as an understanding of how they can be used in nephrology patient care. Specifically highlighted are some questions and issues that clinicians have raised in our various research studies that have explored ePRO use and integration in the movement toward person-centered kidney care (Schick-Makaroff, 2017; Schick-Makaroff and Molzahn, 2014, 2015, 2017; Schick-Makaroff, Tate et al., 2019).

Approaches to Medication Management in Patients with Kidney Failure Opting for Conservative Management.

After consideration of risks and benefits, some patients with kidney failure choose conservative management. Conservative management of kidney failure (CM-KF) does not include dialysis or transplant and utilizes primarily pharmacologic strategies for symptom management, which can be challenging due to the number and complexity of symptoms. Additionally, there are safety concerns regarding altered pharmacokinetics and the adverse effects induced by some of the therapies that may be selected to treat symptoms. This review describes common kidney failure symptoms and provides recommendations for pharmacologic management in CM-KF. Selection of medication should be individualized to the patient and comorbidities, drug interactions, cost, and adverse effects should be carefully considered. Additional studies specifically focused on CM-KF are needed.

Improved Quality of Life in the Pediatric Patient on Hemodialysis: Academic Success with Implementation of a Full-Time Schoolteacher.

Children living with kidney failure who are on hemodialysis are at risk for having a poor quality of life. Within the pediatric hemodialysis unit, patients were not receiving adequate educational services. Alternative school options available for patients on hemodialysis were insufficient to meet their needs. This deficit contributed to patients' academic failures, and decreased their self-esteem and quality of life. To improve academic services for patients on hemodialysis, a full-time schoolteacher was employed. The addition of the hemodialysis schoolteacher supported patients' academic success, which led to a significant improvement in the patients' quality of life.

Interpretation of Renal Quality of Life Profile scores in routine clinical practice: an aid to treatment decision-making.

PURPOSE: High Renal Quality of Life Profile (RQLP) scores are associated with impaired health-related quality of life; however, the clinical meaning of the scores is difficult for clinicians and healthcare planners to interpret. The aim of this study was to determine clinical significance of RQLP scores which could be used to aid clinical decision-making. METHODS: The anchor-based technique (a method for categorizing numeric scores to ease interpretation) was used to develop a categorization system for the RQLP scores using a global question (GQ). The GQ scores (i.e. no effect to extremely large effect) were mapped against the RQLP scores, and intraclass correlation coefficient (ICC) was used to test their agreement. The RQLP and the GQ were administered to 260 adult patients (males = 165 and females = 95) with chronic renal failure (CRF). RESULTS: The mean RQLP score was 67.2, median = 61, SD = 41.5, and range 0-172. The mean GQ score was 1.74, median = 2, SD = 1.27, and range 0-4. The mean, mode, and median of the GQ scores for each RQLP score were used to devise several sets of categories of RQLP score, and the ICC test of agreement was calculated. The proposed set of RQLP score banding for adoption includes: 0-20 = no effect on patient's life (GQ = 0, n = 35); 21-51 = small effect on patient's life (GQ = 1, n = 66); 52-93 = moderate effect on patient's life (GQ = 2, n = 87); 94-134 = very large effect on patient's life (GQ = 3, n = 54); and 135-172 = extremely large effect on patient's life (GQ = 4, n = 18). The ICC coefficient for the proposed banding system was 0.80. CONCLUSION: The proposed categorization of the RQLP will aid the clinical interpretation of change in RQLP score informing treatment decision-making in routine practice.

Impacting the Trajectory of Chronic Kidney Disease With ARPN-Led Renal Teams.

