immediate start peritoneal dialysis is it really an option? · immediate start peritoneal dialysis...

QAH Hospital

Portsmouth Hospitals NHS Trust 4/12/2016

Immediate Start Peritoneal Dialysis

Is It Really an option?

Gerry Endall

PD Nurse Specialist

16TH March 2016

QAH Hospital

Portsmouth Hospitals NHS Trust

Do we really need that option?

4/12/2016

QAH Hospital


Peritoneal Dialysis is a well established complementary

alternative to Haemodialysis as a first line renal replacement

modality

Van Biesen W, Vanholder R, Larneve N,

The role of peritoneal dialysis as a first line renal replacement

Modality PDI 2000; 20:375-83

QAH Hospital


What deems to be good practice?

Catheters being inserted in a timely manner (1 & 2)

Catheter insertion performed within 2 weeks and 24 hours for

an urgent start before commencing dialysis (1 & 2)

QAH Hospital


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QAH Hospital


QAH Hospital


Why do Immediate starts?

‘No decision about me without me’

Patients to have access to the treatment of their choice.

QAH Hospital


The evidence

‘Studies have indicated that PD may offer an initial survival

advantage, particularly in non diabetics and younger diabetic

patients’(6)

‘Preservation of vascular access’(7)

‘Better outcomes after renal transplantation(8)

Lower risk of infection with hepatitis B&C (9)

Circumvents the need for temporary Haemodialysis

QAH Hospital


And it goes on ...........

‘There are ‘believers’ and ‘non believers’

There are no RCT,s to really distinguish between HD and PD.

There are quality of life studies suggesting a better quality of

life up to and after one year (10)

QAH Hospital


Utilize Immediate Start Peritoneal Dialysis

This gives exposure to the programme.

Initiates an evidence based treatment.

Gains experience in areas of treatment that may not have been

undertaken.

Increases home therapy profile

Home therapies are cost effective compared with in-centre (5).

QAH Hospital


To make immediate starts work you require:

PATIENT EDUCATION AT TIME OF ADMISSION

PD TEAM FACILITATE CATHETER ACCESS

SELDINGER TECHNIQUE/RAPID LIST SURGICAL EMERGENCY LIST

NEPHROLOGIST+PD NURSE SURGEON + THEATRE TIME/STAFF

INTIATION OF PERITONEAL DIALYSIS BY PD TEAM

THE USE OF AN EVIDENCE BASED PROTOCOL

DAILY REVIEW WITH THE PD TEAM

GOOD EDUCATION AND SUPPORT TO WARD & MEDICAL TEAMS

PD CHAMPIONS

BAXTER PD AND ACCESS ACADEMY (NEPHROLOGISTS)

THE USE OF CARDS TO INSTIGATE PRESCRIPTION

CLEARFLEX FOR LESS CONNECTIONS

GOOD PRESCRIPTION CHART FOR RESULTS (SEE CHART)

MAINTAINING A POOL OF APD MACHINES

Implementation of Immediate start Peritoneal Dialysis

QAH Hospital


Implementing Immediate start dialysis Requires A Unique

Infrastructure and Treatment Approach

Outreach

Pathway

Standard Operating Procedure.

Access

Logistics of starting Peritoneal dialysis - time of day

Ability to provide Assisted Automated Peritoneal Dialysis.

Training schedules.

Equipment and ancillaries ( deliveries Weekly)

A single procedure for Immediate and long term Access

QAH Hospital


Patient Criteria/Selection

Each unit must decide there own selection criteria

Electrolyte imbalance upper and lower limits

Fluid balance

Albumin upper and lower limits

Selection for surgical or Percutaneous insertion.

Each patient should be a case by case.

QAH Hospital


PD Nurses role

Initiate education and support at the initial stages.

Training of nursing staff and nephrologists

How to instigate rapid access routes surgical/percutaneous

Equipment and supplies, range of catheter sizes, ‘ready to go’

Percutaneous packs.

