Alison Thomas

A systematic review of factors influencing decision-making in adults living with chronic kidney disease

OBJECTIVE To identify factors influencing patient involvement in decision-making in the context of chronic kidney disease (CKD) and effective interventions to support their decision-making needs. METHODS A systematic review included studies and decision support tools that involved: (1) adults with CKD, (2) studies published from 1998-2008; and (3) a focus on patient decision-making needs, and/or barriers and facilitators to shared decision-making. Studies were quality appraised. RESULTS Forty studies were appraised. These studies mainly focused on the decisions patients with CKD faced around the choice of renal replacement therapy and withholding/withdrawing dialysis. Moreover, studies typically focused on health care professionals provision of information about the decision rather than identifying decisional conflict and supporting patients in decision-making. No studies were found that identified the patients point of view about factors that might influence or inhibit quality decision-making. Factors influencing CKD patients participation in decision included: (1) interpersonal relationships; (2) preservation of current well being, normality and quality of life; (3) need for control; and (4) personal importance on benefits and risks. Of the four patient decision aids identified, none had been evaluated for effectiveness. CONCLUSION Patients with CKD face decisions that are likely to cause decisional conflict. Most studies focused on information needs related to renal replacement therapy and withdrawing or withholding dialysis. There was less focus on other decision-making needs in the context of those choices and across the trajectory of CKD. Although patient decision aids and implementation of shared decision-making have been evaluated in patients with other medical conditions, little is known about interventions to support patients with CKD making quality decisions. PRACTICE IMPLICATIONS Patients with CKD have decision-making needs across the trajectory of their illness. Although little is known about supporting patients with CKD decision-making, support could be provided with protocols and tools that have been developed for other chronic illness situations. Development of CKD-specific clinical practice guidelines that include decision support best practices could benefit CKD patients. Research priorities include development and evaluation of CKD focused decision support tools and processes.

How to Begin a Quality Improvement Project

Quality improvement involves a combined effort among health care staff and stakeholders to diagnose and treat problems in the health care system. However, health care professionals often lack training in quality improvement methods, which makes it challenging to participate in improvement efforts. This article familiarizes health care professionals with how to begin a quality improvement project. The initial steps involve forming an improvement team that possesses expertise in the quality of care problem, leadership, and change management. Stakeholder mapping and analysis are useful tools at this stage, and these are reviewed to help identify individuals who might have a vested interest in the project. Physician engagement is a particularly important component of project success, and the knowledge that patients/caregivers can offer as members of a quality improvement team should not be overlooked. After a team is formed, an improvement framework helps to organize the scientific process of system change. Common quality improvement frameworks include Six Sigma, Lean, and the Model for Improvement. These models are contrasted, with a focus on the Model for Improvement, because it is widely used and applicable to a variety of quality of care problems without advanced training. It involves three steps: setting aims to focus improvement, choosing a balanced set of measures to determine if improvement occurs, and testing new ideas to change the current process. These new ideas are evaluated using Plan-Do-Study-Act cycles, where knowledge is gained by testing changes and reflecting on their effect. To show the real world utility of the quality improvement methods discussed, they are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis). This provides an example that kidney health care professionals can use to begin their own quality improvement projects.

A patient-focused approach to thrombolytic use in the management of catheter malfunction.

Thrombus‐related catheter malfunction is a significant problem for catheter‐dependent dialysis patients. The primary medical intervention is the local luminal installation of thrombolytic agents (TLAs). There are three major TLA installation methodologies: locking, push, and infusion protocols. A systematic literature review of existing TLA protocols for treating dialysis catheter malfunction was performed using the PubMed and EMBASE (Drugs and Pharmacology) databases from the time of each databases inception to August 2005. Thrombolytic administration was then categorized according to the patients clinical need: (1) an acute/immediate requirement, such as when malfunction prohibits dialysis initiation, and (2) rescue therapy, such as when the thrombus threatens to significantly impair current or subsequent dialysis clearance. Published TLA protocols are discussed in the context of their clinical requirement (acute or rescue therapy). A unifying clinically relevant management algorithm that considers the etiology of catheter malfunction as being thrombus related or not, and an approach to TLA use based on clinical presentation is described. This algorithm was developed after a systematic review of the literature. The application of this treatment algorithm requires prospective validation and study.

