Concurrent Workshop Descriptions

Concurrent Session Abstracts

 

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Workshop 1: Modality Education – The Alberta Experience

Stephanie Lorda, Tracy Zeilerb, Frances Reintjesa

Louise Morrin, BSc (PT), MBA,c

aAlberta Kidney Care – North, University of Alberta Hospital, Edmonton, AB. bAlberta Kidney Care – South, Sheldon Chumir Health Center, Calgary, AB.

cSenior Provincial Director, Digestive Health and the Kidney Health Strategic Clinical Networks, Alberta Health Services

Description: Our presentation will focus on the standardization of modality education in Alberta and the Modality Educator role in providing evidence-based, patient-focused treatment options for failing kidneys. Alberta Kidney Care, the provincial health authority, identified that new dialysis starts, failing renal transplants, and chronic kidney disease patients within the province were not receiving consistent education (Manns et al., 2005). Additional support and education was needed on modality options including transplant, peritoneal dialysis, home hemodialysis, hemodialysis and conservative care.  Our provincial approach has created the unique opportunity to ensure consistency of process and reduce fragmentation that might otherwise occur in more localized healthcare delivery systems. We will review the provincial education pathways that have been developed to ensure consistency in patient assessment and education. Data collection strategies and the evolution of the Modality RN role over the past several years will also be highlighted. Our discussion about the challenges and successes along the way will illustrate how our provincial approach has ensured that all patients are given the opportunity to explore their treatment options.

Reference: Manns, B. J., Taub, K., VanderStraeten, C., Jones, H., Mills, C., Visser, M., & McLaughlin, K. (2005).  The impact of education on chronic kidney disease in patients’ plans to initiate dialysis with self-care dialysis:  A randomized trial.  Kidney International, Vol. 68(2005), pp. 1777-1783.

 

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Workshop 2: Once Upon A Time. The Evolving Story of Diabetes and Chronic Kidney Disease: Past, Present & Future

Lori Berard, RN, CDE, Nurse Consultant, Diabetes Management and Clinical Trial Operations Winnipeg MB

Diabetes is the leading cause of kidney disease in Canada (1). Since 1998, Diabetes Canada has advocated a three-pillared approach to reduce the rate of progression of CKD in patients with diabetes: A1c reduction, BP control and use of ACEi/ARB. Recent results from SGLT2i & GLP1 Cardiovascular Safety trials have expanded clinical treatment strategies to align more closely with the Diabetes Canada (ABCDES3) Vascular Protection Checklist (2). This workshop will explore the history of treatment strategies in type 2 diabetes with emphasis on approaches that demonstrate clear benefit for the heart (cardiovascular protection) and impact on the kidney. Case examples will be explored to outline and discuss the practical elements required to co-manage multiple comorbidities in a multi-disciplinary setting.

Learning Objectives:

  • Define CKD and its prevalence in diabetes
  • Recognize unmet needs in the management of CKD in diabetes
  • Review the renal and cardiovascular complications associated with diabetes as highlighted by the Vascular Protection Check List
  • Share current standards of care in the treatment of CKD in patients with diabetes
  • Summarize the safety & efficacy outputs from recently reported SGLT2i-focussed trials in type 2 diabetes and how these will impact on multidisciplinary management approaches
  • Consider the relevance of recent trials and guideline recommendations to your practice

 

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Workshop 3: The Story of Simulation based Education of Alberta Kidney Care-North

Dianne Walz, RN, Clinical Nurse Educator, Alberta Kidney Care – North (AKC-N), Alberta Health Services
Anita Fenn, RN, BScN, CNeph©, Clinical Nurse Educators, Alberta Kidney Care – North (AKC-N), Alberta Health Services
Nadine Terpstra, RN, BScN, Med HSE, Simulation Consultant, Central Zone, eSIM Provincial Simulation Program, Alberta Health Services

Objectives: To share the story of using simulation based education (SBE) for enhancing skills, attitude and knowledge of new and current hemodialysis interdisciplinary teams with the Alberta Kidney Care North program. This workshop will include presentation, hands-on demonstration and practice, and discussion.

Background: Incorporating simulation education is an effective strategy for building competencies within teams.  Literature demonstrates that experiential learning has a significant impact on how healthcare professionals and clinical teams function.  Insitu simulation provides an innovative opportunity for nursing teams to practice a clinical event in a deliberate way. It also provides an opportunity to identify any gaps/glitches in existing procedures or practices.

The simulation based education (SBE) component provided an opportunity for Hemodialysis nurses to practice and problem solve real life clinical situations and identify gaps without any harm to actual patients.  Reflective debriefing was an integral part of the education.

With the use of a high fidelity mannequin, or a standardized patient (human patient actor) HD staff were able to practice clinical scenarios in real time.

Using simulation increased the team’s skills and knowledge to respond to a high risk event.   It reinforced teamwork behaviors, and identified safety and knowledge gaps with no harm to actual patients.

Workshop:   maximum 40 participants

Presentation: The presentation includes telling the story of SBE within Alberta Kidney Care – North (AKC –N).   It includes the history/evolution of SBE and the progressions that have been made within the program. It will include examination of scenario development, considerations for setting up the learning space, and the incorporation and the importance of pre-briefing and debriefing that promotes deliberate reflection for staff involved in each scenario.

Hands-On: Providing a demonstration of a scenario(s), from set up and pre-brief, asking select participants to engage in the scenario and debrief, opening it up to all participants to ask questions.

The goal is to demonstrate and simulate how a hemodialysis machine is utilized and set up to create a circulatory system for scenarios that allow the learners to perform complications/troubleshoot during a dialysis session.

Conclusion: Session will reflect on AKC-N eSIM experience in regards to impact on patient care and staff evaluations.

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Workshop 4: Dialysis Water Systems: Designing for the Unexpected

Specifying and designing an effective dialysis water treatment system involves sorting through a host of considerations. Join us for an interactive workshop as we design a system together. Learn how to identify and mitigate risks. Discover how to ask the questions needed to ensure your system delivers when you need it the most.

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Workshop 5: NxStage Simply Home Workshop

Leacia Dyck, Clinical Educator, NxStage Medical Inc.

Sharon Fairclough, Clinical Educator, NxStage Medical Inc.

Introducing the NxStage Simply Home Course! Get expert knowledge and insight on home hemodialysis and learn more about the possible benefits of frequent hemodialysis therapy. This workshop features the Home Hemodialysis Guide – A Guide to Implementing Best Practice in Home Hemodialysis.

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1A: Managing Challenging Patient Interactions

Dr. Nicholas Mitchell, Assistant Professor, the Department of Psychiatry, University of Alberta, Senior Medical Director of the Addiction and Mental Health Strategic Clinical Network, Provincial Medical Director, Addiction and Mental Health Provincial Team, Alberta Health Services, Edmonton, AB

A discussion of how a team can manage difficult patient interactions, including identifying challenging behaviours and developing behavioral expectations.

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1B: Renal transplant: A license to eat?

Susan L. Martin, RD, University of Alberta Hospital, Edmonton, AB

Does a new kidney mean saying good-bye to old dietary restrictions? Spoiler alert: No. Follow the journey of a patient with chronic kidney disease as they venture to navigate the world of diet and kidney transplantation. Discover what the kidney transplant diet encompasses, as we review dietary recommendations that can help patients recover from surgery, maintain nutritional requirements, and minimize side effects of immunosuppression. Food safety, food-drug interactions, and the risk of post-transplant diabetes will be discussed. This presentation brings to light the impact that healthy eating can have on successful kidney transplantation.

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1C: Home Dialysis Patients’ Perspectives on the Utilization of Patient-Reported Outcomes: Keep Me Involved!

Rita Iradukunda, BScN, University of Alberta, Edmonton, AB (Presenter)

Kara Schick-Makaroff, PhD, MN, RN, University of Alberta, Edmonton, AB

Introduction: Patient-reported outcomes (PROs) have increased in importance as a means of improving per- son-centred care. However, the integration of PROs in dialysis remains unexplored. Further, patients living with end-stage kidney disease on dialysis have not been consulted about how they would like their PRO information to be used in their care.

Purpose of study: The purpose of this research was to explore how home dialysis patients would like their PRO information to be used in their routine care.

Method: Using a qualitative descriptive design, we conducted six patient focus groups (n=27), and seven patient interviews (n=7). The average age of the 34 patient participants was 53.2 years. The majority were men [21/34 (61.8%)]. All interviews and focus groups were audio-recorded, transcribed, and coded using NVivo. Thematic analysis was undertaken to answer the research question.

Results: Home dialysis patients identified that they would like their PRO data to be used in their care for: (1) following-up on “How are you doing?”; (2) integrating with “the big picture” over time; (3) sharing information within and across healthcare providers; and (4) engaging in shared decision-making.

Conclusion: As recommended by these participants, use of PRO reports and trends over time may enable patients to participate in their care as they collaborate with their multidisciplinary care providers.

