Immediate Start Peritoneal Dialysis Is It Really an option? Gerry Endall PD Nurse Specialist 16 TH March 2016

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1 4/12/2016 Page 1 Immediate Start Peritoneal Dialysis Is It Really an option? Gerry Endall PD Nurse Specialist 16 TH March 2016

2 4/12/2016 Page 2 Do we really need that option?

3 Peritoneal Dialysis is a well established complementary alternative to Haemodialysis as a first line renal replacement modality Van Biesen W, Vanholder R, Larneve N, The role of peritoneal dialysis as a first line renal replacement Modality PDI 2000; 20:375-83

4 What deems to be good practice? Catheters being inserted in a timely manner (1 & 2) Catheter insertion performed within 2 weeks and 24 hours for an urgent start before commencing dialysis (1 & 2)

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8 Why do Immediate starts? No decision about me without me Patients to have access to the treatment of their choice.

9 The evidence Studies have indicated that PD may offer an initial survival advantage, particularly in non diabetics and younger diabetic patients (6) Preservation of vascular access (7) Better outcomes after renal transplantation(8) Lower risk of infection with hepatitis B&C (9) Circumvents the need for temporary Haemodialysis

10 And it goes on... There are believers and non believers There are no RCT,s to really distinguish between HD and PD. There are quality of life studies suggesting a better quality of life up to and after one year (10)

11 Utilize Immediate Start Peritoneal Dialysis This gives exposure to the programme. Initiates an evidence based treatment. Gains experience in areas of treatment that may not have been undertaken. Increases home therapy profile Home therapies are cost effective compared with in-centre (5).

12 4/12/2016 Page 12 Implementation of Immediate start Peritoneal Dialysis To make immediate starts work you require: PATIENT EDUCATION AT TIME OF ADMISSION PD TEAM FACILITATE CATHETER ACCESS SELDINGER TECHNIQUE/RAPID LIST SURGICAL EMERGENCY LIST NEPHROLOGIST+PD NURSE SURGEON + THEATRE TIME/STAFF INTIATION OF PERITONEAL DIALYSIS BY PD TEAM THE USE OF AN EVIDENCE BASED PROTOCOL DAILY REVIEW WITH THE PD TEAM GOOD EDUCATION AND SUPPORT TO WARD & MEDICAL TEAMS PD CHAMPIONS BAXTER PD AND ACCESS ACADEMY (NEPHROLOGISTS) THE USE OF CARDS TO INSTIGATE PRESCRIPTION CLEARFLEX FOR LESS CONNECTIONS GOOD PRESCRIPTION CHART FOR RESULTS (SEE CHART) MAINTAINING A POOL OF APD MACHINES

13 Implementing Immediate start dialysis Requires A Unique Infrastructure and Treatment Approach Outreach Pathway Standard Operating Procedure. Access Logistics of starting Peritoneal dialysis - time of day Ability to provide Assisted Automated Peritoneal Dialysis. Training schedules. Equipment and ancillaries ( deliveries Weekly) A single procedure for Immediate and long term Access

14 Patient Criteria/Selection Each unit must decide there own selection criteria Electrolyte imbalance upper and lower limits Fluid balance Albumin upper and lower limits Selection for surgical or Percutaneous insertion. Each patient should be a case by case.

15 PD Nurses role Initiate education and support at the initial stages. Training of nursing staff and nephrologists How to instigate rapid access routes surgical/percutaneous Equipment and supplies, range of catheter sizes, ready to go Percutaneous packs. The Pathway refers patients to the PD Team, This initiates the flow of Treatment.

16 PD Nurses role Continued Pre-clerking to include (preparing for band 7 to clerk patients) Prescription of laxatives or use of PGD,s Prophylactic antibiotics for percutaneous - PGD,s. Cannulation to aid the patient flow. Prescription for immediate start along side SOP.

17 Immediate Start Overview Day 1 3 Day 4 6 Day 7 10 Dwell Volume 1.2l 1.5l 1.5 2l Dwell Time 60 min 90 min 120 min Fluid Clearflex 1.36% Balance 1.5% Clearflex 1.36% Balance 1.5% Clearflex 1.36% Balance 1.5% Immediate Start APD protocol (adapted from Povlsen and Ivarsen, 2006 nephrology Dialysis Transplantation

18 Prescription Chart to monitor Treatment regimens Addressograph Label: Date Time Date Time Date Time Date Time Date Time Date Time Date Time Total Volume: Therapy Time: Dialysate / Strength: Batch Number: Expiry Date: Fill Volume: Dwell Time No. of Cycles: Last Fill: Batch No. / Expiry Date Tidal % Volume: Additives: Doctors Signature PD Entry & Exit Site Check: Initial Drain Volume: Total UF: Lost Dwell: Appearance: Nurses Signature: Additives CODING Type of Fluids H Heparin D Dianeal V Vancomycin P Physioneal G Gentamicin E Extraneal K+ Potassium N Nutrineal I Insulin F Fresenius B Balance C Clearflex

19 clear flex 5L bag for ease balance 5L bag By kind permission of Baxter Healthcare Corporation