Health care reform demands improvements in population health and the patient experience while reducing costs. This demand is referred to as The Triple Aim of Improvement. A sense of urgency must be created for development of new models of care that impact outcomes earlier in the disease process. One new model of care addressing the triple aim is the Advanced Practice Registered Nurse (APRN)-Led Specialty Care Team. APRN-Led Specialty Care Team members engage patients and implement evidence at a point in the disease trajectory that is most likely to influence population outcomes, resources, and cost. In the pilot described in this article, a nurse practitioner, a registered nurse, a licensed practice nurse, a registered nurse certified diabetes educator, a registered dietitian, and a clinical pharmacist provided care to 20 patients with diabetes and chronic kidney disease, using the chronic disease trajectory model. The team was trained and supported through virtual technology and chronic kidney disease clinical decision-making tools. This APRN-Led Renal Specialty Care Team was embedded into primary care, using group appointments with nephrology support. Lessons learned regarding implementation, with a focus on the role of the nursing executive, are presented along with recommendations for future implementation.

Adherence in paediatric renal failure and dialysis: an ethical analysis of nurses' attitudes and reported practice.

Minors have difficulty adhering to the strict management regimen required whilst on renal dialysis for chronic renal failure. This leads to ethical tensions as healthcare professionals (HCPs) and parents try, in the minor's best interests, to ensure s/he adheres. All 11 dialysis nurses working in a large, regional paediatric dialysis unit were interviewed about their perceptions and management of non-adherence and the ethical issues this raised for them. Participants reported negative attitudes to non-adherence alongside sympathy and feelings of frustration. They discussed the competing responsibilities between nurses, parents and minors, and how responsibility ought to be transferred to the minor as s/he matures; the need for minors to take responsibility ahead of transferring to adult services; and, the process of transferring this responsibility. Our discussion concentrates on the ethical issues raised by the participants' reports of how they respond to non-adherence using persuasion and coercion. We consider how understandings of capacity, traditional individual autonomy, and willpower can be used to comprehend the issue of non-adherence. We consider the relational context in which the minor receives, and participates in, healthcare. This exposes the interdependent triad of relationships between HCP, parent and minor and aids understanding of how to provide care in an ethical way. Relational ethics is a useful alternative understanding for professionals reflecting upon how they define their obligations in this context.

Physiologic and psychosocial approaches to global management of the hemodialysis patient in the Southern Alberta Renal Program.

As frontline nurses, we know firsthand the many challenges of renal disease faced by our patients and the impact on their lives and their families. How can we help them cope with their illness? How can we improve their quality of life? How can we prevent the complications inherent to the disease? How do we know we are doing a good job? Where do we start? The purpose of this presentation is to showcase the global management of the hemodialysis (HD) patient. It provides a collaborative and systematic approach to assessing, implementing, evaluating and coordinating the physiologic and the psychosocial aspects of their care. It is a model of case management followed by the Southern Alberta Renal Program (SARP) in meeting the many and complex needs of our hemodialysis patients. The quality indicators, to name a few, that relate to the physiologic aspects of their care are dialysis adequacy and fluid removal, improved blood pressure (BP) control, maintenance and improved vascular access function, anemia, bone and mineral disease management, nutritional, and diabetes management. The psychosocial aspects of care encompass goals of care, residential support, transportation, and mobility programs in the community. There may be positive implications resulting from our practice that we believe would be invaluable in terms of improved patient care, increased adherence to therapeutic regimens, improved mortality and morbidity and overall enhanced quality of life. Moreover, better communication would possibly be fostered and wise and prompt use of resources may be a result. To date, we have not done studies to prove or disprove these outcomes.

Satellite dialysis nursing: technology, caring and power.

AIM: This paper is a report of an exploration of nurses' perceptions of the quality of satellite dialysis care and how aspects of power that influenced quality nursing care. BACKGROUND: In Australia, the majority of people living with established kidney failure undertake haemodialysis in nurse-run satellite dialysis units. Haemodialysis nurses provide the majority of care, and their perceptions of what constitutes quality nursing care may influence their care of the person receiving haemodialysis. METHOD: A critical ethnographic study was conducted where data were collected from one metropolitan satellite dialysis unit in Australia over a 12-month period throughout 2005. The methods included non-participant observation, interviews, document analysis, reflective field notes and participant feedback. FINDINGS: Three theoretical constructs were identified: 'What is quality?', 'What is not quality?' and What influences quality?' Nurses considered technical knowledge, technical skills and personal respect as characteristics of quality. Long-term blood pressure management and arranging transport for people receiving dialysis treatment were not seen to be priorities for quality care. The person receiving dialysis treatment, management, nurse and environment were considered major factors determining quality dialysis nursing care. CONCLUSION: Aspects of power and oppression operated for nurses and people receiving dialysis treatment within the satellite dialysis context, and this environment was perceived by the nurses as very different from hospital dialysis units.

