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Chronic Kidney Disease (CKD) Special Interest Group (SIG) Networking Session
Sally Campoy
Betsy King, MSN, RN, CNN, is Area Clinical Educator, DaVita, White Plains, NY. She is a member of ANNA’s Northeast Tri-State Chapter.
Debbie Miller, RN, CNN, is Regional Education Manager, Gambro Healthcare, Alexandria, VA. She is a member of ANNA’s Capitol Chapter.
| The
CKD SIG held its first networking session during the ANNA National
Symposium in Las Vegas on April 2005. Two topics were discussed: (a)
how to increase awareness of CKD, and (b) how to set up a CKD program.
This will present the latter. |
Identify Goals for VA Clinic
I shared with the group my experience in setting up the CKD clinic at
the Denver Veterans’ Affairs (VA) Medical Center. In 2000, I met with
the renal physicians to develop a nurse-managed CKD clinic for persons
with CKD stages 3 and 4. I identified my goals for the clinic
that were agreed upon by the physicians. These goals were:
- Promote
referrals to the CKD clinic when the estimated GFR is < 30-35
ml/minute. These referrals came from the other renal clinics in which
renal attending physicians, renal fellows, residents, and/or medical
students had determined the cause of renal disease and established the
diagnosis of CKD.
- Protect
remaining renal function. Efforts to slow the progression to CKD stage
5 included blood pressure control, diabetes control, use of angiotensin
converting enzyme inhibitors or angiotensin receptor blockers, slowing
the rate of proteinuria, and avoiding nephrotoxins.
- Early
recognition and management of complications. Blood pressure control,
diabetes control, anemia, bone disease, nutrition, and electrolyte
imbalances are assessed at each clinic. In addition, a hepatitis B
profile is done so the immunization series can be started prior to
dialysis or transplant. Cardiovascular risk factors are also
addressed, such as smoking cessation and lipid management. The
medication list is reviewed at each clinic visit. Ongoing review of
potential nephrotoxins is also reinforced as indicated in each clinic.
- Prepare
the person for renal replacement therapy. Education sessions on
treatment modalities are offered for each person and his/her support
person{s}.
- End-of-life
issues or palliative care. Some patients opt for no treatment.
Discussion is done with the patient and his/her support person to
review signs and symptoms of end stage renal failure and options for
care, such as hospice.
Why
did we select the CKD management clinic instead of a screening clinic?
The VA has emphasized the estimated glomerular filtration rate (GFR)
rather than serum creatinine. The laboratory now includes the MDRD
calculation along with the serum creatinine value on the lab report.
The collaborative renal team conducted multiple education sessions with
the VA primary care providers on the NKF guidelines of CKD and
interventions in CKD stages 1 and 2. The VA also developed VA clinical
practice guidelines for patients with CKD that included factors for
early nephrology referrals. Criteria included were having an
estimated GFR less than 60 ml/minute, proteinuria greater than 1 gram
per day, and uncontrolled hypertension. With these above interventions,
referrals to the VA renal clinic have increased dramatically, making a
screening clinic unnecessary.
Identify Key Team Members
Key team members were identified in the development phase. In the NP
managed clinic role, I examine the patients, determine the clinical
intervention(s), provide the patient education, and make the referrals.
The NP works collaboratively with the renal physicians and involves
them in the clinic as needed. I review my cases with my chief
collaborating physician on a monthly basis to ensure all aspects of
care are being addressed. The renal and/or outpatient dietician(s) and
renal social worker are part of the team. The outpatient dietician
and/or renal dietician teach diet, e.g. maintain adequate protein,
carbohydrate counting for diabetes, low sodium, low potassium (if
indicated), low cholesterol, and/or weight loss (if indicated). Either
dietician is involved, based upon her availability. The renal social
worker counsels persons with adjustment problems to chronic disease
when self-care is compromised and makes dialysis referrals in the
community. The social worker performs the social work evaluations for
kidney transplant candidates.
Organize Education Program
The
education program is done in two sessions. The first usually occurs
during the clinic appointment, especially during the first visit to the
CKD clinic. This includes the strategies to delay progression to CKD
stage 5. By the time the person comes to the CKD clinic, he/she may
have no idea of his advanced kidney disease or is overwhelmed with the
information. Giving the person some strategies that can immediately be
implemented will give him/her a better sense of control. Some persons
will “see the light” and institute interventions to delay progression,
e.g., improve medication compliance or quit smoking.
This information is reinforced at each clinic visit, such as “You did a
great job getting your blood pressure below 130/80. How are you doing
on your diabetes management in order to get the hemoglobin A1C goal
below 7?” The second class is a more formal education session
done in a separate appointment. It reviews renal replacement therapy
options with the patient and his/her support person(s). Either the NP
or one of the dialysis nurses does this session. Since my background
includes peritoneal dialysis, hemodialysis and renal transplant, I
assess which modality will be the best option for the individual and
will emphasize that option during the training session. For example,
the best option for a blind 75-year-old with diabetes, living alone in
a senior apartment building, may be in-center hemodialysis. So the
education session will focus on hemodialysis, access and palliative
care options. All options are reviewed in those patients who would be
candidates for any modality.
