Money or Patient well-being

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1 John A. Navis President, Janin Group Inc TEL: CELL: Money or Patient well-being Continual decisions by you and everyone involved focusing on the goal of patient well-being

2 Percent of Patients Choosing PD Stephenson et al. Prichard Schreiber et al. Korevaar et al. Rodd et al. (N = 150) 1 (N = 74) 2 (N = 5,065) 3 (N = 735) 4 (N = 256) 5 by Nephrologists Nephrology trainees are not trained adequately in PD and are not comfortable recommending it as a modality. 29% of USA training programs could not provide their fellows with the experience of at least 5 PD patients 57% of USA training programs could not provide experience with at least 10 PD patients Data from Issues and Economics of Dialysis Therapies, Amilar Exume MD, PD University, Nov Stephenson et al. Dial Transplant 1993; 22: , Schreiber et al. Nephrol News Issues 2000; 14:44, Prichard. Perit Dial Int 1996; 16: Korevaar et al. Kidney Int 2003; 64: Rodd et al. Perit Dial Int 2004; 24:S26. 7 Data from Issues and Economics of Dialysis Therapies, Amilar Exume MD, PD University, Nov 2013 Nephrologists need to be committed and receive appropriate training. 8 by Nurses Nurses need to be committed: To get the training they need in order to guide the PD patient in their self-care To be willing to take patient calls at awkward hours, including evenings and weekends To team up with the nephrologist to solve any patient issues that affect the success of the PD therapy 9 HD is: Procedure oriented Patient passive Comes in Sits down Tubing attached Wait 2-4 hrs Go home Problem predictable PD is: Messy patient oriented 7-10 day training & then home Patient active in own care No direct supervision Delayed problem reporting Possible hospitalization because someone erred Ensure your nurses are committed to PD for the well-being of their patients. 10 by Surgeons 85-87% of PD catheters are implanted by surgeons with inadequate training. 86% of surgical residents placed 10 catheters or less during training. * Surgeons need to recognize: The catheter is the first step of a life-support system The catheter style and size is important Where and when and how it is implanted all affect the long-term survival of the catheter *data from Wong, et al, Clinical Journal of the American Society of Nephrology, 2010, 5: Find surgeons who are committed to PD and willing to get trained on best practices for the implantation of the catheter. 11 to Policies & Procedures Samples available from: CMS Renal Physicians Association ASDIN ASN ISPD PDI Magazine Corporations: Baxter, Fresenius, Merit Medical 12 2

3 Two Cautions: 1.Not everything written will work for your program. Read, study, pick, and choose. 2.These organizations have already committed themselves to the growth and success of PD. They cannot commit for you. 13 does not cost; Lack of commitment costs much 14 will lead to excellence which results in a successful PD program. for the long-haul Tenacity to follow the policies & procedures Willingness to amend as needed 15 Two great resources that define excellence in a successful PD program: PD Access Guide 2012 published by Baxter Corp John Crabtree MD, Beth Pirano MD, Steven Guest MD, Catherine Firanek BSN, MBA Peritoneal Dialysis & the Process of Modality Selection, Peter Blake MD, Robert Quinn MD, Matthew Oliver MD, PDI Vol 33 No 3, 2013, pages Your persistence in striving for excellence results in: Meeting or exceeding patient s expectations Growth of the PD Program Decreased complications 17 Be persistent to do all the little things well. Pay attention to the details, such as: Make sure the patient is marked to determine the best size and style of catheter. Make sure the catheter is inserted at the correct angle and that the coil is in the optimum location. Do not cut the rectus muscle; puncture and dilate instead. Do not use a suture at the exit-site. Make sure the patient understands his responsibility for catheter care. Follow-up, over and over. 18 3

4 Be persistent to: Understand the policies Follow the procedures Adapt the policies and procedures as needed Ask What happened? Ask Why did it happen? 19 Lead your committed team nephrologist, nurse, surgeon To strive for excellence To meet and exceed patient expectations To exceed national standards Be persistent be steadfast be tenacious endure for the long-haul for the patients well-being and the success of your program. 20 If your PD program is to succeed, you must insist on: The best analytical measures The best access procedure The best catheter selection and tools Insist on analytical measures that are systematic and reproducible: Evaluate each patient to see if he is a good candidate for PD therapy. Patient s life-style? Patient s expectations? Home care available? Cognitive skills? Mechanical skills? Cooperativeness? See Dr. Blake s article for 6 major steps as part of this process. Peritoneal Dialysis & the Process of Modality Selection, Peter Blake MD, Robert Quinn MD, Matthew Oliver MD, PDI Vol 33 No 3, 2013, pages Insist on the best access procedure that produces consistently good results. If a catheter is implanted poorly, it will fail. If it is placed using the best demonstrated practices, it will succeed. There are 3 basic implantation methods for PD catheters. Implantation Technique Frequency of Use in U.S. Interventional Radiology or Nephrology 5% Peritoneoscopy 8% Surgical (6 variations) 87%

