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Expanding PD Horizons: The SOH Experience · 2015. 12. 29. · Tunneling trocar instead of curved...
Transcript of Expanding PD Horizons: The SOH Experience · 2015. 12. 29. · Tunneling trocar instead of curved...
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Expanding PD Horizons: The Expanding PD Horizons: The SOH Experience SOH Experience
Henni Dyck PCTM, BN, MHSHenni Dyck PCTM, BN, MHSLouise McBeth RH Clinician, RNLouise McBeth RH Clinician, RN
Seven Oaks HospitalSeven Oaks HospitalRenal Health ProgramRenal Health ProgramWinnipeg, ManitobaWinnipeg, Manitoba
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Overall ObjectivesOverall Objectives Sharing our experiences with the following:Sharing our experiences with the following:
1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program
2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions
3.3. Expansion of services to allow forExpansion of services to allow for ER intake ER intake of PD patientsof PD patients
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ObjectivesObjectives Sharing our experiences with the following:Sharing our experiences with the following:
1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our programand challenges to our program
2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions
3.3. Expansion of services to allow forExpansion of services to allow for ER intake ER intake of PD patientsof PD patients
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BackgroundBackground
Access to timely insertion of a chronic PD Access to timely insertion of a chronic PD catheter is an important aspect of a catheter is an important aspect of a successful PD programsuccessful PD program
Wait times for this service is weeks to Wait times for this service is weeks to months from consult to placement due to months from consult to placement due to limited OR time and availability of a surgeonlimited OR time and availability of a surgeon
Efficient transitions to PD, even on an Efficient transitions to PD, even on an elective basis, is challenging elective basis, is challenging
Safe and effective PD catheter placements Safe and effective PD catheter placements can be performed by noncan be performed by non--surgical specialists surgical specialists including Radiologists and Nephrologistsincluding Radiologists and Nephrologists
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Background (cont)
2525--30% of patients presenting with 30% of patients presenting with ESRD have not been seen by a ESRD have not been seen by a NephrologistNephrologist
Such patients would have historically Such patients would have historically started acutely on HD, and rarely started acutely on HD, and rarely converted to PDconverted to PD
Most patients are adverse to change Most patients are adverse to change once they become familiar with one once they become familiar with one modalitymodality
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Plan
VGH in BC has an established Bedside VGH in BC has an established Bedside PD Catheter Implantation Program under PD Catheter Implantation Program under the direction of Dr. Suneet Singhthe direction of Dr. Suneet Singh
We sought their leadership in developing We sought their leadership in developing our own Bedside PD Catheter our own Bedside PD Catheter Implantation Program. Training Implantation Program. Training provided to provided to Dr. Sean ArmstrongDr. Sean Armstrong, , LouiseLouise and and CindyCindy by Vancouver teamby Vancouver team
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Purpose
Initial purpose of our insertion program Initial purpose of our insertion program was not to replace surgical catheter was not to replace surgical catheter insertions, but rather to increase total insertions, but rather to increase total capacity in the system, and to offer capacity in the system, and to offer this option (on an emergent basis) for this option (on an emergent basis) for those patients experiencing abrupt those patients experiencing abrupt renal declinerenal decline
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Purpose (cont)Purpose (cont)
As time went on the demand As time went on the demand increased. To address this, a increased. To address this, a weekly slate was developed for PD weekly slate was developed for PD catheter placement to accommodate catheter placement to accommodate nonnon--urgent, uncomplicated casesurgent, uncomplicated cases
Since initiation of the program, the Since initiation of the program, the PD population at our site has almost PD population at our site has almost doubleddoubled
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The Process in 2009: BEDSIDE
Wait: 1-3 days
Wait: depending on training availability
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The Process in 2009: SURGICAL
Wait:MONTHS!!
Wait: minimum 1
week, possibly more
depending on availability of
training
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TechniqueTechnique Success After Initial Success After Initial Insertion (87/98)Insertion (87/98) March 2009March 2009-- Feb 2011Feb 2011
88%
12%
Courtesy Sean Armstrong, MD
Major complication:1) NSTEMI (which occurred approximately 1 hour
after the procedure)2) Bladder perforation.