Implications for nephrology care:Integrating PROs in kidney care may create opportunities for home dialysis patients to advocate for themselves and join in decision-making, thereby promoting a person-centered approach to care.

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1D: Our Unique Vascular Access Approach: Transhepatic Central Venous Catheter

Patricia A. Quinan, MN, RN, CNeph(C), Clinical Nurse Specialist/Vascular Access Coordinator, Humber River Hospital, Toronto, ON

Purpose: A plan to establish functional non-conventional vascular access (VA) became necessary for our patient’s survival. This case report describes a unique approach for a patient who is not a candidate for conventional VA procedures.

Description: Our patient had multiple thrombosed upper extremity arteriovenous (AV) accesses, bilateral central vein occlusion, several catheter-related bacteremias and hospitalizations, and is currently receiving dialysis with a tunneled femoral central venous catheter (CVC).

After discussion with interventional radiologists, vascular surgeons, and nephrologists, the plan of care included establishing short-term central VA, removing the CVC, and surgical placement of a left leg AV graft (AVG) as the definitive VA.

The interventional radiologist considered translumbar and transhepatic catheter approaches; however, due to the possibility of thrombosis of the inferior vena cava with a translumbar approach and the plan for placement of a leg AVG, our patient was scheduled for a transhepatic approach.

Evaluation and outcomes: A right tunneled transhepatic catheter was successfully inserted, and the CVC was removed. Five days later, a left leg AVG was placed, and cannulation was initiated 25 days after surgery. The transhepatic catheter was removed 38 days after surgery.

Implications for nephrology practice/education: Due to the risks of bleeding, dislodgement, and catheter migration associated with transhepatic catheters, the patient was hospitalized and closely monitored. Nurses on the nephrology unit and in hemodialysis played a vital role ensuring the catheter remained in situ, and successfully maintained cannulation, thereby allowing for the removal of the transhepatic catheter. Our single patient experience proved to be highly successful and may be considered for patients who have exhausted conventional VA options.

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1E: Parts Control System for Provincial Dialysis Technical Support – Design Philosophies and Capabilities

Brandon Beaudry, CET, Manager, Clinical Engineering COV/AHS Renal Support, Alberta Health Services

Clinical engineering at Alberta Health Services Edmonton has designed a web-based software program that is being used to manage the parts inventory of the renal dialysis technical support team. The program captures more accurate parts usage across all teams. In addition, we support the local technical college co-op summer student program.

This session will review the capabilities of the application and its design philosophy as it applies to a province-wide technical support team. This in-house design has given us full visibility of our provincial stock across eight facilities, minimized redundant ordering, reduced dead stock, maximized pricing discounts, and created a more efficient reorder process.

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2A: The Role of the NP in Neprhology

Colleen M. Astle, MN, RN, C Neph (C), NP Dialysis Access, Grey Nuns Hospital, Edmonton, AB

Nurse practitioners (NPs) have been a part of Alberta Kidney Care North since 2004 beginning with 2 and expanding to 4 practitioners. At present 4 NPs work within the program in varied roles and geographical locations: in transplant at the University of Alberta Hospital, consults at the Royal Alexander Hospital, a third manages the educators and quality control at the University Hospital and the 4th is responsible for dialysis access at the Grey Nuns Hospital. Though self-sufficient the NPs work closely with the Nephrologists, surgeons, and other Nephrology team members to provide safe, coordinated care for the renal patients.

This presentation will review how the role of NPs in the Alberta Kidney Care – North program, in particular the role of the Dialysis Access NP, began and evolved, how it is being managed and where it is going.

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2B: Perspectives of Patients and Multi-care Kidney Clinic Providers on a Shared-care Model for the Long-term Management of Stable Kidney Transplant Recipients

Monika Ashwin1, HBSc, MD(c)

Pei Xuan Chen1, HBSc, BScN(c)

Olusegun Famure1, MPH, Med, CHE (Presenter)

Theresa McKnight1, MN, BScN, RN

Franz-Marie Gumabay1, HBSc, BScN(c)

Michelle Minkovich1, HBSc

Cynthia Selvanathan1, HBSc, PharmD(c)

Ioana Clotea1, HBSc(c)

Wendi Qu1, HBSc(c)

Joseph Kim1,2,3, MD, PhD, MHS, FRCPC

1Multi-Organ Transplant Program, University Health Network, Toronto, ON 2Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON

Purpose: Although Canadian kidney transplant recipients (KTRs) are conventionally managed by transplant nephrologists, the growing KTR population has begun to challenge the capacity of transplant centres (TCs) to provide long-term care. Adopting a shared-care model (SCM) between multi-care kidney clinics (MCKCs) and TCs has been proposed to address this issue. We investigated attitudes of KTR and MCKC providers on SCM, identified barriers to adopting SCM, and suggested solutions to provide an optimal model of care.

Methods: Self-reported, cross-sectional surveys were distributed to adult KTRs receiving follow-up care at our TC during regular clinic appointments, and to MCKC teams across Ontario. Survey domains included: general information of KTRs and MCKCs, attitudes and perceived barriers to SCM, and recommendations to facilitate SCM implementation.

Results: Of the 217 KTRs who were approached, 175 were included in our analyses. Sixty-seven KTRs (38%) had a positive attitude towards SCM. KTRs were more receptive to SCM when they lived farther from the TC, with all KTRs living over 500 km away preferring shared-care over other models. MCKCs that completed the provider survey (n=7) expressed concerns about insufficient funding (n=6), overloaded clinics (n=3) and limited resources (n=3), but were open to receiving continued educational support from TCs in the form of web-based resources and pre-tailored oral presentations (n=7).

Conclusions: Both patients and providers are interested in standardized SCM. Among providers, lack of funding is the most commonly identified implementation barrier.

Implications: Shared-care between TC and MCKC is a feasible long-term model; however, additional educational, clinical and financial support will be required.

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2C: X-Ray Vision CCPD: What’s Really Going on During the Night

Danielle House, RN, CNeph (C) – Peritoneal Dialysis Unit, Peterborough Regional Health Centre, Peterborough, ON

Objectives:  The Peterborough Regional Health Centre Peritoneal Dialysis (PD) unit first introduced remote monitoring of continuous ambulatory peritoneal dialysis (CCPD) in June 2018. It is a two-way, web-based remote monitoring system between the patient and the PD clinic, providing daily data of therapy.  Our goal was to increase compliance and to improve communication between the patient and the PD team.

Method/Process:  The PD team transitioned 75% of our patients on CCPD patient to remote monitoring by training them on a new automated PD cycler that would enable remote monitoring.  Once our patient transitioned to remote monitoring, we could quickly identify issues, and were able to make prompt changes to the cycler settings and PD prescription from our desktop as needed.  To ensure safety, our first priority was to transition patients who were marginal and who were non-adherent to their therapy.

Outcomes:  Through the implementation of a remote monitoring system, we were able to ensure safety and compliance in patients on PD.  The PD team also identified potential patient issues, and were able to act appropriately in a timely manner.

Conclusion:  This method of monitoring appears to increase the communication between the PD team and the patient while ensuring safety of the patient. This also gives the patient the autonomy they need to remain independent at home.

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2D: Venous Needle Dislodgement: A Preventable Cause of Significant Harm and Death in Hemodialysis Patients

Natalie Ferraro, RN, Kidney Care Clinical Manager, SCH Hemodialysis Unit, Niagara Health System, St. Catharines, ON (Presenter)

Archna Parikh, RN, SCH Hemodialysis Unit, Niagara Health System, St. Catharines, ON (Presenter)

Audrey Tassillo, RN, Regional Vascular Access Nurse, Kidney Care Program, Niagara Health System, St. Catharines, ON (Presenter)

Hemodialysis is a life-sustaining treatment. Adverse side effects and occasional life-threatening clinical complications can occur. Venous needle dislodgment (VND) is one of the most serious incidents that can occur during HD treatment. If the blood pump is not stopped, either by activation of the dialysis machine’s protective system or manually, the patient can bleed to death within minutes. The Kidney Care program at Niagara Health commits to using best practice measures to drive improvements in care. VND prevention (“The Project”) was piloted, implemented, and evaluated. A quality improvement initiative aimed at eliminating VND occurrences.

In the last year, Niagara Health has created a collaborative special project workgroup to review VND occurrences and consequences. Preventative strategies and resources were developed for frontline staff and patients. From this work, a risk assessment tool and clinical care pathway were created. Standard securement and taping practices were established, and a trial of an external moisture monitoring system was implemented at three participating centers.

A robust education plan for frontline staff was created through best practice and evidence-based literature. The Kidney Care Program will promote sustainability by routinely collecting and reviewing observational data. Review and modification will be done annually with PDSA cycles. Collaboration with patients was an integral part of the development of educational material to identify their role in safe care and prevention.

Everyone has a role in making health care safer. Improving safety in our organization requires active engagement by senior leaders, providers, managers, staff, and patients. The VND project is one example of our organization’s commitment to promoting safety and reducing harm events.

