Continuous quality improvement: at the grassroots.

As a philosophy and a belief system, continuous quality improvement (CQI) provides the basis for organizational commitment to strategic leadership, customer focus, an empowered workforce, and reliance on evidence to improve processes and outcomes. This paper describes the process engaged in by the hemodialysis unit at St. Joseph's Health Care, London to formalize our CQI processes. The paper emphasizes: the selection of outcome measures, the strategies to link outcomes to improvement opportunities, and the resulting improvement projects. The formal commitment to CQI has affected both patient care and staff morale in many positive ways.

The impact of increased blood flow rates on recirculation in central venous hemodialysis catheters.

A recent practice change in our unit from Quinton dual lumen PermCaths to Vas-Cath Optiflow central venous catheters resulted in the routine achievement of bloodflow rates (BFR) of 500 ml/min. Previously BFRs of 300-400 ml/min were the norm. The increased BFR was achieved without any apparent increase in venous pressure, prompting us to consider the possibility that increased recirculation was occurring. This paper presents the results of a study designed to answer the following questions: (a) What is the difference in recirculation rates between Quinton dual lumen PermCaths and Vas-Cath Optiflow dual lumen catheters? and (b) What is the impact of increased BFR on recirculation rates in Optiflow hemodialysis catheters? The study documented recirculation rates in two groups of patients. In Group 1, the Optiflow group, recirculation rates were calculated for 10 subjects, first at 350 ml/min and then at 500 ml/min. In Group 2, the PermCath Group, recirculation rates were calculated for 10 subjects at 300 ml/min. Paired t-tests were performed to compare Group 1 at 350 ml/min with Group 2. No significant differences were found within or between groups suggesting that recirculation rates were not affected by increased BFR.

Incidence of sleep pattern disturbance in a peritoneal dialysis sample.

Our experience and the research literature suggest that sleep pattern disturbance (SPD) is a problem among dialysis patients. The purpose of this study was to describe the scope of sleep problems among willing patients on peritoneal dialysis at a mid-size university teaching hospital. To examine SPD, this descriptive study used a sleep diary that patients completed each morning for a week. Patients were asked to describe sleep latency, perceived difficulty falling asleep, number of arousals, use of sedatives, whether they awoke feeling rested, sleep efficiency, and factors preventing or inducing sleep. The sample consisted of 22 respondents whose average age was 60.5 years. With respect to the variables included in the sleep diary, respondents reported: 82% sleep latency of 40 minutes or less; of 154 nights studied, difficulty falling asleep on 41 (27%) of the nights; 82% experience of 15 or fewer sleep arousals per week (that is, approximately 2 arousals per night); 64% no use of sedatives during the week; 55% experience of feeling rested on awakening 5 or more mornings per week; and 55% experience of sleep efficiency above 80%. Of the factors reported to interfere with sleep, treatment-related factors such as alarms and other machine-related problems were, by far, the most predominant, reported by 82% of respondents. These findings compare very favorably with reports in the literature noting the incidence of SPD among dialysis patients to be as high as 73%. Information regarding factors that are barriers or facilitators to sleep have formed the basis of some practice changes within our program to address this distressing problem.

Personality traits and self-care in adults awaiting renal transplant.

This article reports the pretransplant findings of the first phase of a three-phase, longitudinal study examining relationships among personality traits and self-care abilities and behaviors of Ontario adults pre- and post-renal transplant. A consortium of Ontario nurse researchers representing three of Ontario's five renal transplant centers conducted this research. All adults on the cadaver transplant lists of 15 Ontario dialysis centers were invited to participate. One hundred ninety-eight adults awaiting renal transplant were enrolled in the study, representing a 70% response rate. A cross-sectional, correlational design was used for the pretransplant phase. Self-report measures with known psychometric properties were used; validity and reliability of the measures were supported by the sample. Data were analyzed using descriptive approaches, correlational analyses, multiple regression, and path analysis. Relationships were supported among selected personality traits, health state and self-care abilities and behaviors. Further research to examine personality traits and health state in relation to adult self-care is warranted.

How five advanced practice nurses in nephrology spend their time.