How to Sustain Change and Support Continuous Quality Improvement

To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).

How to Diagnose Solutions to a Quality of Care Problem

To change a particular quality of care outcome within a system, quality improvement initiatives must first understand the causes contributing to the outcome. After the causes of a particular outcome are known, changes can be made to address these causes and change the outcome. Using the example of home dialysis (home hemodialysis and peritoneal dialysis), this article within this Moving Points feature on quality improvement will provide health care professionals with the tools necessary to analyze the steps contributing to certain outcomes in health care quality and develop ideas that will ultimately lead to their resolution. The tools used to identify the main contributors to a quality of care outcome will be described, including cause and effect diagrams, Pareto analysis, and process mapping. We will also review common change concepts and brainstorming activities to identify effective change ideas. These methods will be applied to our home dialysis quality improvement project, providing a practical example that other kidney health care professionals can replicate at their local centers.

Development of a hemodialysis safety checklist using a structured panel process

BackgroundThe World Health Organization created a Surgical Safety Checklist with a pause or “time out” to help reduce preventable adverse events and improve communication. A similar tool might improve patient safety and reduce treatment-associated morbidity in the hemodialysis unit.ObjectiveTo develop a Hemodialysis Safety Checklist (Hemo Pause) for daily use by nurses and patients.DesignA modified Delphi consensus technique based on the RAND method was used to evaluate and revise the checklist.SettingUniversity-affiliated in-center hemodialysis unit.ParticipantsA multidisciplinary team of physicians, nurses, and administrators developed the initial version of the Hemo Pause Checklist. The evaluation team consisted of 20 registered hemodialysis nurses.MeasurementsThe top 5 hemodialysis safety measures according to hemodialysis nurses. A 75% agreement threshold was required for consensus.MethodsThe structured panel process was iterative, consisting of a literature review to identify safety parameters, individual rating of each parameter by the panel of hemodialysis nurses, an in-person consensus meeting wherein the panel refined the parameters, and a final anonymous survey that assessed panel consensus.ResultsThe literature review produced 31 patient safety parameters. Individual review by panelists reduced the list to 25 parameters, followed by further reduction to 19 at the in-person consensus meeting. The final round of scoring yielded the following top 5 safety measures: 1) confirmation of patient identity, 2) measurement of pre-dialysis weight, 3) recognition and transcription of new medical orders, 4) confirmation of dialysate composition based on prescription, and 5) measurement of pre-dialysis blood pressure. Revision using human factors principles incorporated the 19 patient safety parameters with greater than or equal to 75% consensus into a final checklist of 17-items.LimitationsThe literature review was not systematic. This was a single-center study, and the panel lacked patient and family representation.ConclusionsA novel 17-item Hemodialysis Safety Checklist (Hemo Pause) for use by nurses and patients has been developed to standardize the hemodialysis procedure. Further quality improvement efforts are underway to explore the feasibility of using this checklist to reduce adverse events and strengthen the safety culture in the hemodialysis unit.AbrégéContexteL’Organisation mondiale de la Santé a mis au point une liste de contrôle de la sécurité chirurgicale offrant ainsi la possibilité de faire une pause ou de « prendre du temps » pour réduire les effets indésirables qui sont prévisibles et pour améliorer la communication. Un outil similaire pourrait améliorer la sécurité du patient et diminuer la morbidité associée au traitement sur un service d’hémodialyse.Objectif de l’étudeMettre au point une liste de contrôle de la sécurité en hémodialyse (Hemo Pause) pour utilisation quotidienne, à l’intention des infirmières et des patients.Type d’étudeL’évaluation et la révision de la liste de contrôle ont été effectuées avec une version modifiée de l’outil de construction de consensus Delphi, basée sur la méthode RAND.Contexte de l’étudeService de dialyse affilié à un centre universitaire.ParticipantsLa version initiale de la liste de contrôle de sécurité Hemo Pause a été mise au point par une équipe multidisciplinaire comprenant médecins, infirmières et personnel administratif. L’équipe d’évaluation de l’outil était formée de 20 infirmières autorisées œuvrant en hémodialyse.MesuresLes 5 mesures de sécurité les plus importantes, selon les infirmières en hémodialyse. Un seuil d’entente de 75% était requis pour le consensus.MéthodesLa méthode d’appel au panel s’est effectuée de façon itérative. Celle-ci consistait en: une revue de la littérature afin de faire ressortir les paramètres de sécurité; l’attribution, par le panel d’infirmières en hémodialyse, d’une valeur pour chacun des paramètres; une réunion de concertation de groupe durant laquelle le panel a raffiné les paramètres, et, finalement, d’un questionnaire anonyme visant à évaluer le consensus atteint par le panel.RésultatsLa revue de la littérature a fait ressortir 31 paramètres de sécurité des patients. La revue individuelle faite par les membres du panel a réduit cette liste à 25 paramètres, puis celle-ci a été de nouveau réduite à 19 lors de la réunion de concertation de groupe. L’évaluation finale s’est soldée sur les 5 mesures de sécurité les plus importantes suivantes: 1) la confirmation de l’identité du patient; 2) la mesure du poids du patient avant la dialyse; 3) la vérification de nouvelles prescriptions et leur retranscription; 4) la confirmation de la composition du dialysat avec la prescription, et 5) la mesure de la pression artérielle avant la dialyse. Utilisant des principes concernant des facteurs humains, une révision des 19 paramètres de sécurité des patients avec un consensus plus grand ou égal à 75% a permis d’établir une liste de contrôle finale de 17 items.Limites de l’étudeLa revue de la littérature n’était pas systématique. Cette étude s’est déroulée en un seul centre; de plus, le panel ne représentait ni le patient ni sa famille.ConclusionsUne liste de contrôle de la sécurité en hémodialyse (Hemo Pause) a été mise au point afin de standardiser les traitements d’hémodialyse. Des efforts poussés d’amélioration de la qualité sont en branle afin d’explorer la faisabilité de l’utilisation de cette liste de contrôle innovatrice pour réduire les occurrences d’événements indésirables, et renforcer la vigilance sur les services d’hémodialyse.

Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study

Background Patients with end-stage renal disease are at high risk for medical errors given their comorbidities, polypharmacy and coordination of care with other hospital departments. We previously developed a hemodialysis safety checklist (Hemo Pause) to be jointly completed by nurses and patients. Our objective was to determine the feasibility of using this checklist during every hemodialysis session for 3 months. Methods We conducted a single-center, prospective time series study. A convenience sample of 14 nurses and 22 prevalent in-center hemodialysis patients volunteered to participate. All participants were trained in the administration of the Hemo Pause checklist. The primary outcome was completion of the Hemo Pause checklist, which was assessed at weekly intervals. We also measured the acceptability of the Hemo Pause checklist using a local patient safety survey. Results There were 799 hemodialysis treatments pre-intervention (13 January–5 April 2014) and 757 post-intervention (5 May–26 July 2014). The checklist was completed for 556 of the 757 (73%) treatments. Among the hemodialysis nurses, 93% (13/14) agreed that the checklist was easy to use and 79% (11/14) agreed it should be expanded to other patients. Among the hemodialysis patients, 73% (16/22) agreed that the checklist made them feel safer and should be expanded to other patients. Conclusions The Hemo Pause safety checklist was acceptable to both nurses and patients over 3 months. Our next step is to spread this checklist locally and conduct a mixed methods study to determine mechanisms by which its use may improve safety culture and reduce adverse events.