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2E: Home Hemodialysis Technical Considerations – The Alberta Perspective

Ed Doppler, BSc, EET, CET – Clinical Engineering, Alberta Health Services, Calgary, AB (Presenter)

Shripal Parikh, AScT, cdtClinical Engineering, Alberta Health Services, Calgary, AB (Presenter)

Home hemodialysis is a popular and often preferred choice of dialysis in Canada.  It offers lifestyle choices and health benefits to patients that are otherwise not so much available to patients undergoing treatment in the hospital environment.  Since patient dialysis at home is unsupervised, it is imperative that patient safety becomes the highest priority for the health care provider.  A multidisciplinary approach is required to cover all aspects of home hemodialysis.  The technical team is an important part of that team.

This presentation will detail the role of biomedical/dialysis technician personnel as an integral part of the health care provider team in Alberta.  Challenges faced from starting patients on home dialysis to providing continual equipment care and support will be discussed, and solutions to problems will be outlined.  A complete quality assurance program for adherence to current Canadian Standards Association (CSA) standards will be outlined and discussed.  In achieving these goals and meeting these challenges, a patient-centric approach is always maintained.

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3A: CNA Certification Preparation and Updates

Cathy Cake, VP Atlantic, Canadian Association of Nephrology Nurses and Technologists

Rick Luscombe, VP Western, Canadian Association of Nephrology Nurses and Technologists

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3B: Improving care and overcoming barriers through learnings from our patients and families

Ethel Macatangay, MHSM, BScN, RN, CNeph(C), Scarborough Health Network, Scarborough, ON

Andrea Goertzen, BN, RN, CNeph(C), MB (Presenter)

Angela Robinson, RN, (CNeph(C), BC (Presenter)

Sharon McDonald, BN, RN, CMSN(C), CNeph(C), NL (Presenter)

SIGNhd is a vendor-sponsored nursing interest group specializing in home dialysis. This forum allows for shared practices and approaches to care within dialysis programs throughout Canada. In sharing inspiring patient and family stories about overcoming difficult barriers to home hemodialysis (HHD) and demonstrating success in carrying out HHD independently, HHD nurse leaders learned some valuable lessons in hearing each respective patient’s story.

Patients know themselves best, especially when it comes to their capabilities and limitations. As care providers, we are often quick to make assumptions about our patients and families’ abilities to do HHD successfully as the “lens” we use often reflects our own biases and perceptions on what would constitute a “successful start” onto home hemodialysis.

We will share patient and family stories from four home hemodialysis programs across Canada (Newfoundland, Manitoba, British Columbia, and Ontario) and the innovative solutions developed in helping to support patients and their families complete their hemodialysis successfully at home.

Teaching patients and families the clinical aspects of HHD, and enabling them to apply their own strategies, as part of the care plan, are what leads to success. Care providers having the patience and willingness to work with their patients and families to create integrated and individualized strategies that dealt with what would otherwise have been barriers to HHD led to ideal patient and family outcomes in all patient stories shared among members of our nursing interest group.

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3C: Renal Transplant Assessment of Transgender Patient: A Case Report

Emily A. Christie1, MD (Presenter)

Robert Pauly1, MD

Laurie Mereu2, MD

Ronald Moore3, MD

Craig Buchholz4, MD

Ngan N. Lam1, MD

1Division of Nephrology, University of Alberta, Edmonton, AB

2Division of Endocrinology & Metabolism, University of Alberta, Edmonton, AB

3Division of Urology, University of Alberta, Edmonton, AB

4Division of Psychiatry, University of Alberta, Edmonton, AB

The number of individuals with gender identity issues who are seeking medical attention appears to be increasing over time. Access to medical care for gender non-conforming patients is impacted by various barriers including structural barriers, gender-based discrimination, and transphobia. Transgender patients represent a minority of Canadians with end-stage renal disease (ESRD); however, this population has unique and important considerations in terms of assessment for renal transplantation.  We present the case of a young patient transitioning from female to male, who presented for assessment for renal transplant. We review the unique considerations from the medical, hormonal, surgical, and psychological standpoints relevant to his care. This case highlights the importance of a multi-disciplinary team for transgender individuals as they transition their ESRD therapy to renal transplant and throughout their subsequent gender-affirming procedures and treatments.

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3D: Fluid control in hemodialysis patients: Too much, too little or just right

Judy Ukrainetz, BN, RN, CNeph(C) – Northern Alberta Renal Program, Edmonton, AB (Presenter)

Branko Braam, MD, PhD FASN, Internist, Nephrologist/Professor of Medicine, Northern Alberta Renal Program, Edmonton, AB

Managing fluid in patients on hemodialysis (HD) is one of the essential aspects of treatment. Studies have shown how chronic fluid overload is strongly linked to mortality (Wizemann, et al., 2009) and, on the flip side, removing too much fluid is linked to morbidity and the loss of residual renal function (McIntyre, 2010). Looking at these together, we can see the importance of accurate methods of determining how much fluid to remove during hemodialysis.

The purpose of this presentation will be to discuss how the Body Composition Monitor (BCM) works using the technology of “bioimpedance” to help determine a patient’s dry weight and the benefits of using this technology along- side clinical assessment. We will discuss the pathways of how the BCM is being integrated into becoming a standard practice of care for patient on hemodialysis at the University of Alberta Hospital. Some of the challenges and successes in introducing a new concept into the hemodialysis world will also be explored. Overall, the presentation will highlight the importance of using an objective measurement of hydration status, the BCM, to help guide fluid management.

References:

McIntyre, C. W., Burton, J. O., Selby, N. M., Leccisotti, L., Korsheed, S., Baker, C. S., & Camici, P. G. (2008).  Hemodialysis-induced cardiac dysfunction is associated with acute reduction in global and segmental myocardial blood flow.  Clinical Journal of American Society of Nephrology, 3(1), 19-26.

Wizeman, V., Wabel, P., Chamney, P., Zaluska, W., Moissl, U., Rode, C., … Marcelli, D. (2019). The mortality risk of overhydration in haemodiaysis patients. Nephrology Dialysis Transplantation, 24(5), 1574-1579.

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3E: Canada’s funniest home hemo

Brandon Beaudry, CET – Manager, Clinical Engineering, Misericordia Hospital, Edmonton, AB

Join us for a fun-filled look at the world of technical support for the home hemodialysis patient.

The success of home dialysis takes the support of all the members of a highly skilled and experienced clinical and technical team. It takes people who are compassionate about the health and well-being of patients, and a desire to ensure that the patient is not burdened by their condition, but rather is able to incorporate their critical treatment into their daily lives and activities.

Technical support of home patients on dialysis is unique within the clinical engineering community. No other pro- gram across the country, other than the home hemodialysis programs, requires biomedical technologists to deal so directly with patients, let alone support them in their own home environment.

We will be inviting technologists from across Canada to share their stories and experiences in a casual fun-filled discussion. We hope that others will gain an interest in this unique aspect of our profession.

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4A: Six domains of quality: Evaluating an intradialytic exercise program

Iwona Gabrys1, BKin, ACSM-CCEP, CSEP-CEP, Clinical Kinesiologist (Presenter)

Christina West1, BScKin, CSEP-CEP, Clinical Kinesiologist

Frances Reintjes1, BScN, BSc Spec, RN

Kailash Jindal2, MD, FRCPC, Professor of Medicine

Stephanie Thompson2, MD, PhD, FRCPC, Assistant Professor

1Alberta Kidney Care North, Alberta Health Services, Edmonton, AB 2Division of Nephrology, University of Alberta Hospital, Edmonton, AB

Description:There is a growing interest in exercise pro- grams in hemodialysis (HD) units. Intradialytic exercise (IDE) programs have primarily focused on measures of physical function. However, the literature on program structure and processes is limited. We applied the six domains of quality: effectiveness, appropriateness, accessibility, efficiency, acceptability, and safety to evaluate an IDE program over a 13-month period in Alberta Kidney Care North dialysis outpatient centres.

Evaluation and outcomes:: Our strongest domain of quality was effectiveness. From 275 baseline assessments con- ducted, the six-minute walk test improved from a baseline of 243 m (SD = 143 m) to 298 m (SD = 145 m) (p < 0.001), and the 30-second sit-to-stand outcome measures improved from 4 (SD = 0.9) to 9 (SD = 5.12) (p < 0.001) at six months. The weakest quality domain was acceptability. Follow-up data at six and 12 months were missing for approximately 70% and 85% of the cohort, respectively. Program discharge criteria were not defined. Therefore, an explanation for incomplete reassessment data such as illness, transplant, death, loss of interest, or decline in reassessment was unknown. Adherence rates were unknown due an apparent low level of HD unit staff engagement to document exercise participation.

Implications: Our IDE program is effective. However, we must develop a comprehensive set of common quality indicators to improve acceptability. To conduct a Plan-Do- Study-Act (PDSA) cycle, detailed information on acceptability is required including reasons for program discharge and for non-attendance at reassessments, program participation, and discharge criteria, and a measure of patient satisfaction with the IDE program.

