No Place Like ehome. Anna Gozdzik. Contributors: Zita Abreu Jovina Bachynski Cyndi Bhola

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1 No Place Like ehome Anna Gozdzik Contributors: Zita Abreu Jovina Bachynski Cyndi Bhola

2 ENABLE HOME OPTIMIZATION, MANAGEMENT AND EDUCATION

3 Objectives Principle of shared decision-making Evolution of ehome ehome team structure and process Strategies Femoral catheters egraft Bedside PD catheter Dialysis Start Unit Current state Lessons learned

4 Patient Centered Care 1988 Picker Institute coined term patientcentered care shift focus away from diseases and back to patient and family Care that is respectful of patient preferences and values ensures that values guide all clinical actions Shared decision making - the pinnacle of patient centered care Barry and Edgman-Levitan, 2012

5 Shared Decision Making in ESRD Involves clinician and patient Patients are encouraged/supported to consider options (benefits/harms) in order to achieve informed preferences (Elwyn, Frosch, et al., 2012; Elwyn, Dehlendorf et al., 2014) GOAL: To arrive at a quality decision that is informed by a broad range of evidence and patient values (Murray, Bissonnette, Kryrowuchko, Gifford, and Calverley, 2013)

6 Shared Decision Making Model Elwyn, Frosch, et al., 2012

7 Shared Decision Making 2 major challenges for professional wishing to implement SDM approach: 1. Acquisition of a range of interpersonal skills, underpinned by a positive attitude towards the concept 2. Knowledge about the existence of the legitimate choices and access to technical information about the associated harms/benefits of options Elwyn, Edwards, Kinnersley, and Grol, 2000

8 Reaching a Cool State: Patient V 54 male, CKD stage IV (HTN) general nephrology clinic, admitted Aug 2015 (AKI) PMHx: HTN and previous 30 p.y. smoking Very overwhelmed emotional intensity of high stakes medical situations may lead to cognitive overload (Rosenbaum, 2015) Achieve cool/calm state: (1) skilled clinicians attending to patients emotions and lived experience; (2) decision aids/tools slow down decision process

9 Evolution of ehome Unintentionally working in silos towards a common goal

10 Consequences of IJ CVC CVC CV stenosis CV stenosis CVC No fistula

11 Urgent Start Dialysis Patients Little or no planning Acute: In-hospital Acute: Previously Unknown ER 20-40% Acute on known chronic HD (VASPRO, 2015) (Hughes et al., 2013; Watson, 2008)

12 Initiatives New start hemodialysis unit Innovation room Bedside PD catheter insertions Dedicated nephrologist for vascular access egraft to avoid the use of CVC Femoral catheters to save the arm veins

13 Patients Starting HD with CVC from CKD Clinic 80% 70% 60% 68% 50% 40% 43% 30% 20% 10% 22% 21% 21% 0%

14 ehome Team Patient

15 Structure Multidisciplinary weekly rounds Collaboration 45 minute meeting facilitated by nurse navigator Patient discussions

16 Process Scope New start dialysis patients (incident), current HD patients (prevalent), unknown CKD patients Steps Clinician identifies a patient who needs urgent dialysis. Goals Non-tunneled femoral catheter inserted by fellow Tunneled femoral catheter inserted by IR PD catheter (Surgical, bedside) Educate all patients about modality options, including access, with focus on home options Focus on decreasing the use of internal jugular CVC Ensure health equality

17 Algorithm for Urgent Start Nonreversible Renal Failure Patients Patient identified in AM Report as needing dialysis In- Centre HD Palliative Nurse navigator assesses if patient is a candidate for home dialysis & provides dialysis education Pt goes for PD & HHD tour NO VAC arranges fistula/graft/ femoral line Undecided Decided

18 Algorithm for Urgent Start Nonreversible Renal Failure Patients Undecided Decided Dialysis Start Unit PD or VA coordinator referral PD or VA coordinator referral HHD Unit PD Unit PD Unit HHD Unit In- Centre HD

19 Strategy to Avoid Internal Jugular CVC These patients could be: a PD candidate OR a HD candidate with an alternate access (i.e., non-catheter) Emphasizes that indeed, catheter IS temporary Preserves thoracic veins for later AVF/ AVG

20 J Vasc Access, 2014, 15(Suppl 7) Safe, well-tolerated, effective temporary access

6% (IJ) vs 1.1% (fem) No difference in rate of bacteremia: 2.3/1000 days (IJ) vs 1.

