RESEARCH IN BRIEF
The quality of nursing care during intradialytic fluid removal in haemodialysis: time to change practice? Mette S Ludvigsen, Hanne M Hermansen and Magnus Lindberg Accepted for publication: 26 September 2014
Aims To estimate the quality of nephrology nursing during intradialytic removal of excess fluid in patients undergoing haemodialysis (HD) using ultrafiltration rate (UFR) as a nursing-sensitive quality indicator.
Background Knowledge accumulation within nursing science combined with technological advancements has improved the possibility of providing high quality, safe care to patients undergoing haemodialysis (Davenport 2011). Haemodialysis is a way of removing retained fluid (by ultrafiltration), electrolytes and waste products in people suffering from end-stage renal disease. One goal in haemodialysis is to ensure that the fluid removal is optimal and uncomplicated i.e. without intradialytic hypotension (IH), cramping or syncope. IH is observed in one out of four dialysis treatments although highly dependent on both patient condition and clinical practice patterns. Known risk factors for IH includes comorbidities such as diabetes, long dialysis vintage, accuracy of the prescribed dry weight, and practice patterns such as dialysate sodium and dialysate temperature. Adjusting the UFR is a common nursing intervention to prevent side effects (Sands et al. 2014). However, empirical evidence suggests that rapid fluid removal influences patient outcome negatively in terms of cardiovascular morbidity and mortal-
Authors: Mette S Ludvigsen, RN, PhD, MEANS, Clinical Research Nurse, Department of Renal Medicine, Aarhus University Hospital; Hanne M Hermansen, RN, Ward Manager, Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark; Magnus Lindberg, RN, PhD, MEANS, Clinical Lecturer, Department of Health and Caring Sciences, University of G€avle, G€avle; Department of Public Health and Caring Sciences, Uppsala University,
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736, doi: 10.1111/jocn.12735
ity (Flythe & Brunelli 2011). Until now adequate haemodialysis practice has been defined by small molecule clearance (Kt/V) (Flythe & Brunelli 2011) based on international benchmarks defined as; the clearance (K, in ml/min) of urea multiplied by the duration of the dialysis treatment (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL), which is approximately equal to the total amount of body water. The adjustment of total urea removal (Kt) for volume of distribution is important. In a large patient, a given degree of urea loss represents a lower rate of removal of the total body burden of urea (and presumably of other small uraemic toxins). According to international clinical practice guidelines (e.g. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative), the Kt/V should always be equal to or above 12. Most haemodialysis units do not have on-site nephrologists and care is provided by nurses; haemodialysis nursing care thus has a considerable impact on patient outcome. The UFR has been suggested to be a potential nursing-sensitive process indicator, defined as an explicitly and measurable item referring to the structures, processes or outcomes of care, to estimate quality of nephrology nursing (Lindberg & Ludvigsen 2012); the rate should not exceed 10 ml/h/Kg (Flythe & Brunelli 2011).
Design A cross-sectional quality assurance project.
Uppsala; Department of Nephrology and Haematology, G€ avle Hospital, G€ avle, Sweden. Correspondence: Mette Spliid Ludvigsen, Clinical Research Nurse, Department of Renal Medicine, Aarhus University Hospital, Brendstrupsgaardsvej 100, 8200 Aarhus N, Denmark. Telephone: +45 784 52526. E-mail: [email protected]
1733
Research in brief
Methods Audit is an internationally recognised way to evaluate existing practices. Approval was granted by the Danish Data Protection Agency (Journal number 2007-58-0010). Routinely collected treatment data from a single Scandinavian haemodialysis centre were used. At this centre, the haemodialysis treatment process is automatically documented in the Therapy Data Management SystemTM (TDMS) (Fresenius Medical Care, Bad Homburg, Germany). At the time of the study, the centre had 220 patients receiving either acute or chronic haemodialysis treatment. All patients with no residual urine output, undergoing at least three dialysis sessions per week, and requiring ultrafiltration were selected by a convenience sampling procedure. Total sample amounted to 104 patients. Data regarding weight before dialysis, blood pressure before and after dialysis, level of serum sodium and dialysate sodium, dialysate temperature and relative blood volume on the mid-week treatment session were extracted from the TDMS. Data on estimated dry weight, ultrafiltration volume, and treatment time were also extracted to calculate the UFR (Lindberg & Ludvigsen 2012); single-pool Kt/V was measured. Routinely, nurses recorded any occurrence of IH, cramping and syncope. IH was defined as a decrease in systolic blood pressure by >20 mmHg or a decrease in mean arterial pressure by 10 mmHg (Agarwal 2012). Cramping was defined as an involuntary contraction of muscles; syn-
cope was defined as a loss of consciousness. Descriptive and comparative analyses were conducted using IBM SPSS Statistics version 20.0 for Windows (Chicago, IL, USA). Subgroups for body weight comparison were created using quartile distributions. Subgroups for age comparison were inspired by the National Library of Medicine controlled vocabulary thesaurus Medical Sub Headings for the three out of four age groups: Adult: 19–44 years, Middle aged: 65–79 years, Aged: 80 years and over. There was no MeSH definition for the fourth age group (45–64 years) in this study.