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4B:Emotional intelligence and above the line provision of renal care: How can we be our best selves in a vexatious world?

Julie Ann LawrenceMScN, RN(EC), CNeph(C) – Nurse Practitioner, Renal Program, Kidney Care Centre, London Health Sciences Centre, London, ON

The interfacing of renal health professionals with patients/families is a rewarding experience.  Many of us as care providers entered into the renal field and remain here years, if not decades, later.  Yet over time, nurses and allied health professionals can suffer from empathy fatigue, frustration or even burnout.  Likewise, our patients who have a high burden of one/multiple chronic disease(s) can further challenge our goal to arrive to work as our ‘best selves’.

During this presentation, a framework of emotional intelligence will be presented that has been used in a large teaching centre and modified for presentation to renal staff. In our experience, staff are encouraged to hone skills in emotional intelligence in order to cultivate a higher level of insight and self-awareness of their own beliefs and actions. A platform for viewing the world differently, and working in an environment that encourages ‘above the line’ interaction and practice, facilitates discovery and skill in handling one’s own emotions as well as the emotions and responses of others.

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4C: I Never Miss My Anti-Rejection Medications…

Dr. Kevin Wen, MD, FRCPC, Assistant Professor, Department of Medicine, Division of Nephrology, University of Alberta

Despite the advances in potent immunosuppressive therapies, long-term kidney allograft survival has not significantly improved in the past 20 years. Poor adherence to immunosuppressive medications, leading to antibody mediated rejection (ABMR), is one of the most important factors limiting long-term graft survival. Immunosuppression non-adherence is common, with estimated prevalence of up to 36%.

In this presentation, I will discuss:

  • a) Prevalence and Impact of Immunosuppression Medication Non-Adherence in Solid Organ Transplant patients.
  • b) Pros and Cons of Adherence Measurement Methods. c) Interventions to Improve Adherence.
  • c) Ongoing Smartphone App Project and Planned Pragmatic Intervention Trial involving University of Alberta and University of Calgary.

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4D: Development and implementation of clinical decision support for acute kidney injury: Measurement of frontline healthcare providers’ perceptions and experiences

Meha Bhatt1, MSc

Eleanor Benterud1, MN, RN (Presenter)

Indraneel Datta2, MD, MSc, FRCSC

Elijah Dixon2, MD, MSc, FRCSC

Sharon Falk3, BScPharm

Sandy Zhang3, PharmD

Sonia Ficaccio-Scarcelli3, RN

Jennifer Landry1, MD, FRCPC

Anthony MacLean3, MD, FRCSC

Evan Minty1, MD, MSc FRCPC

Gregory Samis2, MD, FRCSC

Rohan Lall2, MD, FRCSC

Neesh Pannu4, MD, SM, FRCPC

Matthew T. James1,5, MD, PhD, FRCPC

1Department of Medicine, University of Calgary, Calgary, AB 2Department of Surgery, University of Calgary, Calgary, AB 3Alberta Health Services, Calgary, AB 4Department of Nephrology, University of Alberta, Edmonton, AB 5Department of Community Health Sciences, University of Calgary, Calgary, AB

Quality improvement (QI) initiatives are effective strategies for enhancing healthcare delivery and improving patient outcomes. However, QI initiatives can have significant effects on workflow, thus involvement of end-users in the development and implementation can optimize accessibility and uptake. Here we describe the perceptions and experiences of healthcare providers during the development and implementation of clinical decision support for acute kidney injury (AKI).

An AKI clinical decision support initiative was developed to improve recognition and management on surgery units in Alberta. Frontline providers were involved in the development of unit-specific processes for AKI care. Nursing staff, physicians, and pharmacists were invited to complete pre-implementation surveys to assess the awareness of AKI, usability surveys for the electronic tools, and semi-structured interviews to obtain feedback and refine processes.

Pre-implementation surveys indicated that it was important to improve AKI care on the participating units. Clinical staff reported that the electronic tools were easy to use and accessible. During post-implementation interviews, nursing staff reported that the initiative increased AKI awareness and has potential for improving patient care. The initiative is being evaluated continuously through usability surveys and interviews during the post-implementation period.

This AKI clinical decision support initiative was co-developed with end-users, and is being refined regularly to increase sustainability. Clinical staff report high usability of the electronic tools, and adequate uptake of the recognition and management processes. Full evaluation of the initiative will identify the impact of this initiative on patient outcomes, including progression of AKI, length of hospital stay, and healthcare costs.

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4E: What’s At Risk? Patient Safety and Bacterial Endotoxin Testing – Sponsored by Charles River

John Phaneuf, Regional Sales Manager, Charles River

John Phaneuf, Regional Sales Manager for Charles River, will be discussing the significance of endotoxin testing in injectable pharmaceutical products and implantable medical devices as it pertains to patient safety. The presentation will also cover the importance of using Limulus amoebocyte lysate (LAL) in endotoxin testing and how the biomedical industry is protecting the Horseshoe Crab.

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5A:A Pioneer Approach: The First Patient on Home Intradialytic Parenteral nutrition(IDPN)

Kathleen Brown, RN, CNeph(C) – Department of Nephrology, Peterborough Regional Health Centre, Peterborough, ON

Margaret Avery Stewart, MSc, RD – Department of Nephrology, Peterborough Regional Health Centre, Peterborough, ON (Presenter)

Kelly-Jo Clarke, BScN, RN, CNeph(C) – Department of Nephrology, Peterborough Regional Health Centre, Peterborough, ON

Purpose:  Through the Ontario Renal Network’s (ORN) mandated target of 28% of patient’s dialyzing at home, we continue to consider uncommon methods to keep established patients on home hemodialysis (HHD) supported at home whilst ensuring optimal, patient-focused outcomes. One established HHD patient experienced complex health challenges resulting in profound malnutrition requiring intradialytic parenteral nutrition (IDPN), which was implemented at home as the first such case in Canada.

Method/Description: It was identified through blood work, normalized protein nitrogen appearance (nPNA), quad muscle length density (QMLT), physical assessment, and intake reporting that the patient’s nutritional needs were unmet.  IDPN was recommended by our renal dietitian after trial of oral intake proved insufficient to provide adequate nutrition for this patient. There was immediate buy-in from the patient and caregiver to trial IDPN with further desire to retain HHD and IDPN, which was implemented through additional training to enable the safe administration of IDPN at home. An 18-year program experience with IDPN allowed us to mobilize an extension to HHD with IDPN. We were able to engage key stakeholders in a collaborative effort to support this patient’s newly identified nutritional needs.

Routine quantitative markers validate the cost to the program versus benefit to the patient and continue presently.

Evaluation/Outcome: This patient was able to remain at home and receive the nutrition that was required to restore best possible health outcomes as correlated with baseline quantitative data.

Next Steps: Continue to monitor and support patient and discontinue IDPN when no longer required.

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5B: Calciphylaxis (Calcific Uremic Arteriolopathy): A case of a multi-intervention Approach

Paulina Bleah, MN, NP-PHC – Department of Nephrology, University Health Network, Toronto, ON

Calciphylaxis or calcific uremic arteriolopathy (CUA) is a rare disorder that is typically seen in patients with end-stage renal disease (ESRD) on dialysis (Harris, Kiaii, Lau, & Farah, 2018). CUA-attributed mortality rates in the literature range from 45% – 80% at one year, with cause of death mainly due to sepsis (Harris et al., 2018). It is characterized by progressive cutaneous necrosis associated with small and medium-sized vessel calcification (Harris et al., 2018; Olaoye & Koratala, 2017). Treatment requires a multi-intervention approach to address this challenging disease.

Case Presentation: A 53 year-old-male with ESRD on intermittent hemodialysis, presented to the hemodialysis unit with painful skin ulceration to the right leg and necrotic ulcers with eschars to the left leg. His past medical history was significant for hypertension, diabetes, and atrial fibrillation. A clinical diagnosis of CUA was made, and the patient was admitted to hospital for management. His lab presentation indicated elevated phosphate and parathyroid hormone, and borderline calcium levels. Medication history was significant for warfarin, calcium carbonate, and calcitriol. Management of CUA required a multi-intervention, which included: (1) sodium thiosulfate; (2) discontinuation of all medications that may contribute to CUA including warfarin, calcitriol, and calcium carbonate; (3) initiation of sevelamer carbonate (Renvela®) and cinacalcet; (4) intensified hemodialysis; (5) local wound care and pain management; and (6) hyperbaric oxygen therapy. The patient tolerated the treatment, and dramatic clinical improvement in terms of wound healing were noted within three weeks. After two months of treatment, the patient wounds healed, and he was discharged home.

Discussion: This case illustrates that multi-intervention approach to CUA management can be successful in treating this group of patients (Harris et al., 2018).

References:

Harris, C., Kiaii, M., Lau, W., and Farah, M. (2018).  Multi-intervention management of calcific uremic arteriolopathy in 24 patients. Clinical Kidney Journal.,11(5): 704-709. Olaoye, A. O., & Koratala, A. (2017). Calcific uremic arteriolopathy. Oxford Medical Case Reports, 10,197-198.