The purpose of this paper is to report the results of a descriptive study undertaken to examine the scope of practice of five Masters-prepared nephrology nurse practitioner/clinical nurse specialists (NP/CNS) in a mid-size university teaching hospital program. Four of the NP/CNSs practised in three acute care sites, and one in the regional dialysis program. Impetus for the study came from two sources. First, a sixth person practising in the role was retiring and was not to be replaced. Second, the current three-site model for acute care was being transformed into a two-site model, thus creating opportunities to reduce variability in practice among the NP/CNSs. The study examined the activities of the NP/CNS role through the completion of a time documentation tool (TDT) by five nurse practitioners on each of 10 consecutive days of practice. The TDT was adapted from Ackerman's Model of Advanced Practice (1996). The model outlines five domains of practice for advanced practice nurses (APN): direct comprehensive care, support of systems, research, education, and publication and professional leadership. The NP/CNSs spent an average of 9.21 hours at work daily with a range of 8.6 to 10.3 hours. The TDT captured an average of 8.6 hours of working time with a range of 7.3 to 9.9 hours. An average of 72% of time was spent in clinical practice (range 64-83%). An average of 16% (range 11-20%) of time was spent in support of systems. Research (average 4%, range 3-7%), education (average 6%, range 3-16%), and publication and professional leadership (average 2%, range 0-6%) figured less prominently. The major activities performed within the clinical practice domain and the support of systems domain showed less variability across sites than was anticipated. The results of the study have helped the NP/CNSs and their management colleagues analyze and adapt the role to changing clinical requirements and economic realities.

Incidence of sleep pattern disturbance (SPD) in a hemodialysis sample.

Personal experience suggests that sleep pattern disturbance (SPD) is a serious problem for the patients we serve. The purpose of this study was to identify the scope of sleep problems among all willing patients in a medium-sized hemodialysis unit in a university teaching centre. This descriptive study examined SPD through the use of a sleep diary that subjects were asked to complete each morning for a week. Subjects were asked to describe sleep latency, sleep quantity, number of arousals, whether they awoke feeling rested, factors that interfered with sleep the night before, and sleep inducers employed the night before. They were also asked to record their dialysis schedule. Each subject's chart was reviewed with respect to medications and evidence of other medical problems that interfered with sleep. Findings were benchmarked with results from the literature. Information regarding facilitators and barriers to sleep has provided some basis for an interdisciplinary plan of care to address this distressing problem.

Original research: the relationship between dialysis adequacy and quality of life: a report of a pilot study.

Adequacy of dialysis, as measured by urea kinetic modelling (UKM), is considered an extremely important clinical outcome for all dialysis programs. While improving adequacy has been clearly linked to decreased mortality among hemodialysis patients, the relationship between adequacy and patients' quality of life remains less clear. Patients with higher Kt/Vs live longer, but do they live better? This paper describes the results of a pilot study designed to examine the relationship between adequacy of hemodialysis and the patient's perceived quality of life. This time series study employed a convenience sampling technique consisting of all willing new patients to join an in-centre hemodialysis program in a six-month period. The adequacy of each new patient's dialysis prescription was determined by analyzing urea kinetics at one and three months following the commencement of therapy. Dialysis prescription changes were made by the interdisciplinary team, as necessary and where possible, to achieve a minimum Kt/V of 1.2. Each new patient's quality of life was measured at the same time intervals, that is, one and three months using two instruments. The first, the SF36 is a generic 36-item instrument designed to measure a range of functioning and well-being. The second, the Kidney Disease Questionnaire (KDQ) is a disease-specific quality of life instrument designed for use with chronic hemodialysis patients. Results showed that both adequacy and quality of life scores improved from one to three months. There are, however, too many competing explanations to assume a relationship between the two variables. Future analysis with a larger sample will employ an analysis of covariance to look for relationships.

Dialyzer re-use: a solution for the '90s.

Current economic and fiscal imperatives in health care demand innovative and cost-effective methods of care delivery. At St. Joseph's Health Centre in London, Ontario since 1990 we have been pioneering the process of dialyzer re-use in order to reduce costs while maintaining quality care. This paper will describe the process of introducing dialyzer re-use to our unit with particular emphasis on its implications for staff education, patient communication, capital equipment acquisition and the development of dialyzer re-use methods. The paper will also report the findings of an evaluation study designed to answer the following research questions: What is the effect of successive dialyzer re-uses on the clearance of urea, creatinine and phosphate? What is the incidence of fever developing during a dialysis treatment in a re-use program? What are the cost savings attributable to the introduction of re-use? Discussion of the research findings will focus on patient's and staff's reaction to the practice change and key learnings from our experience.