Most consult services were identified during the planning stage. Some,
however, were added as the clinic progressed or as new VA services were
developed. Since erythropoietin and IV Iron were used more routinely,
an IV infusion service was needed. The emergency procedures room would
administer the infusion on an “as-needed” basis, but the patient volume
quickly exceeded their ability to manage it and it was not emergent
therapy. Patient volume for both chronic and acute patients precluded
the dialysis unit as a suitable venue. With the development of the
oncology IV treatment clinic that already included IV iron therapy,
additional renal patients were incorporated into their workload. An
injection clinic, staffed by LPNs, is consulted to give erythropoietin
injections, teach the patient or family self-injections, and administer
the hepatitis B vaccine series. They are available daily and usually
able to administer the injection on the same days as the renal clinics.
The pharmacy has been instrumental in the development of several new
programs. The first is a medication management clinic for the
non-compliant patient or the unstable patient with diabetes, who needs
aggressive control. The second is a lipid management clinic that works
with patients with hard- to-control lipids. Both are consulted as
needed. Vascular surgery service is consulted for early access
placement. Consults are made when the GFR is less than 30 ml/minute in
diabetics or in patients with proteinuria, and less than 20 ml/minute
in non-diabetics or proteinuria less than 1 gram a day. Biweekly
meetings are held with the vascular surgery nurse clinician to review
all patients needing an access and prioritizing access placement
schedules. Interventional radiology is consulted for those early
accesses that are not developing well. Monthly meetings with
interventional radiology and the renal team review all procedures that
were done and to decide upon an action plan. Finally, the transplant
service is consulted on those patients who may be transplant
candidates. As the VA renal transplant coordinator, I can initiate the
renal transplant evaluation when the estimated GFR < 25 ml/minute.
The patient is referred to the appropriate transplant center when the
work-up is completed.
Barriers to Program
Over
the past 5 years, there have been barriers to our referrals to the CKD
program. Staff continues to use the serum creatinine instead of the
estimated GFR. Reinforcement to change this practice is on-going. The
distance to the Denver VA renal clinic is another barrier as our region
covers several states in mountainous regions, making travel difficult.
Unfortunately, there are some patients who have had little or no
preparation or discussion about their renal disease, leading to shock
upon learning of their diagnosis. Often, this can delay the needed
preparations for early access until they are psychologically ready to
proceed. There is also the “feel-good” syndrome (Crawford, 2005). Most
patients do not have symptoms of CKD until the later stages, so why
prepare now? It takes a great deal of education and gentle convincing
for early access. Some patients will delay surgery until the need for
replacement therapy.
Other problems have been encountered. The volume of referrals to the
renal clinic has increased by greater than 10% annually. Additional
renal fellow clinics were added. Since there is still only one NP in
the renal clinic, the fellows have been trained to order necessary
consults if there is a delay getting into the CKD clinic. An additional
challenge has been surgeon ”buy-in” for “fistula first,” which was
achieved by frequent meetings with them. On-going reinforcement of the
VA directive for “fistula first” has resulted in 70% AV fistulas in the
Denver VA dialysis unit. IV iron referrals have increased the infusion
clinic burden volume tremendously. Requests are now limited to 1 or 2
days per week.
Finally, referrals to outside renal providers have also increased. The
small dialysis unit at the Denver VA cannot dialyze all the patients in
CKD stage 5. The social worker and nurse practitioner work with the
patient to identify the dialysis unit closest to the patient and the
appropriate nephrologist for referral.This involves additional time to
make the referral and on-going communication to that provider until the
patient starts dialysis.
Summary
The
issue of reimbursement for NP is not an issue in the VA system,
although it can be a barrier for the private sector. How to make this
cost-effective was discussed during the networking session and will
continue to be explored.
The nephrology nurse is in a key position to participate in CKD
clinics/programs. By virtue of his/her nursing expertise in assessment,
incorporation of psychosocial factors, and patient education, the nurse
can play a pivotal role in successful management of persons with CKD.
References
Crawford, P.W. (2005), Lessons learned in an urban CKD clinic. Nephrology News & Issues, 19, 243- 249.
NIDDK. (2005, January). Chronic kidney disease awareness, prevalence
and trends among U.S. adults, 1999 to 2000. Journal of the
American Society of Nephrology.
| The Practice Issues in Nephrology Nursing department
focuses on issues identified by ANNA's Special Interest Groups. Address
correspondence to: Karen Robbins, Associate Editor, through the
Nephrology Nursing Journal; East Holly Avenue/Box 56; Pitman NJ
08071-0056; (856) 256-2320, or by emailing her at kcr_nnj@yahoo.com.
The opinions and assertions contained herein are the private views of
the contributors and do not necessarily reflect the views of the
American Nephrology Nurses' Association. |
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