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5C: Peritoneal dialysis (PD) unit orientation for new PD nurses: the London Health Sciences Centre (LHSC) checklist approach

Suzanne E Webster, HBScHK, dip SIM, R. Kin – London Health Sciences Centre, London, ON (Presenter)

Katie-Lyn E Watson, RN – London Health Science Centre, London, ON (Presenter)

Susan M McMurray, BN, RN, CNeph(C) – Baxter Corporation, Mississauga, ON

For many years, PD staff at the London Health Sciences Centre PD Unit remained consistent with minimal staff turnover. An unprecedented number of retirements left our PD unit staffed with only one to two expert PD staff nurses. This presented many challenges including the need to have enough “seasoned” staff to train new patients and staff, as well as provide home visits, clinic follow-up, and ongoing troubleshooting and problem-solving to minimize patient attrition.

Join us on a journey of PD orientation from program development to implementation and follow-up. This presentation will follow the story of the clinical administrator, clinical consultant, and novice PD nurse as they navigate PD orientation.

This presentation will explore the steps in developing our PD Staff Nurse Orientation Plan, as well as share the tool that was developed and provide feedback from nurses who utilized the new plan for PD orientation.

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5D: Venous Needle Dislodgement: A Preventable Cause of Significant Harm and Death in Hemodialysis Patients

Natalie Ferraro, RN, Kidney Care Clinical Manager, SCH Hemodialysis Unit, Niagara Health System, St. Catharines, ON (Presenter)

Archna Parikh, RN, SCH Hemodialysis Unit, Niagara Health System, St. Catharines, ON (Presenter)

Audrey Tassillo, RN, Regional Vascular Access Nurse, Kidney Care Program, Niagara Health System, St. Catharines, ON (Presenter)

Hemodialysis is a life-sustaining treatment. Adverse side effects and occasional life-threatening clinical complications can occur. Venous needle dislodgment (VND) is one of the most serious incidents that can occur during HD treatment. If the blood pump is not stopped, either by activation of the dialysis machine’s protective system or manually, the patient can bleed to death within minutes. The Kidney Care program at Niagara Health commits to using best practice measures to drive improvements in care. VND prevention (“The Project”) was piloted, implemented, and evaluated. A quality improvement initiative aimed at eliminating VND occurrences.

In the last year, Niagara Health has created a collaborative special project workgroup to review VND occurrences and consequences. Preventative strategies and resources were developed for frontline staff and patients. From this work, a risk assessment tool and clinical care pathway were created. Standard securement and taping practices were established, and a trial of an external moisture monitoring system was implemented at three participating centers.

A robust education plan for frontline staff was created through best practice and evidence-based literature. The Kidney Care Program will promote sustainability by routinely collecting and reviewing observational data. Review and modification will be done annually with PDSA cycles. Collaboration with patients was an integral part of the development of educational material to identify their role in safe care and prevention.

Everyone has a role in making health care safer. Improving safety in our organization requires active engagement by senior leaders, providers, managers, staff, and patients. The VND project is one example of our organization’s commitment to promoting safety and reducing harm events.

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5E: Optimizing The Patient Experience

Jennifer Tanasichuk, Clinical Applications Specialist, Chief Medical Supplies

As health care providers the interactions we have with our patients are very important to us. On average, a patient on dialysis is with us for 9 to 12 hours a week, that’s more time spent with us than some of our own family members; in fact they tend to become our family. We are their liaison to the doctor, their social worker, their pharmacist and their advocate to help them navigate through their health care journey so that it’s possible to live a better life.

We have the responsibility to ensure that our patient’s treatments are continuously being evaluated to deliver the optimal care. We are responsible for providing education so they can access the resources available to improve their lives both inside and outside the health care facility. We as health care providers are the key to optimizing the patient experience. Join us to learn more about how you can help improve the health care journey for your patient.

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6A:What’s bugging your patient

Margie Kensah, RN, CNeph(C), Baxter Healthcare Canada

Description:This presentation includes information on identifying infection in PD including: (1) a review of the ISPD recommendations on peritonitis rates, and (2) discussion of lab tests that are commonly used to diagnose peritonitis, taking a “behind-the-scenes” look at how the specimens are processed including the WBC count with differential, the Gram stain, and culture and sensitivity. In addition, several common peritonitis-causing organisms will be presented, with description of their attributes and the suggested treatment. The 2016 ISPD Guideline update on catheter removal and re-insertion is also reviewed. Finally, key management strategies to help prevent peritoneal dialysis-related infections will be discussed in terms of the importance of root cause analysis, catheter placement, training programs, connection methods, exit-site care, as well as prevention of bowel-source infections. Real scenarios will be discussed throughout this presentation.

Target Audience: PD nurses and nephrology staff members and nurses (chronic kidney disease, transplant, and hemodialysis) who wish to expand their knowledge related to infectious complications. It will also benefit nurses studying for their CNeph(C) exam.

Learning Objectives:

  1. Identify infections related to PD.
  2. Describe lab tests that are commonly used to confirm diagnosis of peritonitis.
  3. Discuss attributes of common peritonitis-causing organisms.
  4. List key management strategies to help prevent peritoneal dialysis-related infections.

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6B:Demystifying myths in nephrology

Sylvia D. Zuidema, MSc, NP – Alberta Kidney Care North, University of Alberta Hospital, Edmonton, AB (Presenter)

Sandeep K. Dhillon, BScPharm, ACPR – Department of Pharmacy, Royal Alexandra Hospital, Edmonton, AB

Providing quality care to nephrology patients requires constant acquisition of knowledge and continuous re-evaluation of existing medical beliefs and practices.  As healthcare providers, we should critically evaluate standard practices and question whether or not the practice is “fake news.” If evidence or logic is lacking in medicine, it may be a medical myth.

Purpose: The purpose of this oral presentation will be to critically examine several nephrology myths and to encourage the questioning of widely accepted practices and beliefs.

Description: Using a case study approach we will discuss several nephrology-related concepts including the pathophysiology of hyperkalemia and treatment, fluid management and resuscitation, contrast nephropathy, diuretic administration and acute kidney injury mortality/morbidity.

Evaluation/Outcome: Upon completion of this presentation, participants will be able to “bust” a few myths.

Implications for practice: It is our hope that participants will reflect upon controversial topics and facilitate discussion in their respective fields, and promote practice change based on best medicine.

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6C: Decreasing incidences of peritonitis through home visits and retraining

Rebecca Law, BScN, RN, CNeph(C), Clinical Practice Leader, Scarborough Health Network, Scarborough, ON (Presenter)

Vlad Padure, MScN, NP-PHC – Clinical Manager, Humber River Hospital, Toronto, ON (Presenter)

In 2016, the Ontario Renal Network (ORN) began collecting peritonitis rates across all provincial home dialysis programs. With over 90 peritoneal dialysis (PD) patients, Humber River Hospital had the second highest infection rate in the province with 0.5 cases per year at risk. We utilized the data collected to drive quality improvement (QI) in the program with the goal of reducing peritonitis rates.

The QI team identified three main areas for improvement. The first initiative was to preform an initial home assessment for all potential PD patients. We also conducted standardized home assessments every four months and post peritonitis in our prevalent PD patients. Through these visits, we identified environmental risk factors and poor technique, which placed patients at an increased risk for infection. The third strategy was to implement a PD clinic care bundle, which assessed the patient’s hygiene and catheter care at every clinic visit. Our home dialysis team met on a monthly basis to discuss root causes for each peritonitis event and evaluated the efficacy of the interventions.

For the Q2 18/19 fiscal year, the peritonitis rate has dropped to 0.10 cases per year at risk compared to the provincial average of 0.21. The decrease in peritonitis can be attributed to the implementation of the aforementioned strategies intended to reduce the risk factors for peritonitis through continued assessment, education, and reinforcement of proper PD techniques.

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6D: The JUNO goes to Living Kidney Donation – Starring Kidney Paired Donation

Clay Gillrie, RN, BScN, MSN – Senior Program Manager – Living Donation and Transplantation, Canadian Blood Services (CBS)

Living kidney donation and the Kidney Paired Donation (KPD) program continue to evolve in Canada. Despite the benefits of living donation, and the enormous potential to impact transplant waitlists there are still significant barriers to overcome educating healthcare professionals and the public and increasing living kidney donation rates.

This presentation will briefly outline the evolution of living kidney donation in the Canadian context including past present and future. Common myths and misconceptions about living donation will be explored, current challenges and issues will be described and current national initiatives to advance living kidney donation will be outlined. The narrative will include the evidence and support that makes living kidney donation the JUNO winner for best transplant option and best graft outcomes and will describe how one national registry program has become the starring character in the living kidney donation story in Canada – The Kidney Paired Donation program which to date has facilitated 691 transplants across the country.