21 RCT Evidence: Cathedia Study Parienti et al., 2008, JAMA, 299(20) mechanical complications in IJ vs femoral CVC: e.g., hematoma 3.6% (IJ) vs 1.1% (fem) No difference in rate of bacteremia: 2.3/1000 days (IJ) vs 1.5/1000 (fem) No significant difference in catheter dysfunction and URR: 50.8% (fem) vs 52.8% (jugular) Crit Care Med, 2010, 38(4)

significant difference between fem and IJ in cath colonization, CRBSI, and

22 Meta-Analysis and Systematic Review No significant difference in rate of CRBSI and DVT between femoral and subclavian/ij sites Crit Care Med, 2010, 40(8) No significant difference between fem and IJ in cath colonization, CRBSI, and thrombotic complications Fewer mechanical complications in fem venous access Cochrane Syst Rev, 2012, 40(8)

23 Urgent Start Outcomes Transition from femoral catheter

24 egraft 40 inserted, 3 failed 1 removed for infection 2 thrombosed Patients avoided IJ CVC insertion by having egraft placed

25 PD Catheter Insertions January 2013 to December % urgent unknown 40% urgent known 32% (n=49) 68% (n=101) laparoscopic bedside

26 Bedside PD Results 50% 45% 40% Primary failure rate: 28% (bedside) vs 4% (laparoscopic) 44% 37% 35% 30% 25% 20% 15% 10% 5% 0% 6%

27 Dialysis Start Unit (DSU) New start dialysis unit Isolated 2 HD & 2 PD stations 72 patients to date Staffed by PD unit nurses and 1 HHD nurse Nurses well informed and experienced

28 DSU Outcomes 60% 50% 40% 30% 20% 10% 0% Home modality Facility based HD Recovered kidney function

29 Provincial Data

30 Activity of Acute Patients 25% 20% 15% 10% 5% 0%

31 Modality Selection of Acute Patients 60% 41% chose home based modality > provincial target of 40% 50% 40% 30% 20% 10% 0% IC-HD PD HHD

32 Lessons Learned Strong leadership Commitment and shared vision from all members Mandatory weekly meetings Successful communication Data collection

33 Bibliography Barry, M. J. and Edgman-Levitan, S. (2012). Shared decision-making The pinnacle of patient-centered care. New England Journal of Medicine, 366, Elwyn, G., Dehlendorf, C., Epstein, R. M., Marrin, K., White, J., and Frosch, D. L. (2014). Shared decision making and motivational interviewing: Achieving patient-centered care across the spectrum of health care problems. Annals of Family Medicine, 12(3), ). Elwyn, G., Frosch, D, Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Barry, M. (2012). Shared decision-making: A model for clinical practice. Journal of General Internal Medicine, 27(10), Elwyn, G., Edwards, A., Kinnersley, P., and Grol, R. (2000). Shared decision making and the concept of equipoise: The competencies of involving patients in healthcare choices. British Journal of General Practice, 50(460), Ge, X., Cavallazzi, R., Li, C., Pan, S. M., Wang, Y. W., and Wang, F.-L. (2012). Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database of Systematic Reviews, issue 3. Art. No.: CD DOI: / CD pub3

34 Bibliography Gravel, K., Legare, F., and Graham, I.D. (2006). Barriers and facilitators to implementing shared decision-making in clinical practice: A systematic review of health professionals perceptions. Implementation Science, 1: 16. Hingwala, J., Bhola, C., Lok, C. E. (2014). Using tunneeld femoral vein catheters for urgent start dialysis patients: A preliminary report. Journal of Vascular Access, 15(Suppl. 7), Hughes, S.A., Mendelssohn, J.G., Tobe, S.W., McFarlane, P.A., & Mendelssohn, D.C Factors associated with suboptimal initiation of dialysis despite early nephrologist referral. Nephrology Dialysis Transplant, 28, Mehrotra, R., Marsh, D., Vonesh, E., Peters, V., and Nissenson, A. (2005). Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney International, 68, Murray, M. A., Bissonnette, J., Kryworuchko, J., Gifford, W. and Calverley, S. (2013). Whose choice is it? Shared decision making in neprology care. Seminars in Dialysis, 26(2),

35 Bibliography Parienti, J.-J., Thirion, M., Megarbane, B., Souweine, B., Ouchikhe, A., Polito, A., Charbonneau, P., (2008). Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy A randomized controlled trial. Journal of the American Medical Association, 299(2), Parienti, J.-J., Megarbane, B., Fischer, M.-O., Lautreette, A., Gazui, N., Marin, N., du Cheyron, D. (2010). Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: A randomized controlled study. Critical Care Medicine, 38(4), Rosenbaum, L. (2015). The paternalism preference Choosing unshared decision making. New England Journal of Medicine, 373(7), VASPRO (2015). University Health Network Vascular Access Database. Watson, D. (2008). Post-dialysis pre-dialysis care: The cart before the horse Advanced practice nurse intervention and impact on modality selections. The CANNT Journal, 18(1),

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