20 By kind permission of Baxter Healthcare Corporation and Fresenuis Medical Care

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23 4/12/2016 Page 23 PATHWAY INSTRUCTIONS FOR USE: Pathway begins in low-clearance clinic when the patient requires a Home Assessment.. The pathway continues through to initiation of training and independence on Dialysis. This pathway was written to direct care for the majority of patients requiring peritoneal dialysis catheter insertion This pathway is not cast in stone. Use your professional judgement to decide whether it is appropriate to follow or deviate from it. However, if the patient deviates from the pathway, please record this as a variance and clearly state a rationale and action plan. CRITERIA FOR USE: Any patient referred for peritoneal dialysis (PD) catheter insertion including: Medical or surgical insertion New catheter Replacement catheter Immediate start Peritoneal Dialysis. GOALS OF CARE The patient receives optimal care prior to and following PD catheter insertion Patient safety is maintained Patient progresses along the pathway for timely commencement of renal replacement therapy (RRT) Patient receives education and self management skills To promote and ensure standardisation and continuity of care across disciplines.

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26 Training Staff PD Champions PD staff to be visible. Yearly training in CAPD /APD Nursing secondment from all areas of Renal.( 8 weeks) All new staff attend the unit for 1 week. Picture books and troubleshooting book with each machine. Machine left ready to go with prescription, fluids and equipment On call PD staff to advise or be called in

27 Access PD team responsible for Percutaneous delivery (Ready to go pack) Cannulation for IV Access PD nurse trained as anaesthetic nurse, responsible for assessing, monitoring, and delivering anaesthetic during the procedure. Drug of choice (FENTANYL). Conscious sedation protocol. 3 day interventional list to upgrade to 5 day cover including nurse insertions

28 Cost friendly to the Trust Does patient require inpatient stay? Utilize day ward beds for Procedures. Surgical beds. Cost pressures - surgical v Percutaneous The instigation of Aapd to assist early discharge.

29 conclusion Immediate start peritoneal dialysis can enhance patient choice. It is a safe and feasible option for patients, who might otherwise transfer to haemodialysis. This concept can enhance the patients quality of life. It can also promote a home therapy programme and may help to penetrate and raise the profile of PD not only as a dialysis option but as an option for immediate start.

30 References specification for the commissioning of peritoneal dialysis pathway 2. Preparation for peritoneal dialysis, Renal association The Renal Association, 12 th Annual Report Patient pledge, Liberating the NHS, NHS Kidney Care Baboolal K, McEwan P, Sondhi S, Spiewanowski P, Wechowski J and Wilson K, The cost of renal dialysis in a UK setting a multicentre study. Nephrology Dialysis Transplantation, 2008; 23: Van Biesen W, Van Holder R, Lamere N, The Role of Peritoneal Dialysis as a first line Renal replacement Modality, PDI 2000; 20: Hakim R, Himmelfarb J, Haemodialysis access failure: a call to action. Kidney international, 1998; 54: Heaf J G, Lokkegaard H, Madsen M, Initial Survival Advantage of Peritoneal Dialysis Relative to Haemodialysis. Nephrology Dialysis Transplant 2002; 17: Liem Y S, Wong J B, Hunink N G et al, Comparison of Haemodialysis and Peritoneal Survival in the Netherlands. Kidney International 2007; 71: Cendoroglo M, Draibe S, Silva A et al, Incidence and Risk Factors for Hepatitis B and C Virus Infection among Haemodialysis and CAPD Patients. Nephrology Dialysis Transplant 1995; 10: Kutner N, Zhang R, Barnhart H, Collins A, Health status and quality of life reported by incident patients after 1 year on HD or PD. Nephrology Dialysis Transplant ion 2005; 20:

31 4/12/2016 Page 31 References Povlsen (2014) Nephrology dialysis and transplantation Can Peritoneal Dialysis of be applied to unplanned initiation of Chronic Dialysis Ghaffari A, Kumer V, guest S (2013) Infrastructure requirements for a urgent start Peritoneal Dialysis Programme International society of peritoneal dialysis guidelines Peritoneal dialysis for acute kidney injury (August 2014)volume 34 NO Baxter PD Healthcare (2010) Healthcare Information Pack: Practical tips for training APD, Patients on Homechoice with Physioneal Clear-flex Renal Association (2010) Clinical practice guidelines for Peritoneal Dialysis Renal Association (2009) Clinical practice guidelines for Peritoneal Access NHS Kidney Care (2010) Speciation for the commissioning of Peritoneal Dialysis Pathway Jo, Y., Shin, S, K., Lee, J,H., Song, J,O., Park, J, H. (2007) Immediate initiation of CAPD following percutaneous catheter placement without break-in procedure. Peritoneal Dialysis International. Vol 27 pp Povlsen, J, V., Ivarsen, P. (2006) How to start the late referred ESRD patient urgently on chronic APD. Nephrology Dialysis and Transplantation.Vol 21, Sup 2, pp Wiles, K., Uniacke M., Borman, N., Todd, M., Endall, G., Gibbs, P., Macanovic, J. (2010) Acute peritoneal dialysis experience

32 Never believe that a few caring people can t change the world, for indeed that s all who ever have. Margaret Mead - Anthropologist