Both of the patients remain on peritoneal dialysis
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Lessons learned from initial insertions:
Multiple scars below the umbilicus
No patients with significant obesity where anatomy is distorted
Foley pre-procedure to any suspected neurogenic bladder
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Once our program was established, we were invited to teach the bedside implantation technique to nephrologists/nurses from Regina General Hospital
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An epiphany! An epiphany! The Regina ExperienceThe Regina Experience
Teaching the Regina group was a positive Teaching the Regina group was a positive experience and allowed us to reexperience and allowed us to re-- examine our own policies and examine our own policies and procedures. This resulted in the procedures. This resulted in the following changes:following changes:
An aggressive bowel prep regimeAn aggressive bowel prep regime
A stringent criteria for patient A stringent criteria for patient selectionselection
An abdominal xAn abdominal x--ray preray pre--procedure to procedure to ensure adequate bowel evacuationensure adequate bowel evacuation
Exclusion of patients with previous Exclusion of patients with previous abdominal surgeriesabdominal surgeries
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Bowel prep
Poor
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Bowel prep
Adequate
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Recipe for successRecipe for success
After each implantation, we After each implantation, we reviewed/discussed the procedure reviewed/discussed the procedure and implemented further and implemented further improvements to the procedure, improvements to the procedure, most notably the following changes:most notably the following changes:
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Aggressive bowel prepAggressive bowel prep
PrePre--procedure xprocedure x--raysrays
3030--40mLs of Buffered Lidocaine40mLs of Buffered Lidocaine
Verres needle instead of temporary Verres needle instead of temporary cathetercatheter
Tunneling trocar instead of curved KellyTunneling trocar instead of curved Kelly
No exit site stab woundNo exit site stab wound
Tubing (straw) with suturesTubing (straw) with sutures
Patients filled with 2Patients filled with 2--2.5 litres fluid per 2.5 litres fluid per insertioninsertion
Summary of improvements:
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Success rate since new bowel cleanse regime instituted September 2011 to present
38/38
100%
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Program OutcomesProgram Outcomes
oo PD patient numbers have increased!PD patient numbers have increased!oo Virtually no waiting period to implant PD Virtually no waiting period to implant PD
catheters at the bedside catheters at the bedside oo Provision of Provision of ““full servicefull service”” care as patients care as patients
transition from RH to PD within a familiar transition from RH to PD within a familiar clinic environment clinic environment
oo Late referrals are now urgently assessed, Late referrals are now urgently assessed, and if found to be suitable, have a PD and if found to be suitable, have a PD catheter placed the following daycatheter placed the following day
oo Patients have improved modality options Patients have improved modality options when seen urgently when seen urgently
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Program OutcomesProgram Outcomes
NonNon--functioning catheters can be functioning catheters can be removed/reremoved/re--inserted in a timely fashioninserted in a timely fashion
Uremic patients can be admitted to Uremic patients can be admitted to hospital and started on daily low volume hospital and started on daily low volume APDAPD
Surgeon has more OR time for complex Surgeon has more OR time for complex catheter placementscatheter placements
Improved continuity of patient care Improved continuity of patient care
Cost effective to the Manitoba Renal Cost effective to the Manitoba Renal ProgramProgram
Continued opportunities to Continued opportunities to maintain/improve standards of care based maintain/improve standards of care based on best practice guidelineson best practice guidelines
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Patient OutcomesPatient Outcomes
Improved patient preparedness Improved patient preparedness through intense/thorough prethrough intense/thorough pre-- procedure education = successful procedure education = successful catheter function catheter function
Little to no pain post implantationLittle to no pain post implantation
Smaller incision = patients start PD Smaller incision = patients start PD sooner with fewer complications sooner with fewer complications (leaks)(leaks)
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Patient OutcomesPatient Outcomes
Little/no issues with Little/no issues with ““dry tummy dry tummy discomfortdiscomfort”” prior to initiating fills prior to initiating fills during training as we are able to during training as we are able to accommodate earlier training accommodate earlier training schedulesschedules
Increased satisfaction with their Increased satisfaction with their care continuum (RH, PD catheter care continuum (RH, PD catheter insertion, and PD train)insertion, and PD train)
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PD Population GrowthPD Population Growth
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Challenges to programChallenges to program
Ever increasing referrals to the RH Ever increasing referrals to the RH clinic and tremendous growth in clinic and tremendous growth in numbers created staffing and space numbers created staffing and space issuesissues