Results The cross-sectional measure implied that in four out of ten patients the UFR was higher than 10 ml/h/Kg. The mean UFR was 93 ml/h/Kg (SD 32) and the variability ranged between 37–185 ml/h/Kg. Consequently, some patients were exposed up to an 85% higher rate than the recommended cut-off for safe practice (10 ml/h/Kg) (Table 1). Younger age (F[3,100] = 4012, p = 0010) and low body weight (F[3,100] = 4651, p = 0004) were associated with a too rapid fluid removal (Fig. 1). The subsequent multiple comparisons with the Tukey0 s HSD post hoc test identified the differences to be between the ‘81·9 Kg
Body weight, subgroups by quartile
Age groups
Figure 1 Distribution of UFR ml/h/kg by age and body weight.
the Tukey0 s HSD test isolated the differences between the ‘819 kg’ groups (p = 0006). Low relative blood volume, however, was the result of too rapid fluid removal. The other variables analysed by bivariate analysis (Table 1) showed no association with fluid removal rate. The IH was similar in both groups. This could be explained by the dialysis nurse knowledge of the patient’s normal reaction to fluid removal. As the patient is continuously monitored throughout the dialysis session, the nurse can use her previous knowledge of the patient to adjust the UFR without risking side effects.
dialysis nurse in collaboration with the patient should adjust the session length according to the patient’s fluid removal needs. To fully involve patients in decision-making to ensure high-quality dialysis care, a continuing dialogue between the nurse and the patient is necessary. Throughout the patient’s illness trajectory evidence of the impact of both Kt/V and UFR on health and survival should be a focus point in the nurse-patient collaboration.
Key words dialysis, haemodialysis, intradialytic fluid removal, nursingsensitive quality indicator, ultrafiltration rate
Conclusions
Acknowledgements
The results of this study show that the quality of nephrology nursing during intradialytic fluid removal could be improved. Particular attention should be addressed to the younger haemodialysis population as well as patients with low body weight as these tend to be predisposed to excess UFR during haemodialysis. Nurses are skilled to prevent side effects in patients during haemodialysis. However, the quality of nursing care to prevent long term side effects can be further improved.
We thank Mette Poulin Gurre Petersen, RN, Department of Renal Medicine, Aarhus University Hospital, Denmark, for her acquisition of data for this study. We thank Marianne Godt Hansen, MA in International Business Communication, who provided language support on behalf of Aarhus University Hospital, Denmark.
Relevance to clinical practice Our findings suggest that determination of dialyses time only by Kt/V needs to be replaced by a new and more individual practise where fluid and waste product removal is determined separately. A minimum treatment time for adequate waste product removal should be applied and the © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736
Source of funding This study was funded by the Department of Renal Medicine, Aarhus University Hospital (MSL and HMH), the Faculty of Health and Occupational Studies, University of G€ avle (ML), the Faculty of Medicine, Uppsala University, Njurstiftelsen (ML). The funding sources had no involvement in study design, in the collection, analysis and interpretation of data, in the writing process, or in the decision to submit the paper for publication.
1735
Research in brief
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (2) drafting the article
or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interests The authors declare that they have no conflict of interests.
References Agarwal R (2012) How can we prevent IH? Current Opinion in Nephrology and Hypertension 21, 593–599. Davenport A (2011) Using dialysis machine technology to reduce IH. Hemodialysis International 15(Suppl 1), S37–S42. Flythe JE & Brunelli SM (2011) The risks of high ultrafiltration rate in chronic
hemodialysis: implications for patient care. Seminars in Dialysis 24, 259– 265. Lindberg M & Ludvigsen MS (2012) Ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis. International Journal of Nursing Studies 49, 1320–1324.
