Water Treatment for Hemodialysis: Keeping Patients Safe.

All nurses with any responsibility for hemodialysis need to know and understand the clinical ramifications of water treatment and dialysate preparation. Although some hemodialysis programs may have full-time technical staff who operate and test the water treatment and dialysate preparation systems, many programs rely on nursing staff for the day-to-day operation and testing of these systems. It is critical for all staff members to work together to keep patients safe. This article details reasons safe water and dialysate are critical for patients on hemodialysis and reviews components of water treatment systems, dialysate concentrate preparation, and monitoring and testing necessary to assure that both water and dialysate are safe for patient use. Integrated hemodialysis systems (i.e., those that combine water treatment and dialysate preparation and delivery in an individual machine "package") are also described.

"It's not what you see but what you hear ": Understanding environment protection officers' responsive decision making.

Responsive regulation asserts that regulatory enforcement actions are likely to be more effective in promoting compliance when they respond to a duty holder's motives, capabilities, and external pressures. However, operationalizing responsive approaches that also possess qualities of consistency and transparency remains a challenge for environmental management authorities. This study applied a mixed-method qualitative approach to capture the responsive decision making influences on government environment protection officers in a field context when engaging with different duty holders. These insights then informed compliance narratives across a series of business behavior segments to guide more consistent, transparent and responsive decision making among environment protection officers. Our findings revealed how different constellations of observations, interactions and displays of willingness and ability impact the choice of regulatory responses. Challenges encountered in applying responsive regulation in practice involved difficulties ascertaining business capability, identifying causal links between response strategies and compliance outcomes, and how the use of discretion can impact on consistent and transparent decision making.

Water Treatment for Hemodialysis: What You Must Know to Keep Patients Safe.

It is critical for all staff members to work together to keep patients safe. Nephrology nurses with responsibility for hemodialysis (HD) need to know and understand the clinical ramifications of water treatment and dialysate preparation. Although some HD programs may have full-time technical staff who operate and test the water treatment and dialysate preparation systems, many programs rely on nursing staff members for the dayto- day operation and testing of these systems. This article details the reasons safe water and dialysate are critical for patients on HD; and reviews components of water treatment systems, dialysate concentrate preparation, and the monitoring and testing necessary to assure that both water and dialysate are safe for patient use. Integrated HD systems (i.e., those that combine water treatment and dialysate preparation and delivery in an individual machine "package") are also described.

Facilitating adaptive management in a government program: A household energy efficiency case study.

Interim evaluations of government programs can sometimes reveal lower than expected outcomes, leading to the question of how adjustments can be made while the program is still underway. Although adaptive management frameworks can provide a practical roadmap to address this question, a lack of successful learnings and poor implementation have hampered the progress and wider application of adaptive management. Using a case study involving an energy efficiency government program targeting low-income households, this article provides supporting evidence on how adaptive management can be facilitated and applied. Factors such as proactive and responsive leadership, establishing a research-practice interface, and recognizing the skills, expertise, and contributions of multiple stakeholders guided adjustments to the program, and later paved the way for longer-term organizational learning that impacted how other programs are delivered. Implications for knowledge and practice, and a discussion of the challenges faced in the program, advance current thinking in adaptive management.

Water treatment for hemodialysis: an update.

While nurses may not routinely service the water treatment system or mix the dialysate, they are responsible for understanding all of the clinical ramifications of water treatment and dialysate preparation for hemodialysis as a part of the entire dialysis treatment picture. Although the water treatment system has historically been in the technicians' domain, knowing the technical aspects is important for the entire team to work together to ensure patient safety and well-being. This article describes the composition of water treatment systems for hemodialysis, as well as the monitoring and testing necessary to assure that both water and dialysate are safe for patient use.

Foscarnet in the management of cytomegalovirus infections in hematopoietic stem cell transplant patients.

Despite significant advances in the day-to-day management of patients receiving hematopoietic stem cell transplantations, including the introduction of new antiviral drugs, cytomegalovirus (CMV) infection continues to be a major cause of morbidity and mortality. The aim of this article is to undertake a literature-based review of foscarnet in this therapeutic setting and to align current best-published evidence with recent recommendations presented at the European Conference on Infections in Leukaemia. Ganciclovir remains the mainstay of CMV infection/disease antiviral management protocols. However, approximately a third of patients develop severe neutropenia and others become resistant to ganciclovir, and thus, a reasonably large proportion of patients are not able to receive and/or continue with this medication. Foscarnet is a suitable option as both pre-emptive therapy or for the treatment of active disease in these patients. Randomized trials have demonstrated that foscarnet is equally effective when compared with ganciclovir for pre-emptive treatment of CMV infections: the outcome was comparable with ganciclovir in terms of control of antigenemia and survival rates. There is a paucity of information for its use in the prophylaxis of CMV, although preliminary data show that it was effective in some patients at high risk of CMV reactivation. The main adverse events associated with foscarnet are renal impairment, serum electrolyte and hemoglobin disturbances, seizures and local genital irritation/ulceration. Foscarnet is a well-established antiviral option in immunocompromised patients, and it is usually administered as a second-line option to ganciclovir. In patients receiving hematopoietic stem cell transplantation, it has proven efficacy when used pre-emptively to treat CMV reactivation, as an alternative to and also in combination with ganciclovir.

What's the problem? River management, education, and public beliefs.

This paper invokes the theory of planned behavior (TPB) as a diagnostic tool to explain an existing public education program's limited success at improving river water quality in the City of Perth, Western Australia. A reflective, client-driven research approach was used. A facilitated expert workshop defined an environmental problem (excess nutrients leaving gardens and entering waterways) and a desired behavior (residents purchasing environmentally sensitive fertilizer) to address the problem. A TPB-based belief elicitation survey captured respondents' beliefs regarding the desired behavior. The findings suggest respondents were aware of the links between purchasing environmentally sensitive fertilizer and river water quality. However, this behavior is compromised by the challenges in identifying appropriate products, product quality concerns, and cost. Viewing the content of a public education program through the lens of the TPB reveals insights into how and why the program fell short in achieving one of its key behavioral change goals.

The new Medicare PPS and home dialysis.

Overall, we believe that bundling of payments to dialysis facilities is positive for home dialysis. The incentive for higher utilization of home therapies comes down to the fact that, with treatments for all modalities being paid at the same rate, providers will see that home modalities cost less than facility-based treatments. The adjustment for home training treatments is certainly helpful, but it is not incentive enough on its own. From our perspective, one of the biggest financial incentives for home dialysis and more frequent dialysis therapies is that these patients are statistically known to spend less time in the hospital, over time costing taxpayers and the ESRD Program less money. We will continue to encourage CMS to consider the overall cost implications of more frequent dialysis. We are hopeful that when hospitalization costs are accounted for, CMS will do even more to encourage the use of these modalities.

Managing risk for silicone tubing applications.

Quality must be designed into medical devices, including into their raw materials and components. Operating according to the critical principles of medical device good manufacturing practices ensures that the silicone tubing incorporated into devices has the highest standards of quality and safety.