Renal failure and specialist palliative care: an assessment of current referral practice.

AIMS: This retrospective audit assessed the referral practice for patients with end-stage renal failure from the nephrology service to the specialist palliative care team in a large teaching hospital in the north-west of England. METHODS: Forty-nine referrals with 'renal' as a primary diagnosis over a two-year period were identified from referral data. General and palliative care notes were reviewed and a data collection tool was designed. RESULTS: Most common reasons for referral were for 'placement' (38.6%) and 'dying/distressed' patients (22.7%), although psychological support was also prevalent (15.9%). Renal teams discussed stopping dialysis in the majority of cases (89%), but documented preferred place of care less frequently (48.3%) and achieved discharge to these locations in less than half of cases (21.4%). CONCLUSION: There was well-established referral practice between the renal and the specialist palliative care team at the hospital examined. The renal team appropriately referred for symptom control and support in the dying phase of patients. There are issues surrounding placement and increased implementation of end-of-life care tools, including the Liverpool Care Pathway, Gold Standards Framework and Preferred Place of Care documentation for renal patients, which needs to be an ongoing priority.

Historia y desarrollo de las técnicas continuas de reemplazo renal (TCRR): el papel realizado por la enfermería / History and development of continuous renal replacement therapy (CRRT): the role of nursing

Objetivo: Conocer la historia de las técnicas continuas de reemplazo renal (TCRR), y el papel de la enfermería, desde su descubrimiento hasta su evolución técnica, y desde su uso temprano en el tratamiento de la insuficiencia renal aguda hasta las actuales terapias extracorpóreas secuenciales y su aplicación en cuidados intensivos (UCI). Metodología: Se han utilizado diversas fuentes documentales procedentes de libros y literatura científica relacionada con nuestro tema. Resultados principales: La historia de cómo se comenzó a conocer el funcionamiento del sistema renal y sus patologías, está ligada a la propia historia del hombre que abarca desde las primeras civilizaciones hasta nuestros días. Una sucesión gradual de descubrimientos e inventos, llegarán a sentar las bases de lo que será la futura diálisis. Pero no será hasta 1977 cuando la hemodiálisis se introdujo en UCI como terapia continua. La vinculación de la enfermera, desde los inicios de la diálisis y de la TCRR ha sido esencial para la implementación y desarrollo de esta técnica. Conclusión principal: Los progresivos avances científicos y tecnológicos han dado lugar a que las TCRR sean una de las técnicas más utilizadas y seguras realizadas en cuidados intensivos, donde la enfermera, desde sus inicios, juega un papel fundamental en la implementación de esta técnica (AU)

Objective: To know the history of continuous renal replacement techniques (CRRT), and the role of nursing, from its discovery to its technical evolution, and from its early use in the treatment of acute renal failure to current sequential extracorporeal therapies and their application in intensive care (ICU). Methodology: Various documentary sources from books and scientific literature related to our subject have been used. Main results: The history of how the functioning of the renal system and its pathologies began to be known is linked to the history of man itself, from the first civilisations to the present day. A gradual succession of discoveries and inventions laid the foundations for the future of dialysis. But it was not until 1977 that haemodialysis was introduced in the ICU as a continuous therapy. The involvement of the nurse, from the beginning of dialysis and CRRT, has been essential for the implementation and development of this technique. Main conclusion: Progressive scientific and technological advances have led to CRRT being one of the most widely used and safest techniques performed in intensive care, with the nurse playing a fundamental role in the implementation of this technique from its beginnings (AU)

Direct costs of integrated procedures of conventional hemodialysis performed by nursing professionals.