Sands JJ, Usvyat LA, Sullivan T, Segel JH, Zabetakis P, Kotanko P, Maddux FW & Diaz-Buxo JA (2014) IH: frequency, sources of variation and correlation with clinical outcome. Hemodialysis International 18, 415– 422.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
1736
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736
The quality of nursing care during intradialytic fluid removal in haemodialysis: time to change practice? Mette S Ludvigsen, Hanne M Hermansen and Magnus Lindberg Accepted for publication: 26 September 2014
Aims To estimate the quality of nephrology nursing during intradialytic removal of excess fluid in patients undergoing haemodialysis (HD) using ultrafiltration rate (UFR) as a nursing-sensitive quality indicator.
Background Knowledge accumulation within nursing science combined with technological advancements has improved the possibility of providing high quality, safe care to patients undergoing haemodialysis (Davenport 2011). Haemodialysis is a way of removing retained fluid (by ultrafiltration), electrolytes and waste products in people suffering from end-stage renal disease. One goal in haemodialysis is to ensure that the fluid removal is optimal and uncomplicated i.e. without intradialytic hypotension (IH), cramping or syncope. IH is observed in one out of four dialysis treatments although highly dependent on both patient condition and clinical practice patterns. Known risk factors for IH includes comorbidities such as diabetes, long dialysis vintage, accuracy of the prescribed dry weight, and practice patterns such as dialysate sodium and dialysate temperature. Adjusting the UFR is a common nursing intervention to prevent side effects (Sands et al. 2014). However, empirical evidence suggests that rapid fluid removal influences patient outcome negatively in terms of cardiovascular morbidity and mortal-
Authors: Mette S Ludvigsen, RN, PhD, MEANS, Clinical Research Nurse, Department of Renal Medicine, Aarhus University Hospital; Hanne M Hermansen, RN, Ward Manager, Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark; Magnus Lindberg, RN, PhD, MEANS, Clinical Lecturer, Department of Health and Caring Sciences, University of G€avle, G€avle; Department of Public Health and Caring Sciences, Uppsala University,
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736, doi: 10.1111/jocn.12735
ity (Flythe & Brunelli 2011). Until now adequate haemodialysis practice has been defined by small molecule clearance (Kt/V) (Flythe & Brunelli 2011) based on international benchmarks defined as; the clearance (K, in ml/min) of urea multiplied by the duration of the dialysis treatment (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL), which is approximately equal to the total amount of body water. The adjustment of total urea removal (Kt) for volume of distribution is important. In a large patient, a given degree of urea loss represents a lower rate of removal of the total body burden of urea (and presumably of other small uraemic toxins). According to international clinical practice guidelines (e.g. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative), the Kt/V should always be equal to or above 12. Most haemodialysis units do not have on-site nephrologists and care is provided by nurses; haemodialysis nursing care thus has a considerable impact on patient outcome. The UFR has been suggested to be a potential nursing-sensitive process indicator, defined as an explicitly and measurable item referring to the structures, processes or outcomes of care, to estimate quality of nephrology nursing (Lindberg & Ludvigsen 2012); the rate should not exceed 10 ml/h/Kg (Flythe & Brunelli 2011).
Design A cross-sectional quality assurance project.
Uppsala; Department of Nephrology and Haematology, G€ avle Hospital, G€ avle, Sweden. Correspondence: Mette Spliid Ludvigsen, Clinical Research Nurse, Department of Renal Medicine, Aarhus University Hospital, Brendstrupsgaardsvej 100, 8200 Aarhus N, Denmark. Telephone: +45 784 52526. E-mail: [email protected]
1733
Research in brief
Methods Audit is an internationally recognised way to evaluate existing practices. Approval was granted by the Danish Data Protection Agency (Journal number 2007-58-0010). Routinely collected treatment data from a single Scandinavian haemodialysis centre were used. At this centre, the haemodialysis treatment process is automatically documented in the Therapy Data Management SystemTM (TDMS) (Fresenius Medical Care, Bad Homburg, Germany). At the time of the study, the centre had 220 patients receiving either acute or chronic haemodialysis treatment. All patients with no residual urine output, undergoing at least three dialysis sessions per week, and requiring ultrafiltration were selected by a convenience sampling procedure. Total sample amounted to 104 patients. Data regarding weight before dialysis, blood pressure before and after dialysis, level of serum sodium and dialysate sodium, dialysate temperature and relative blood volume on the mid-week treatment session were extracted from the TDMS. Data on estimated dry weight, ultrafiltration volume, and treatment time were also extracted to calculate the UFR (Lindberg & Ludvigsen 2012); single-pool Kt/V was measured. Routinely, nurses recorded any occurrence of IH, cramping and syncope. IH was defined as a decrease in systolic blood pressure by >20 mmHg or a decrease in mean arterial pressure by 10 mmHg (Agarwal 2012). Cramping was defined as an involuntary contraction of muscles; syn-
cope was defined as a loss of consciousness. Descriptive and comparative analyses were conducted using IBM SPSS Statistics version 20.0 for Windows (Chicago, IL, USA). Subgroups for body weight comparison were created using quartile distributions. Subgroups for age comparison were inspired by the National Library of Medicine controlled vocabulary thesaurus Medical Sub Headings for the three out of four age groups: Adult: 19–44 years, Middle aged: 65–79 years, Aged: 80 years and over. There was no MeSH definition for the fourth age group (45–64 years) in this study.