All the instagramable facts about the Kidney Paired Donation program will be described! You will hear the red-carpet highlights like who should consider KPD, why KPD deserves a star on Canada’s walk of fame as an option for some patients, and all the potential benefits to patients participating in the program. Come learn how KPD works and how thoroughly living donors are assessed using the Canadian KPD eligibility protocol to ensure the risk of donation is as low as possible. The session will finish up with some interesting post JUNO party favorites –statistics you will want to share with colleagues and patients, case examples of how living donation has helped some very hard-to-match transplant candidates find a donor and receive a transplant, and how living donation can improve the quality-of-life for the real JUNO winners – individuals needing a kidney transplant!

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6E: Optimizing The Patient Experience

Jennifer Tanasichuk, Clinical Applications Specialist, Chief Medical Supplies

As health care providers the interactions we have with our patients are very important to us. On average, a patient on dialysis is with us for 9 to 12 hours a week, that’s more time spent with us than some of our own family members; in fact they tend to become our family. We are their liaison to the doctor, their social worker, their pharmacist and their advocate to help them navigate through their health care journey so that it’s possible to live a better life.

We have the responsibility to ensure that our patient’s treatments are continuously being evaluated to deliver the optimal care. We are responsible for providing education so they can access the resources available to improve their lives both inside and outside the health care facility. We as health care providers are the key to optimizing the patient experience. Join us to learn more about how you can help improve the health care journey for your patient.

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7A: Burnout and empowerment among hemodialysis nurses working in Quebec

Christina Doré, PhD, RN, Professor, Faculty of Nursing, University of Quebec, Abitibi-Témiscamingue, Mont- Laurier, QC

The nursing profession is known to be stressful with high rates of burnout. Research indicates that empowerment is a positive strategy to support the practice and well-being of nurses at work, and that professional websites could promote their empowerment and reduce their risk of burnout. Currently, there is no information to assess the severity of burnout or the empowerment status of hemodialysis nurses in Quebec. The purpose of the presentation is to report the results of a mixed study: an online quantitative survey of 308 hemodialysis nurses found that 38% had high levels of emotional exhaustion, 69% had moderate levels of structural empowerment, and 64% of moderate levels of psychological empowerment. Structural and psychological empowerment were significantly related to burnout. Then, a participatory approach using focus groups with a total of seven hemodialysis nurses and consultations with an advisory committee resulted in recommendations on the requirements to be included in a website. The results indicate that a future professional website for hemodialysis nurses should include: professional information, continuing education, information on healthy living habits and networking. This research has important implications for nurses, practice, and research. Overall, burnout levels were high among hemodialysis nurses in Quebec, similar to other North American results, and the hemodialysis nurses were in favor of creating a website to meet their professional and personal needs.

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7B: If I only knew then what I know now: Enhancing patient self management of chronic kidney disease using an electronic health tool

Maoliosa Donald1,2, MSc, BScPT, PhD(c) (Presenter)

Heather Beanlands3, PhD, RN

Gwen Herrington4, MN, RN

Lori Harwood5, PhD, NP

Brenda R. Hemmelgarn1,2, MD, PhD

1Department of Medicine, University of Calgary, Calgary, Alberta, Canada 2Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada 3Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada 4Can-SOLVE CKD Network Patient Partner Co-Lead, Vancouver, British Columbia, Canada 5London Health Sciences Centre, London, Ontario, Canada

Purpose of study:  To co-design a chronic kidney disease (CKD) patient self-management electronic health (eHealth) tool with patients and their caregivers.

Method:  A research team of patient partners, researchers, clinicians, policy makers, and web developers co-designed a CKD patient self-management web-based tool. Our patient-oriented research (POR) is a multi-phase study that included both quantitative and qualitative methods to identify needs and preferences for self-management support identified by patients with CKD and their caregivers. Patient and caregiver stories were shared with team members to illustrate self-management experiences and prioritize components for the CKD patient self-management eHealth tool. Co-designing the eHealth tool was an iterative process that included patients and caregivers in the development and testing phases.

Results: Nine content areas, including understanding CKD, diet, medication, finances, symptoms, travel, mental and physical health, work/school support and emotional, social, psychological support, were identified, along with preferences for information within these areas. Preferred features included visuals, interactive components, on-the-go access, links to resources, and access to personal health information. Feasibility and usability testing are underway, with launch of the tool in Fall 2019.

Conclusion:  Patient engagement in the co-design of a CKD self-management eHealth tool guaranteed that preferences and needs most relevant to patients and their families were included.

Implications for nephrology care: Patients with CKD have multiple needs that differ between individuals based on the complexity of their illness, as well as supports and resources available to them. Although traditional CKD self-management support is important, a CKD patient self-management eHealth tool can complement existing services and provide tailored, timely support to patients and caregivers.

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7C: Social Support: The Peritoneal Dialysis Experience

Danielle Fox1, BN, RN

Robert R. Quinn2,3, MD, PhD, FRCPC

Matthew T. James2,3, MD, PhD, FRCPC

Lorraine Venturato1, PhD, RN

Kathryn King-Shier1,3, PhD, RN, FESC

1Faculty of Nursing, University of Calgary, Calgary, AB

2Cumming School of Medicine, University of Calgary, Calgary, AB

3Department of Community Health Sciences, University of Calgary, Calgary, AB

Background: PD is as effective as other renal replacement therapies, but it is cost-saving and allows patients to maintain their independence at home. Unfortunately, technique failure is common, and social support is necessary for PD success.

Aim: To examine how patients, their family, and nurses view social support and its role in PD management.

Method: This was a qualitative descriptive study. Patients (n=15), family members (n=6) and nurses (n=11) from an adult PD program in Calgary underwent audio-recorded interviews between January and May 2018. Conventional content analysis, using the four types of social support (emotional, instrumental, informational, and appraisal) as an analytic framework, was used to analyze the text data.

Results: Social support was important, impacting the PD experience and technique failure. Sub-themes emerged when participants described social support in the context of home PD therapy. These themes included:  addressing emotional needs and managing emotional support with PD and life tasks; accessing information, receiving information, and learning; and affirmation/external reassurance and self-confidence. The social support needs of patient and family members varied, and were dependent on their existing support networks and individual perspectives of support.

Conclusions. Social support is multi-faceted and an important part of the PD experience. To sustain patients on PD, it is imperative that the breadth of social support needs be understood and individualized to the patient.

Implications. Having a better understanding of social support may help inform healthcare providers who support people on PD and enable patients to continue managing their therapy at home.

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7D: Maximizing vascular access team capacity enhances patient and family engagement and outcomes

Lilla Ploszaj, BScN, RN, CNeph(C) – Clinical Resource Leader – Vascular Access, Scarborough Health Network, Toronto, ON (Presenter)

Wei Zeng, RN – Vascular Access Resource Nurse, Scarborough Health Network, Toronto, ON (Presenter)

Simone Smeets – Vascular Access Clerk, Scarborough Health Network, Toronto, ON (Presenter)

Background:  Early vascular access education of the patients living with chronic kidney disease is important to ensure their understanding of the optimal form of vascular access when choosing their modalities (i.e., hemodialysis). Achieving this goal can also be reached through the establishment and integration of a comprehensive Vascular Access Team who follows the patient across the full continuum of care in providing access education, assessment, monitoring, and maintenance.

Description:  Having a designated Vascular Access Team and standardized access education for patients and families have been proven to decrease expenses and increase efficiency. Furthermore, patient education improves patient’s satisfaction and quality of care through enabling informed decision for suitable access when choosing hemodialysis.

Results:  By developing and implementing the VA Team and providing standardized vascular access education, we have seen an increase in AV fistula use and decrease in CVC use in HD prevalent patients (61% of CVC and 39% of AVF/AVG). We have noticed, therefore, an increase in compliance for access creation and reduction in the follow-up calls regarding clarification preparation for access surgery and care.  Moreover, we have seen a decrease in no shows for access interventions (3.7% in 2015/2016 vs 1.5% in 2017/2018).  Additionally, having a collaborative partnership with the interventional radiology staff enables access to care for urgent interventions versus hospitalization.

Conclusion:  It is imperative to have the VA Team in the patient’s journey. The team members are interdependent, and work in collaboration with the patients and families, and other essential services to enhance access to care.

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7E: Standards to support quality management of kidney dialysis

Jason Maahs – Water Operations Manager, Baxter, Mississauga, ON (Presenter)

James Bellamy – Patient Care Manager, Nephrology, Halton Healthcare, Oakville, ON

A quality management system (QMS) establishes consistency in, and control of, processes and documentation, towards the highest degree of safety and quality for the dialysis providers, clients, and staff. A QMS gives assurance that policies, procedures, and processes are in compliance with Canadian standards, and thus dialysis providers and impacted stakeholders should be educated on the importance of adherence to these standards.