The Pathway refers patients to the PD Team, This initiates the

flow of Treatment.

QAH Hospital


PD Nurses role Continued

Pre-clerking to include (preparing for band 7 to clerk patients)

– Prescription of laxatives or use of PGD,s

– Prophylactic antibiotics for percutaneous - PGD,s.

– Cannulation to aid the patient flow.

– Prescription for immediate start along side SOP.

QAH Hospital


Immediate Start Overview

Day 1 – 3 Day 4 – 6 Day 7 – 10

Dwell Volume 1.2l 1.5l 1.5 – 2l

Dwell Time 60 min 90 min 120 min

Fluid Clearflex 1.36%™

Balance 1.5%

Clearflex 1.36%™

Balance 1.5%

Clearflex 1.36%™

Balance 1.5%

Immediate Start APD protocol (adapted from Povlsen and Ivarsen, 2006 nephrology Dialysis

Transplantation

QAH Hospital


Date

Time

Date

Time

Date

Time

Date

Time

Date

Time

Date

Time

Date

Time

Total Volume:

Therapy Time:

Dialysate / Strength:

Batch Number:

Expiry Date:

Fill Volume:

Dwell Time

No. of Cycles:

Last Fill:

Batch No. / Expiry Date

Tidal % Volume:

Additives:

Doctors Signature

PD Entry & Exit Site Check:

Initial Drain Volume:

Total UF:

Lost Dwell:

Appearance:

Nurses Signature:

Additives Type of Fluids

H Heparin D Dianeal

V Vancomycin P Physioneal

G Gentamicin E Extraneal

K+ Potassium N Nutrineal

I Insulin F Fresenius

B Balance

C Clearflex

CODING

Addressograph Label:

Prescription Chart to monitor Treatment regimens

QAH Hospital


clear flex 5L bag for ease balance 5L bag

By kind permission of Baxter Healthcare Corporation

QAH Hospital


By kind permission of Baxter Healthcare Corporation and Fresenuis Medical Care

QAH Hospital


QAH Hospital


PATHWAY

INSTRUCTIONS FOR USE:

•Pathway begins in low-clearance clinic when the patient requires a Home Assessment.. The pathway continues

through to initiation of training and independence on Dialysis.

•This pathway was written to direct care for the majority of patients requiring peritoneal dialysis catheter insertion

•This pathway is not “cast in stone”. Use your professional judgement to decide whether it is appropriate to follow or

deviate from it. However, if the patient deviates from the pathway, please record this as a variance and clearly

state a rationale and action plan.

CRITERIA FOR USE:

•Any patient referred for peritoneal dialysis (PD) catheter insertion including:

Medical or surgical insertion

New catheter

Replacement catheter

Immediate start Peritoneal Dialysis.

GOALS OF CARE

•The patient receives optimal care prior to and following PD catheter insertion

•Patient safety is maintained

•Patient progresses along the pathway for timely commencement of renal replacement therapy (RRT)

•Patient receives education and self management skills

•To promote and ensure standardisation and continuity of care across disciplines.

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QAH Hospital


Wessex Kidney Centre PD Department

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QAH Hospital


QAH Hospital


Training Staff

PD Champions – PD staff to be visible.

Yearly training in CAPD /APD

Nursing secondment from all areas of Renal.( 8 weeks)

All new staff attend the unit for 1 week.

Picture books and troubleshooting book with each machine.

Machine left ‘ready to go’ with prescription, fluids and

equipment

On call PD staff to advise or be called in

QAH Hospital


Access

PD team responsible for Percutaneous delivery (Ready to go

pack)

Cannulation for IV Access

PD nurse trained as anaesthetic nurse, responsible for

assessing, monitoring, and delivering anaesthetic during the

procedure.

Drug of choice (FENTANYL).

Conscious sedation protocol.

3 day interventional list to upgrade to 5 day cover including

nurse insertions

QAH Hospital


Cost friendly to the Trust

Does patient require inpatient stay ?

Utilize day ward beds for Procedures.