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Solution to this challenge
Admit patient with new catheters to Family Medicine
Start their therapy immediately
Start their training simultaneously
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The Process in 2009: BEDSIDE
Wait: 1-3 days Wait:
depending on training availability
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The Process in 2011-12: BEDSIDE
Wait:1-3
days
Wait:Treatments can begin immediately with hospital admissionTraining schedule irrelevant
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ConclusionsConclusions
PD is a more cost effective kidney PD is a more cost effective kidney replacement therapy with similar replacement therapy with similar outcomes and quality of life outcomes and quality of life compared to other therapies (for compared to other therapies (for the first 2 years)the first 2 years)
Minimally invasive and safe Minimally invasive and safe techniques, in the hands of techniques, in the hands of experienced nephrologists, should experienced nephrologists, should be the mainstay of PD catheter be the mainstay of PD catheter placement programplacement program
Utilization of surgical technique Utilization of surgical technique should be reserved for more should be reserved for more complex casescomplex cases
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Conclusions
Numerous strategies are necessary Numerous strategies are necessary from a program perspective to boost from a program perspective to boost PD ratesPD rates
Bedside PD catheter insertion by a Bedside PD catheter insertion by a trained interdisciplinary team seems trained interdisciplinary team seems to be a viable strategy in more to be a viable strategy in more efficiently transitioning patients on to efficiently transitioning patients on to PDPD
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ObjectivesObjectives Sharing our experiences with following:Sharing our experiences with following:
1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program
2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions
3.3. Expansion of services to Expansion of services to educatingeducating ER ER nursesnurses on specific PD procedureson specific PD procedures
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BackgroundBackground
Initially, all SOH PD patients requiring hospital admission were sent to SBH, our sister PD program
Significant impact to SBH as our PD patient population continued to grow
Desire to care for our own patients within our facility
A planned approach to expanding inpatient PD services was needed, particularly as Family Medicine staff at SOH had no experience with PD patients
Buy-in from stakeholders required
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PlanPlan
1. Develop criteria for PD admission2. Finalize PD forms and PD standing
orders3. Educate FM nurses4. Place PD policy/procedures on medical
unit5. Communicate with FM physicians6. Communicate with Utilization Manager 7. Establish PD supplies on medical unit
including re-stocking process through MM
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Criteria for admission
Single system involvement such as uncomplicated peritonitis requiring admission for pain control as well as observation for resolution of infection
Patients with community acquired pneumonia not requiring assisted/mechanical ventilation
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Criteria for admission (cont)
Cellulitis, exit site or tunnel infections requiring IV antibiotics not able to be arranged in the community
Pancreatitis not requiring MICU admission or urgent surgical review
Admissions for rehabilitation/decreased mobility/stroke/placement/spousal respite
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Education Rollout for FM nursesEducation Rollout for FM nurses
8 hour education day8 hour education day
30 nurses30 nurses
Theory, skills, return demos for twin bag Theory, skills, return demos for twin bag and cyclerand cycler
Resources included copies of procedures, Resources included copies of procedures, pocket guides, videopocket guides, video
Once admissions started:Once admissions started:
Return demo on the unitsReturn demo on the units
OnOn--going support from educators and PD going support from educators and PD nursesnurses
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ChallengesChallenges
Delay between training of nurses and Delay between training of nurses and first admissions (3 months)first admissions (3 months)
Initially nurses were taught both twin Initially nurses were taught both twin bag and cycler thinking we would bag and cycler thinking we would implement both simultaneouslyimplement both simultaneously
It became evident early on that staff It became evident early on that staff did not have a clear understanding of did not have a clear understanding of the cyclerthe cycler
Concepts of dialysis were not easily Concepts of dialysis were not easily grasped due to a lack of exposuregrasped due to a lack of exposure
Medical unit model does not include a Medical unit model does not include a CRNCRN
No after hours resource availableNo after hours resource available
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Lessons learnedLessons learned
Train and implement one therapy at Train and implement one therapy at a timea time
Implement new concepts once staff Implement new concepts once staff comfort increasescomfort increases
Work closely with the nephrologistsWork closely with the nephrologists
Be prepared to provide ongoing Be prepared to provide ongoing support to the unit for an extended support to the unit for an extended period of timeperiod of time
PD supplies need to be considered in PD supplies need to be considered in terms of space needed and volumesterms of space needed and volumes