Standards that have been developed on the topic of QMS in kidney dialysis including the following:

  1. CSA Z364.6, Quality management for kidney dialysis providers is a core standard for a QMS specific to kidney dialysis processes and equipment, for use in a health care facility or home setting for the purpose of providing safe, reliable kidney dialysis treatments and care. This QMS is based on accepted principles of risk management to ensure the safety, quality, and efficacy of dialysis, regardless of method, and to ensure the safety of personnel, clients, and caregivers.
  1. The basic requirements for hemodialysis and peritoneal dialysis performed in a home setting are fundamentally similar among organizations; however, the methodology may vary. The second edition of CSA Z364.5, Safe installation and operation of hemodialysis and peritoneal dialysis in a home setting was developed to provide nephrology personnel with best practice to deliver quality treatment and provide expert guidance for their clients. Adherence to this standard will contribute to providing safe and efficient delivery of such in-home dialysis treatments.
  2. Quality management is a topic across many Kidney Dialysis standards, including the ISO Z23500 series.

The goal of this presentation is to raise awareness amongst dialysis providers and other relevant stakeholders about the existence of these standards and the importance of quality management in the provision of kidney dialysis.

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8A: Mental illness in hemodialysis: An urban outpatient unit approach

Primrose Mharapara, MScN, NP-PHC, CNeph(C) – Department of Nephrology, University Health Network

Psychiatric illness is common among patients with chronic disorders, particularly in those with end-stage renal disease (ESRD). A review by Kimmel et al. (1998) indicated that the following mental disorders were frequently observed in ESRD: depression, dementia and delirium, drug-related disorders (such as alcoholism), schizophrenia, and personality disorders. These disorders account for 1.5 to 3.0 times higher rate of hospitalization among patients on dialysis compared to those with other chronic illnesses, resulting in significant morbidity (Schmidt & Holley, 2017).

Patients maintained on hemodialysis (HD) are more likely to be hospitalized for a psychiatric disorder than are those treated with peritoneal dialysis. The difference in hospitalization rates is probably due to an increased incidence among patients on HD of disruptive behaviors that may lead to hospitalization (Kimmel et al., 1998). There is a paucity of data relating to the effectiveness of therapeutic interventions in the treatment of psychiatric disorders occurring in patients with ESRD. It is unclear if the management is less successful, and thus hospitalization is more common. Resistance to therapy may also contribute to higher hospitalization rates. Although few studies relating to the treatment of psychiatric disorders occurring in patients with ESRD exist, general recommendations for treating such individuals based upon outcomes among those without chronic kidney disease can be made.

This oral presentation focuses on pharmacological and non-pharmacological treatment of three most common psychiatric illnesses (i.e., depression, anxiety, and dementia) in patients on HD in the form of case studies. Therapy will incorporate inter-professional collaboration and guidance from the Ontario Renal Network’s (ORN) “Your Symptoms Matter” initiative.

References:

Schmidt, R. J., & Holley, J. L. (2017). Psychiatric illnesses in dialysis patients. UpToDate. Retrieved from https://www.uptodate.com/contents/psychiatric-illness-in-dialysis-patients

Kimmel,P. L.., Thamer, M., Richard, C. M., & Ray, N. F. (1998).  Psychiatric illness in patients with end-stage renal disease. American Journal of Medicine, 105(3), 214.

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8B: Introducing a novel multidisciplinary approach to dialysis modality education

Tyler G. Tulloch1,2, PhD (Presenter)

Debbie Fillmore1, RN, CNeph(C) (Presenter)

Joseph R. Pellizzari2,3, PhD, CPsych

Randi E. McCabe2,3, PhD, C. Psych

1Kidney Urinary Program, St. Joseph’s Healthcare, Hamilton, ON 2Mental Health & Addictions Program, St. Joseph’s Healthcare, Hamilton, ON 3Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON

Purpose: Modality education is traditionally provided by a renal navigator who presents a comprehensive review of patient options, including transplant and supportive care. Patients may not be prepared to receive this information when it is provided, or may not receive it in a timely manner if dialysis is started urgently. Ensuring that all patients receive timely modality education in a manner that minimizes psychological distress and fosters self-reflection ensures that patients feel supported and choose an option aligned with personal values and lifestyle.

Project description: In September 2018, the Kidney Urinary Program at St. Joseph’s Healthcare Hamilton incorporated a health psychologist role to support home therapy patients and collaborate with the renal navigator to provide decision-making support and psychological treatment following modality education. This novel multidisciplinary approach to modality education is the first of its kind in Ontario, and perhaps nationwide.

Outcomes: Preliminary data indicate that the overwhelming majority (82%) of patients declared peritoneal dialysis (PD) as their first choice of modality. Data collection is ongoing. Complete data comparing modality declarations before and after initiation of this approach will be presented.

Implications: Home therapies, PD and home hemodialysis, confer added benefits to the patient over facility-based hemodialysis, and are less costly. Benefits of increasing PD uptake include more control over dialysis schedule, more freedom for personal activities, slower kidney decline, fewer dietary/fluid intake restrictions, and cost savings to the healthcare system. Benefits of this novel multidisciplinary approach include greater patient satisfaction with healthcare services and their own modality decision.

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8C: Surgical site complications in kidney transplant recipients: Incidence, risk factors, and outcomes in the modern era

Rebecca Wong1, HBSc(c)

Michelle Minkovich1, HBSc

Olusegun Famure1, MPH, Med, CHE (Presenter)

Franz-Marie Gumabay1, HBSc, BScN(c)

Yanhong Li1, MSc

Anand Ghanekar2, MD, PhD, FRCPC

Joseph Kim1,3,4, MD, PhD, MHS, FRCPC

1Multi-Organ Transplant Program, University Health Network, Toronto, ON 2Department of General Surgery, University Health Network, Toronto, ON 3Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON 4Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON

 Background: Post-transplant immunosuppressive regimens inherently compromise wound healing, including at the surgical site. Transplant recipients are, therefore, especially susceptible to surgical site complications (SSC), such as infections and wound dehiscence. We aimed to assess the incidence, risk factors, outcomes, and economic impact of SSC in a large diverse population of kidney transplant recipients (KTR).

Methods: We conducted a single-centre, retrospective cohort study of adult KTR transplanted from January 1, 2005 to December 31, 2015, excluding patients with simultaneous multi-organ transplants, and prior non-kidney transplants. The Kaplan-Meier product-limit method was used to determine the incidence of SSC. Risk factors and outcomes were evaluated using Cox proportional hazard models.

Results: The cumulative incidence of SSC within 30 days post-transplant was 4.19 (95% CI: 3.26-5.39, per 100 person-years). Increased recipient body mass index (HR=1.07, 95% CI: 1.02, 1.12), longer cold ischemic time (HR=1.05, 95% CI: 1.01, 1.09), and being transplanted from 2010-2012 (HR=2.32, 95% CI: 1.23, 4.36 [vs. 2005-2009]) were found to be risk factors for SSC. SSC was not associated with increased hospital readmissions. Median hospital costs incurred by patients with SSC was $2238.46 greater than that of patients with no SSC.

Conclusion:  Higher patient BMIs, longer cold ischemic time, and transplants from 2010-2012 were factors associated with developing SSCs.

Clinical implications: Home care has frequently been used to treat SSC in the modern era. A greater understanding of modern kidney transplant cohorts and clinical management practices may help to reduce incidence of SSC post-transplant and minimize hospital costs.

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8D: A quality improvement initiative for catheter-related bacteremia

Patricia A. Quinan, MN, RN, CNeph(C), Clinical Nurse Specialist/Vascular Access Coordinator, Humber River Hospital, Toronto, ON (Presenter)

Anna Pastuszok, BScPhm, RPh, Renal Pharmacist – Humber River Hospital, Toronto, ON

Purpose: To develop a standardized approach for the diagnosis, management, and treatment of catheter-related bacteremia (CRB).

Description: : Long-term use of central venous catheters (CVC) for hemodialysis (HD) is associated with increased morbidity, mortality, infection, and hospitalization. Programs are encouraged to implement strategies known to reduce infection, including the importance of hand washing for staff and patients, timely and appropriate diagnosis and treatment of catheter-related infections, and reducing long-term catheter use in suitable patients.

The vascular access coordinator, in collaboration with home HD nurses, renal pharmacist, educator, and manager, initiated a CRB working group with the goal of implementing program-wide best practices and quality improvements (QI) aimed at reducing CRB. At monthly meetings, the team reviewed best practices and recommendations, examined local practices, and created CRB documents to develop a standardized approach for our HD patients on conventional, short daily, and nocturnal therapies.

Evaluation/Outcomes:: After consulting the nephrologists regarding appropriate medication, dosing, and treatment duration, CRB documents were sent to nephrologists, nurse practitioner, renal pharmacists, program managers, and medical director for review and approval, and implementation across our program. As a result of our QI initiative, all episodes of CRB for home and facility-based HD patients are reviewed, and confirmed CRB are reported monthly and results shared with staff.

Implications for nephrology practice/education: The home hemodialysis nurses’ valuable contribution facilitated a program-wide QI initiative for the diagnosis, management, and treatment of CRB. Nurses reported that the QI initiative was collaborative, improved knowledge sharing, and assisted them in informed discussions with the nephrologist and nurse practitioner when advocating for their patients.