Surgical beds .

Cost pressures - surgical v Percutaneous £££

The instigation of Aapd to assist early discharge.

QAH Hospital


conclusion

Immediate start peritoneal dialysis can enhance patient choice.

It is a safe and feasible option for patients, who might otherwise

transfer to haemodialysis. This concept can enhance the

patients quality of life. It can also promote a home therapy

programme and may help to penetrate and raise the profile of

PD not only as a dialysis option but as an option for immediate

start.

QAH Hospital


References 1. 2.31 ‘specification for the commissioning of peritoneal dialysis pathway’

2. ‘Preparation for peritoneal dialysis’, Renal association 2010

3. The Renal Association, 12th Annual Report 2009

4. Patient pledge, Liberating the NHS, 2011

5. NHS Kidney Care

Baboolal K, McEwan P, Sondhi S, Spiewanowski P, Wechowski J and Wilson K, The cost of renal dialysis in a

UK setting – a multicentre study. Nephrology Dialysis Transplantation, 2008; 23: 1982 - 1989

6. Van Biesen W, Van Holder R, Lamere N, The Role of Peritoneal Dialysis as a first line Renal replacement

Modality, PDI 2000; 20:375-83

7. Hakim R, Himmelfarb J, Haemodialysis access failure: a call to action. Kidney international, 1998; 54: 1029-

1040

8. Heaf J G, Lokkegaard H, Madsen M, Initial Survival Advantage of Peritoneal Dialysis Relative to

Haemodialysis. Nephrology Dialysis Transplant 2002; 17: 112 – 117.

Liem Y S, Wong J B, Hunink N G et al, Comparison of Haemodialysis and Peritoneal Survival in the

Netherlands. Kidney International 2007; 71: 153 - 158

9. Cendoroglo M, Draibe S, Silva A et al, Incidence and Risk Factors for Hepatitis B and C Virus Infection among

Haemodialysis and CAPD Patients. Nephrology Dialysis Transplant 1995; 10: 240 – 246

10. Kutner N, Zhang R, Barnhart H, Collins A, Health status and quality of life reported by incident patients after 1

year on HD or PD. Nephrology Dialysis Transplant ion 2005; 20: 2159 – 2167

QAH Hospital


References • Povlsen (2014) Nephrology dialysis and transplantation 29.2201

Can Peritoneal Dialysis of be applied to unplanned initiation of Chronic Dialysis

• Ghaffari A, Kumer V, guest S (2013) 33-611

Infrastructure requirements for a urgent start Peritoneal Dialysis Programme

• International society of peritoneal dialysis guidelines

Peritoneal dialysis for acute kidney injury (August 2014)volume 34 NO5 494-517

• Baxter PD Healthcare (2010) Healthcare Information Pack: Practical tips for training APD, Patients on Homechoice with Physioneal

Clear-flex

• Renal Association (2010) Clinical practice guidelines for Peritoneal Dialysis

• Renal Association (2009) Clinical practice guidelines for Peritoneal Access

• NHS Kidney Care (2010) Speciation for the commissioning of Peritoneal Dialysis Pathway

• Jo, Y., Shin, S, K., Lee, J,H., Song, J,O., Park, J, H. (2007) Immediate initiation of CAPD following percutaneous catheter

placement without break-in procedure. Peritoneal Dialysis International. Vol 27 pp 179-183

• Povlsen, J, V., Ivarsen, P. (2006) How to start the late referred ESRD patient urgently on chronic APD. Nephrology Dialysis and

Transplantation.Vol 21, Sup 2, pp 1156-1159

• Wiles, K., Uniacke M., Borman, N., Todd, M., Endall, G., Gibbs, P., Macanovic, J. (2010) Acute peritoneal dialysis experience 2006-

2009

4/12/2016

Never believe that a few caring people can’t change

the world, for indeed that’s all who ever have.

Margaret Mead - Anthropologist

immediate start peritoneal dialysis is it really an option? · immediate start peritoneal dialysis...

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