OBJECTIVE: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals. METHOD: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications. RESULTS: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the "installation and removal of hemodialysis fistula access" caused a significantly lower economic impact compared to "installation and removal of hemodialysis catheter access". CONCLUSION: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.

Nursing care of the patient undergoing coronary artery bypass grafting.

The role of the professional nurse in the perioperative care of the patient undergoing open heart surgery is beneficial for obtaining a positive outcome for the patient. This article focuses on the preoperative and postoperative nursing care of patients undergoing coronary artery bypass graft surgery. Risk assessment, preoperative preparation, current operative techniques, application of the nursing process immediately after surgery, and common postoperative complications will be explored.

Mapping the literature of nephrology nursing.

OBJECTIVES: A bibliometric investigation was done to identify characteristics of the literature that nephrology nurses utilize. It is one component of a broader study, "Mapping the Literature of Nursing," by the Medical Library Association's Nursing and Allied Health Resources Section Task Force to Map the Literature of Nursing. METHODS: Following a standard protocol, this project utilized Bradford's Law of Scattering to analyze the literature of nephrology nursing. Citation analysis was done on articles that were published from 1996 to 1998 in a source journal. Cited journal titles were divided into three zones, and coverage in major article databases were scored for Zones 1 and 2. RESULTS: During the three-year period, journals were the most frequently cited format type. Eighty-one journals were cited in Zones 1 and 2. As Bradford's Law of Scattering predicted, a small number of the cited journals accounted for the most use. Coverage is most comprehensive for cited journals in Science Citation Index, PubMed/ MEDLINE, and EMBASE. When looking just at cited nursing journals, CINAHL and PubMed/MEDLINE provide the best indexing coverage. CONCLUSION: This study offers understanding of and insights into the types of information that nephrology nurses use for research. It is a valuable tool for anyone involved with providing nephrology nursing literature.

Understanding renal dose dopamine.

Low-dose dopamine is a widely administered drug used often in critical care settings to prevent or treat patients with low urinary output. There are new data to support that low-dose dopamine may have side effects and not always increase renal perfusion to the kidneys. This article is a review of the current use of low-dose dopamine, the role of dopamine in the kidneys, and the potential risks of infusing this drug to patients.

Basic tools to integration in management and continuous quality improvement: protocols and procedures.

In order to support interested colleagues with the concepts of Continuous Quality Improvement (CQI) and Clinical Standards for Nephrology Practice, a package of education support has been set up. We enhance the use of procedures, protocols, working plans, guidelines and nursing care plans as instruments of organisational integration. For the nursing care of renal patients in HD and PD we believe that all the procedures and protocols (P&P) above could have an important impact in the renal nursing practice. We propose that group members run a programme which is presented and implemented as a modular package including, theoretical knowledge, setting up working groups involved in literature revision, evaluation of defined P&P after a period of implementation, final implementation & periodic evaluation.

Comparative distribution and use of humour within nurse-patient communication.

There has been increasing interest in the use of humour in patient care within recent years. However, little research has been conducted to show the natural utilisation of humour, particularly from the participants' perspective, within the clinical environment. This study uses ethnomethodological ethnography and conversation analysis methods to investigate the use of humour between nurses and patients with renal failure who were learning about, and to, haemodialyse. It is believed that the project is unique in the utilisation of audiovisual video recordings to measure and describe the frequency, distribution and use of humour. Findings indicated that humour rates and the proportion of humour produced by the patients were differentially distributed between patients but, overall, not between the same patients on different occasions. In addition, in one case a significant positive relationship between the rate of humorous instances per session and time was demonstrated and another patient (D) was found to produce a significantly larger proportion of the humour over time. Further exploration of patient D's increasing use of humour revealed that one important aspect was associated with the patients anxiety and difficulties with regard to "needling'. The findings have implications for understanding the role of humour in health care communication, particularly with reference to developing formal "humorous interventions'.