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8E: Water quality in home hemodialysis (HHD) programs:  Review of standards and barriers to their implementation

Sejal Dave1, MSc (student) (Presenter)

Tania Stafinski2, PhD

Devidas Menon2, PhD, MHSA, BSc

Robert Pauly3, MD, MSc, FRCPC

1Health Policy Research, School of Public Health, University of Alberta

2Health Technology and Policy Unit, School of Public Health, University of Alberta            3Division of Nephrology, Department of Medicine, University of Alberta

Background: Water quality is critical for ensuring the safety of dialysis patients. Since the use of home hemodialysis (HHD) is growing across Canada, there is a need to understand factors affecting water quality.

Method: This research involves two studies: (1) a scoping review and (2) a barriers assessment. A scoping review was conducted to compare existing standards for microbiological and physico-chemical parameters of water for dialysis. A qualitative approach was utilized for the assessment of barriers to implementing standards via semi-structured interviews with health professionals (n=10) at HHD programs in Alberta. During interviews, participants were asked to identify key issues and challenges within each step of the quality management process that could affect the water quality.

Results:  National (n=22) and international (n=4) standards and guidelines were identified from Europe, USA, Germany, Canada, Japan, & Australia/New Zealand. Key themes were: (1) quality criteria for dialysis water and dialysate; (2) approaches to meeting them; (3) implementation of standards/guidelines; (5) monitoring criteria; (6) evaluating adherence; and (7) limitations. The burden on dialysis technicians is greater compared to in-centre units because of factors such as source water quality, seasonal variations, and patient’s geographical location (urban or rural). The key areas of concern are patient compliance, water sampling procedures, logistics, appropriate dialysis technicians to patient ratio, and home conditions.

Conclusion: In comparison to in-centre units, dialysis technical staff face unique challenges with water quality management for HHD. Sophisticated risk assessment techniques need to be adopted to develop local data driven water quality management practices.

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9A: Patient accessibility to the renal dietitian and its impact on phosphate results

Tracy Gower, P.Dt – Nova Scotia Authority Renal Program (Presenter)

Pamela Dill, P.Dt – Nova Scotia Authority Renal Program

Anastasia Kleronomous, P.Dt – Nova Scotia Authority Renal Program

The role of the renal dietitian (RD) is diverse. Advice is often complex and changing dependent on the stage of chronic kidney disease and the individual needs of the patient. Dietary adherence is essential to reducing serum phosphate. Accessibility to a renal dietitian can have great impact on the reduction of hyperphosphatemia. This study examined RD impact on serum phosphate in dialysis patients.

A total of 20 patients who were dispensed Compassionate Tums® (January 1, 2018 to February 21, 2019) were reviewed. Serum phosphate levels were measured on 12 occasions in this evaluation period. Average phosphate result for patients receiving weekly RD education was 1.75 mmol/L.  Average phosphate result for patients receiving less contact from an RD was 2.25 mmol/L.

Results indicated that patients who have face-to-face contact with a renal Dietitian on a weekly basis fare better in meeting phosphate targets. Having access to a renal dietitian prompted discussion of phosphate binder adherence and facilitation of refills. Weekly nutrition education regarding oral intake of phosphates, organic, and inorganic phosphate additives, timing of Tums® with meals, dose of drug per volume of food improved serum phosphate results.

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9B: Everything you wanted to know about PD but were afraid to ask!

Gina Ongjoco, BScN, RN,CNeph(C) – Baxter Healthcare

Description: This presentation will cover the basics of peritoneal dialysis (PD) including continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal Dialysis (APD).

It is designed for nephrology staff members and nurses (chronic kidney disease, transplant, and hemodialysis) who wish to expand their knowledge related to the basics of PD

Learning Objectives:

  1. Develop an understanding of the basic principles of peritoneal dialysis as well as the types of peritoneal dialysis (CAPD and APD).
  2. Develop an understanding of the advantages of PD.

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9C: Development of a standardized shared-care model for the long-term management of stable kidney transplant recipients

Monika Ashwin1, HBSc, MD(c)

Pei Xuan Chen1, HBSc, BScN(c)

Olusegun Famure1, MPH, Med, CHE (Presenter)

Theresa McKnight1, MN, BScN, RN

<Franz-Marie Gumabay1, HBSc, BScN(c)

Michelle Minkovich1, HBSc

Cynthia Selvanathan1, HBSc, PharmD(c)

Ioana Clotea1, HBSc(c)

Wendi Qu1, HBSc(c)

Joseph Kim1,2,3, MD, PhD, MHS, FRCPC

1Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada. 2Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Purpose: Higher transplant volumes and extensive post-transplant follow-up places a strain on the limited resources of transplant centres. Effective long-term management of kidney transplant recipients (KTRs) is warranted to alleviate this strain and improve working capacity of these specialized centres while maintaining optimal care.

Description: A standardized shared-care model that integrates general nephrologists (GNs) and multi-care kidney clinics (MCKCs) with the transplant team can improve efficiency and quality of care provided to KTRs. To explore established protocols and strategies that could be adopted in developing this model, a literature search was conducted using MEDLINE and CINAHL (1970-2016) with the terms: “kidney transplant”, “long-term”, “community”, and “care”. In-depth consultations with transplant and general nephrology teams were held to discuss the logistics of the proposed model.

Outcomes: After screening, fifteen articles were included for review. These articles identified procedures that needed to be considered prior to shared-care implementation, such as outlining the responsibilities of each team, a timeline for follow-up visits, and methods of communication. Based on recommendations reported in literature and from consultations, a comprehensive set of guidelines was created to provide a framework to the model, document overarching procedures, and facilitate coordination between centres.

Implications for nephrology practice: Implementing shared-care would reduce burden on transplant centres and allow resources to be distributed more efficiently. GNs and MCKCs would get more involved in management of KTRs, thus permitting transplant teams to focus primarily on addressing concerns of recently transplanted or unstable KTRs. Shared-care would also bring care closer to home for KTRs, improve accessibility, and reduce travel costs.

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9D: The EMPATHY Initiative: Bringing Nursing Back to the Bedside

Bonnie Corradetti, Patient Advisor, Kidney Health SCN (Presenter)

Natalie D. Ilkiw1, MBA, BScKin (Presenter)

Chandra M. Thomas2, MD, MSc, FRCPC

Braden J. Manns2, MD, MSc, FRCPC

1Kidney Health Strategic Clinical Network, Alberta Health Services, Calgary AB

2Department of Medicine, Division of Nephrology, University of Calgary, Calgary AB

Patients with end-stage renal disease have a high symptom burden. Patients on hemodialysis experience multiple symptoms, which significantly impact their quality of life, health outcomes, and overall wellbeing. The EMPATHY Initiative is evaluating the use of symptom management tools to systematically identify, discuss, and manage patient reported symptoms in hemodialysis units. Outcomes include: patient experience, symptom management, and provider experience in hemodialysis units.

In EMPATHY, patients complete surveys every two months using either the IPOS (Integrated Palliative Care Outcome Scale)–Renal (i.e., a symptom assessment tool) or the EQ-5D-5L tool (i.e., an overall measure of quality of life), or both. Patient results are summarized in a Symptom Report Card, which categorizes their concerns as “not present”, “mild”, or “moderate to severe”. These results will help clinicians facilitate a discussion of the identified symptoms, address patient concerns, and begin a management plan. Treatment aids have been developed, and are available to support the management of symptoms. These include symptom guidelines for clinicians and handouts for patients to encourage self-management. The initiative is currently being implemented in Alberta Kidney Care-South in a phased approach.

Although data collection is currently underway, preliminary feedback from patients and staff has been positive. Patients have reported feeling included, and appreciate the opportunity to discuss their concerns. Multiple patients have reported a reduction in the severity in their symptoms. Staff reported that the process has helped identify patients they can support and feel that it has led to a collaborative environment with a more coordinate approach to patient care.

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9E: The haemodialysis machine – Then, now, and beyond…

Christopher Brookes, BSc, Hemodynamic Technologist – Department of Dialysis, McGill University Health Centre, Montreal, QC

This presentation will be a personal retrospective of the advent of haemodialysis and the equipment needed to perform the treatment based on my 30 plus years of experience in the field of nephrology and dialysis.

The main topic of discussion will be an explanation of how the haemodialysis machine has advanced to improve the safety and efficiency of dialysis treatments from the 1970s to the present. As equipment evolved, a comparison of the technologies used will be discussed. This discussion will include the advancement of equipment to meet some specific needs, such as the introduction of more biocompatable dialyzer membranes, haemofiltration (HF), haemodiafiltration (HDF), treatment efficiency (Kt/V), blood volume monitoring and trending, and the requirements of improved peripheral equipment utilized to enhance the advancements in haemodialysis treatments. Lastly, the improvements in water treatment will be briefly presented.

In concluding this presentation, a discussion regarding further evolution and technologies of the haemodialysis machine, with respect to the requirements of the nephrology environment such as home and self-care, and reduced water use will be presented.