A continuous quality improvement initiative: focusing on primary nurse accountability
Margarita P. Ilumin
In a primary nursing model of dialysis care, each registered nurse is assigned a number of patients for whom he or she assumes the responsibility of planning their care and evaluating patient outcomes on an ongoing basis. The primary nurse is responsible for establishing clear communication between the patient and family, the physician, and other health care team members. When the primary nurse is not present, the other members of the health care team follow the plan of care established and outlined by the primary nurse in the patient’s kardex or care plan.
This article describes the Primary Nurse Monthly Summary, a continuous quality improvement (CQI) initiative to improve primary nursing accountability of the quality management team (QMT) in an incenter dialysis unit in Ontario, Canada. The Primary Nurse Monthly Summary serves both as a patient assessment guide and as an educational tool for primary nurses. This tool incorporates quality indicators and desired patient outcomes into monthly assessments. Predictors of complications and indicators for interventional procedures are incorporated into this tool. The Primary Nurse Monthly Summary provides the primary nurse a frame of reference in identifying problems and in evaluating patient interventions. It guides the primary nurse in providing care that is holistic and meets standards of practice.
CQI Concept and the Primary Nurse
Donabedian (1966) identified structure, process, and outcomes as the three quality determinants of health care. To apply Donabedian’s (1966) model of health care quality in dialysis, structures can include staffing patterns and equipment used to provide dialysis care. Important processes that affect patient care include the quality indicators established by the United States National Kidney Foundation’s Dialysis Outcomes Quality Initiatives (NKF-DOQI) Clinical Practice Guidelines (NKF, 2001). Dialysis quality indicators established by the NKF-DOQI guidelines are: adequacy of dialysis, management of anemia, vascular access management, nutritional adequacy, blood pressure control, and bone disease management. The implementation of clinical practice guidelines and quality indicators has been documented to reduce mortality and improve quality of life for patients on dialysis (NKF, 2001). Quality outcomes are the final results of the processes of care and can include death, hospitalization, infection rates, quality of life, and patient satisfaction with care.
CQI is a process of measuring quality of dialysis care by the outcomes achieved. The NKF-DOQI clinical practice guidelines are an excellent reference on certain expectations of care for dialysis patients, as it provides both process and outcome benchmarks. The Primary Nurse Monthly Summary uses the dialysis quality indicators established by the NKF-DOQI clinical practice guidelines as a frame of reference for the primary nurse in identifying problems and evaluating patient outcomes.
A critical component of the CQI concept is the “empowerment of employees and on the premise that employees have an in-depth understanding of their jobs, believe they are valued, and feel encouraged to improve product or service quality through risk taking and creativity” (Marquis & Huston, 1996, pp. 392-393). CQI has produced, not only improved patient outcomes, but has improved staff morale and retention because of increased empowerment (Wish, 2001).
Quality primary nursing care, in relation to the CQI concept, is then understood as care given by nurses who are knowledgeable and accountable. The continuous education of the primary nurse is one of the objectives of the CQI committee. The Primary Nurse Monthly Summary serves as an educational tool for the primary nurse. By incorporating quality indicators, desired patient outcomes, predictors of complications, and indicators for interventional procedures into monthly patient care review, the Primary Nurse Monthly Summary provides the nurse a template for a comprehensive assessment of each dialysis patient’s needs.
Primary Nurse Monthly Summary
The Primary Nurse Monthly Summary is based on the dialysis quality indicators established by the NKF-DOQI guidelines: adequacy of dialysis, management of anemia, vascular access management, nutritional adequacy, blood pressure control, and bone disease management. As an excellent reference on certain expectations of care for dialysis patients, it provides both process and outcome benchmarks, and it guides the primary nurse in monthly assessments and documentation.
Adequacy of dialysis and access function. The adequacy of dialysis is dependent on a functioning vascular access. Adequacy of dialysis, as measured by percentage reduction urea (PRU), is a reflection of the patency of a vascular access. A PRU of 65% and greater is an indication of adequate dialysis and a well functioning vascular access (NKF, 2001). On the other hand, a PRU measurement of less than 65% or a decrease in PRU from a previous measurement can be an indication of a vascular access problem requiring further investigation.
Other reasons for the decrease in PRU that need to be ruled out by the primary nurse when doing monthly assessments are factors present during the monthly blood measurement not related to vascular access problems. The nurse needs to investigate whether decreased dialysis time, dialyzer clotting related to no-heparin dialysis, or the failure of staff to increase the dialysis machine blood pump to a higher rate play a role in the decrease of PRU measurement.
Regular vascular access surveillance is a responsibility of the primary nurse. Indications of vascular access decline are: cannulation problems, increasing venous pressure noted during dialysis, arterial inflow problems that necessitate decreasing blood flow rate, edema or swelling of the access arm, increased hemostasis time or prolonged bleeding of the needle sites after dialysis, and a decrease in urea clearance as indicated by decreased PRU. Vascular access function decline may further be detected by a Doppler access flow measurement that is less than 600-700 ml/min or a decrease in Doppler access flow from a previous measurement.