Results The cross-sectional measure implied that in four out of ten patients the UFR was higher than 10 ml/h/Kg. The mean UFR was 93 ml/h/Kg (SD 32) and the variability ranged between 37–185 ml/h/Kg. Consequently, some patients were exposed up to an 85% higher rate than the recommended cut-off for safe practice (10 ml/h/Kg) (Table 1). Younger age (F[3,100] = 4012, p = 0010) and low body weight (F[3,100] = 4651, p = 0004) were associated with a too rapid fluid removal (Fig. 1). The subsequent multiple comparisons with the Tukey0 s HSD post hoc test identified the differences to be between the ‘81·9 Kg
Body weight, subgroups by quartile
Age groups
Figure 1 Distribution of UFR ml/h/kg by age and body weight.
the Tukey0 s HSD test isolated the differences between the ‘819 kg’ groups (p = 0006). Low relative blood volume, however, was the result of too rapid fluid removal. The other variables analysed by bivariate analysis (Table 1) showed no association with fluid removal rate. The IH was similar in both groups. This could be explained by the dialysis nurse knowledge of the patient’s normal reaction to fluid removal. As the patient is continuously monitored throughout the dialysis session, the nurse can use her previous knowledge of the patient to adjust the UFR without risking side effects.
dialysis nurse in collaboration with the patient should adjust the session length according to the patient’s fluid removal needs. To fully involve patients in decision-making to ensure high-quality dialysis care, a continuing dialogue between the nurse and the patient is necessary. Throughout the patient’s illness trajectory evidence of the impact of both Kt/V and UFR on health and survival should be a focus point in the nurse-patient collaboration.
Key words dialysis, haemodialysis, intradialytic fluid removal, nursingsensitive quality indicator, ultrafiltration rate
Conclusions
Acknowledgements
The results of this study show that the quality of nephrology nursing during intradialytic fluid removal could be improved. Particular attention should be addressed to the younger haemodialysis population as well as patients with low body weight as these tend to be predisposed to excess UFR during haemodialysis. Nurses are skilled to prevent side effects in patients during haemodialysis. However, the quality of nursing care to prevent long term side effects can be further improved.
We thank Mette Poulin Gurre Petersen, RN, Department of Renal Medicine, Aarhus University Hospital, Denmark, for her acquisition of data for this study. We thank Marianne Godt Hansen, MA in International Business Communication, who provided language support on behalf of Aarhus University Hospital, Denmark.
Relevance to clinical practice Our findings suggest that determination of dialyses time only by Kt/V needs to be replaced by a new and more individual practise where fluid and waste product removal is determined separately. A minimum treatment time for adequate waste product removal should be applied and the © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736
Source of funding This study was funded by the Department of Renal Medicine, Aarhus University Hospital (MSL and HMH), the Faculty of Health and Occupational Studies, University of G€ avle (ML), the Faculty of Medicine, Uppsala University, Njurstiftelsen (ML). The funding sources had no involvement in study design, in the collection, analysis and interpretation of data, in the writing process, or in the decision to submit the paper for publication.
1735
Research in brief
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (2) drafting the article
or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interests The authors declare that they have no conflict of interests.
References Agarwal R (2012) How can we prevent IH? Current Opinion in Nephrology and Hypertension 21, 593–599. Davenport A (2011) Using dialysis machine technology to reduce IH. Hemodialysis International 15(Suppl 1), S37–S42. Flythe JE & Brunelli SM (2011) The risks of high ultrafiltration rate in chronic
hemodialysis: implications for patient care. Seminars in Dialysis 24, 259– 265. Lindberg M & Ludvigsen MS (2012) Ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis. International Journal of Nursing Studies 49, 1320–1324.
Sands JJ, Usvyat LA, Sullivan T, Segel JH, Zabetakis P, Kotanko P, Maddux FW & Diaz-Buxo JA (2014) IH: frequency, sources of variation and correlation with clinical outcome. Hemodialysis International 18, 415– 422.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
1736
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1733–1736