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Tools to guide unit nursesTools to guide unit nurses
Pocket guidePocket guide
Baxter postersBaxter posters
VideosVideos
Quick reference card for cyclerQuick reference card for cycler
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Conclusion
Although challenging, it is important to establish availability of trained nurses on in-patient units to support PD modality
Continuity of patient care (better patient experience and accessibility to patient record information)
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ObjectivesObjectives Sharing our experiences with following:Sharing our experiences with following:
1.1. Bedside Bedside PD catheter implantationPD catheter implantation benefits benefits and challenges to our program and challenges to our program
2.2. Expansion of services to allow for Expansion of services to allow for inin--patient patient PDPD admissionsadmissions
3.3. Expansion of services to Expansion of services to educatingeducating ER ER nursesnurses on specific PD procedureson specific PD procedures
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BackgroundBackground
SOH PD patients were directed to the SBH SOH PD patients were directed to the SBH emergency department after hours. emergency department after hours. Resources at SOH to treat PD specific Resources at SOH to treat PD specific issues were nonissues were non--existentexistent
SOH staff initially consisted of one CRN and SOH staff initially consisted of one CRN and 1.3 EFT PD training nurses1.3 EFT PD training nurses
On call nephrologists were not onOn call nephrologists were not on--sitesite
PD was an unfamiliar specialty to SOHPD was an unfamiliar specialty to SOH
As the As the SOH PD patient population SOH PD patient population increased, there was a greater impact on increased, there was a greater impact on SBHSBH’’s resourcess resources
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OptionsOptions……
1.1. Implement an onImplement an on--call systemcall system2.2. Opening seven days per week and Opening seven days per week and
increasing nursing resourcesincreasing nursing resources3.3. Train core group of ER nurses Train core group of ER nurses 4.4. Train all ER nurses (this option was Train all ER nurses (this option was
chosen)chosen)
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Required skill set (KISS Required skill set (KISS principle)principle)
Signs & symptoms of peritonitis Signs & symptoms of peritonitis
Sample collection of effluent for Sample collection of effluent for peritonitis diagnosisperitonitis diagnosis
CAPD bag exchangesCAPD bag exchangesNot required:Not required:PD dressingsPD dressingsPD flushesPD flushesCycler operationCycler operation
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Teaching strategyTeaching strategy……
Consideration was given to the Consideration was given to the adaptive nature of an ER nurseadaptive nature of an ER nurse
Thus: doing a 30 minute blitz Thus: doing a 30 minute blitz training highlighting the specific training highlighting the specific taskstasks
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Challenges/lessons learnedChallenges/lessons learned
Low volume resulting in insufficient Low volume resulting in insufficient experienceexperience
Unpredictability of patient visits Unpredictability of patient visits makes it difficult for renal educators makes it difficult for renal educators to reinforce learning or assess to reinforce learning or assess competencycompetency
Resources must be made available Resources must be made available (written materials, process (written materials, process algorithm)algorithm)
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Well defined criteria for ER physicians Well defined criteria for ER physicians to follow (who is acceptable)to follow (who is acceptable)
Use a minimal amount of supplies i.e. Use a minimal amount of supplies i.e. only 2 litre 1.5% dianealonly 2 litre 1.5% dianeal
Newest initiative Newest initiative –– not well establishednot well established
Challenges/lessons learnedChallenges/lessons learned
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ThankThank--You!You!
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References
Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2001 to 2010
Figueiredo, A., Goh, B.L., Jenkins, S., Johnson, D.W., Mactier, R., Ramalakshmi, S., Shrestha, B., Dirk, S., & Wilkie, M. 2010. Clinical Practice Guidelines for Peritoneal Access. Peritoneal Dialysis International, 30 (4) pp. 424-429.
Zaman, F., 2008. Peritoneal Dialysis Catheter Placement by Nephrologist. Peritoneal Dialysis International, 28 pp. 138-141.
Expanding PD Horizons: The SOH Experience Overall Objectives�Sharing our experiences with the following:Objectives�Sharing our experiences with the following:BackgroundBackground (cont)PlanPurposePurpose (cont)The Process in 2009: BEDSIDEThe Process in 2009: SURGICALSlide Number 11Lessons learned from initial insertions:Slide Number 13An epiphany! �The Regina ExperienceBowel prepBowel prepRecipe for successSummary of improvements:Success rate since new bowel cleanse regime instituted�September 2011 to presentProgram OutcomesProgram OutcomesPatient OutcomesPatient OutcomesPD Population GrowthChallenges to programSolution to this challengeThe Process in 2009: BEDSIDEThe Process in 2011-12: BEDSIDEConclusionsConclusionsObjectives�Sharing our experiences with following:BackgroundPlanCriteria for admissionCriteria for admission (cont)Education Rollout for FM nursesChallengesLessons learnedTools to guide unit nursesConclusionObjectives�Sharing our experiences with following:BackgroundOptions…Required skill set (KISS principle)Teaching strategy…Challenges/lessons learnedChallenges/lessons learnedThank-You!References