The “Adequacy of Dialysis” and “Access Function” components of the Primary Nurse Monthly Summary are useful to the primary nurse in recognizing and documenting early access deterioration. Early access problems need to be reported to the nephrologist for prompt interventional procedures to prevent the loss of permanent vascular access.
Management of anemia. The NKF-DOQI Guidelines make specific process recommendations about the use of iron and EPO. Outcome benchmarks or quality indicators set by the NKF-DOQI (2001) in anemia management are hemoglobin of 110 to 120 g/L; serum ferritin of 100 to 500 ug/L; and iron saturation of .20 to .50 (NKF, 2001). The primary nurse plays an advocacy role by monitoring trends in hemoglobin and iron levels of ferritin and iron saturation and making recommendations to physicians to adjust EPO and iron dosing according to the dialysis unit’s anemia management protocol. In addition, the primary nurse identifies patients who are not responding appropriately to EPO therapy and consults with the physician to determine the etiologies.
Bone disease management and blood pressure control. Bone disease management and blood pressure control are quality indicators that impose a challenge to many dialysis caregivers, as they are greatly dependent on patient adherence to medication, diet regimens, and fluid restrictions. The primary nurse’s role in patient education is emphasized on these areas. In addition, the primary nurse needs to work with the dialysis dietitian in reinforcing health teachings on dietary and fluid restrictions for blood pressure and phosphate control.
Commonly prescribed drugs that necessitate rigorous and repetitive patient education to ensure appropriate management, include vitamin D analogues, phosphate binders, and antihypertensives. However, many patients suffer from gastrointestinal complaints, such as constipation and indigestion, associated with phosphate binders. Patients need to be taught or reminded to take their binders in the prescribed manner, which is with food or meals, and not to take phosphate binders with oral iron.
Primary nurses have a responsibility to provide ongoing teaching and encourage their patients to adhere to the medical regimen. Patients adhere with their prescription therapy if they understand the reason behind the restrictions.
Nutritional adequacy. Studies have shown that morbidity and mortality in hemodialysis patients are influenced by the nutritional state of each individual. Serum albumin is a predictor of patient morbidity and mortality. An adequate serum albumin is defined as greater than 40 g/L (NKF, 2001).
The primary nurse needs to work with the dietitian to explore dietary issues related to adequate protein intake. Many patients find it difficult to maintain adequate nutrition and to comply with the dietary restrictions associated with low phosphorous intake, since foods that are high in protein are also high in phosphorous. Economic and cultural factors influencing adequate protein intake need to be explored with the patient, as they play important roles in the patient’s choice of food and nutritional status.
Holistic care. Holistic care for dialysis patients is made possible by applying Roy’s theory of adaptation. In Roy’s model of adaptation (Roy & Andrews, 1991), dialysis nurses promote patients’ adjustments to challenges related to health and role changes brought on by renal failure and dependence on dialysis. The adjustments, or adaptations, that people make are: physiological, self-concept, role function, and interdependence modes. Dialysis patients have to make adjustments on most or all of these modes.
Coping in the physiological mode may include protecting one’s vascular access. Coping in the self-concept mode may include a dialysis patient thinking that he is strong enough to recover from a traumatic event. Coping in the role function mode is a dialysis patient taking a leave of absence during the acute phase of illness. Coping in the interdependence mode is a dialysis patient increasing his or her dependence on other people during the time of illness.
Primary nurses assess patient behavior as either an adaptive behavior or as an ineffective response. According to Roy, the goal of nursing is to promote adaptation by maintaining adaptive responses and converting ineffective responses to adaptive ones (Roy & Andrews, 1991). In this regard, past coping mechanisms and other resources need to be explored with the patient. More importantly, the patient’s desires and perceptions need to be taken into account when assessing a response as adaptive or as ineffective, bearing in mind the economic, social, and cultural issues influencing a particular situation.
The development of the Primary Nurse Monthly Summary form provides a systematic approach to comprehensive monthly assessment and documentation. The documentation provides a systematic overview of important processes that affect patient care such as: patient’s access function, adequacy of dialysis, anemia management, patient’s nutritional albumin level, blood pressure, and phosphorous control. Using this form to record assessments and findings can identify trends for timely interventions and referral and improve patient outcomes.
Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44(3), 166-203.
Marquis, B., & Huston, C. (1996). Leadership roles and management functions in nursing: Theory and application. Philadelphia: Lippincott.
National Kidney Foundation (NKF). (2001). K/DOQI clinical practice guidelines for chronic kidney disease: Update 2000. American Journal of Kidney Diseases, 37(Suppl. 1).
Roy, C., & Andrews, H.A. (1991). The Roy adaptation model. The definitive statement. Norwalk, CT: Appleton and Lange.
Wish, J.B. (2001). Quality and accountability in the ESRD program. Advances in Renal Replacement Therapy, 8(2), 89-94.
Margarita P. Ilumin, MSN, RN, CNN, is Director of Nursing, Dialysis Clinics, Inc., Sacramento, CA. She recently completed a Masters Degree in Nursing at D’Youville College, Buffalo, NY. She is a member of ANNA’s Great Lakes Chapter.
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