5 Implantation: Frequency of Use: Complications: Patient Selection: Ancillary Procedures: Interventional Radiology or Nephrology Results at 12 months: 77% * Results at 24 months: 61% * Visualization via Radiology, local anesthesia, uses guide wire with split sheath, done by an interventional radiologist or nephrologist Used for less than 5% of U.S. PD patients Abdominal leaks, occlusions, catheter migration, exit-site infection, exit cuff erosion Very selective, patients without previous surgeries and with low BMI Adhesiolysis and omentopexy are not done * VauxEC, Torrie PH, BarkerLC, Naik RB, GibsonMR. Percutaneousfluoroscopicallyguided placementof peritoneal dialysis catheters--a 10-year experience. Semin Dial Sep-Oct;21(5): Implantation: Frequency of Use: Complications: Patient Selection: Ancillary Procedures: Results at 12 months: 74% * Results at 24 months: 80% ** Peritoneoscopy Uses 2.2mm diameter scope and Y-TEC kit, local anesthesia, 1 puncture, visualize, dilate, insert, done by nephrologist 8% of PD catheter implantations in the U.S. Some catheter migration, occlusions, leaks, & exit-site infections Somewhat selective, limited to patients with no or minor previous surgical procedures, modest BMI Adhesiolysis and omentopexy are not done * Ng E.K., et al, Peritoneoscopic Tenckhoff Catheter Insertion by Nephrologists: Multicenter Analysis of Safety and Effectiveness, PDIAbstracts, Sept 2012, Vol 32, Suppl.3, PageS104 **AshSR. Laparoscopyfor PDcatheterplacement: advantagesanddisadvantagesversusperitoneoscopy. Perit Dial Int Nov-Dec;25(6): Implantation: Frequency of Use: Complications: Patient Selection: Dissection (cut-down) & three laparoscopic variations Surgical, with or without a laparoscope Laparoscopic Y-TEC method Laparoscope + Y-TEC implantation kit Laparoscopic (Dr. Crabtree) Laparoscope with rectus sheath tunneling 87% of PD catheters in the U.S. are implanted by a surgeon. Leaks, occlusions, migration Just about everyone, including those with previous surgeries and high BMI Ancillary Procedures: Usually none Adhesiolysis & Omentopexy can be done. Results (12 months) 40-50% 82%* Results (24 months) (except as noted) Surgical 6 variations Unknown 81% * 96% at 5 years ** * Raw data from Dr. J. Goodman, Univ of AL Birmingham, Feb Data has not yet been reviewed for cause of revision or failure. Data covers 129 procedures over 2 years. ** Crabtree JH, Burchette RJ. Effective use of laparoscopy for long-term peritoneal dialysis access. Am J Surg Jul;198(1): Insist on the best access procedure that produces consistently good results. Find one good surgeon who uses this implantation method, who is well-trained, who implants 3 or more catheters a month, who is committed, persistent, and insistent, and your program will grow rapidly and your patients will have better quality of life Insist on a top-quality catheter placed in the optimum location for the patient. Not all patients are the same size, and therefore each one needs to be measured for the appropriate size and style catheter Photo courtesy of Dr. John Crabtree 5

6 Classic Adult Catheter ARC Adult Catheter ExxTended Catheter Upper Abdomen exit-site ExxTended Catheter Upper Chest exit-site 31 Drawings courtesy of Merit Medical 32 Drawings courtesy of Merit Medical Of the 3 types of PD catheters with 4 exit-site location options, various catheter types, styles, and exit-sites are more appropriate for some patients than others: Best-suited Peritoneal Dialysis Catheter According to Gender and Anthropometric Determinants: Exit-Site Location and Catheter Type Lower Abdomen Exit-Site only: Coiled, permanent preformed angle Middle Abdomen Exit-Site only: Coiled, straight inter-cuff segment Total (n=200) % (n) Female (total n=100) % (n) Male (total n=100) % (n) 21.5% (43) 37% (37) 6% (6) 31% (62) 5% (5) 57% (57) Either Lower or Middle Abdomen Exit-Site 23% (46) 25% (25) 21% (21) Neither Lower nor Middle Abdomen Exit-Site (therefore, Upper Abdomen or Upper Chest) 24.5% (49) 33% (33) 16% (16) Crabtree JH,Burchette RJ,Siddiqi NA. Optimal Peritoneal Dialysis Catheter Type and Exit Site Location: An Anthropometric Analysis. ASAIO J Nov-Dec;51(6): Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl Nov;(103):S How do you know which catheter size and style is right for the individual patient? How do you know which exit site is optimal for him or her? Use a stencil, designed for just that purpose. 34 For Flex-Neck Classic and ARC Catheters

7 1. Insist on analytical measures that are systematic and reproducible. 2. Insist on the best access procedure that produces consistently good results. 3. Insist on a top-quality catheter placed in the optimum location for the patient. 37 : By you, the nephrologist, the PD nurse, and the surgeon to PD with its policies & procedures. : Understand the policies, follow the procedures, and amend as needed for excellence. : On the best analytical measures, on the best access procedure, and on the best catheter and stencil. 38 Patient Questions? 40 John A. Navis President, Janin Group Inc john@janingroup.com TEL: CELL: