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Every Dialysis Patient Deserves an Advanced Practice Nephrology Nurse
by ANNA President Lesley C. Dinwiddie
Imagine,
if you will, a dialysis unit with 24 stations, a patient population of
around 100, a patient care staff mix of nurses and technicians, and a
physician rounding schedule of once per patient per week. The patient
acuity is varied as is the experience and education level of the
patient care staff. The physician may spend 1 to 2 hours per week on
selected shifts seeing patients, reviewing studies, and writing orders
and prescriptions. It sounds pretty much like the average dialysis
unit, doesn’t it?
Now
imagine that the provider and the medical supervisor of this facility
hire an advanced practice nurse (APN) with nephrology nursing
experience to practice full time in this dialysis unit, as a primary
care provider, seeing all patients twice a week for their entire
treatment time. What would be different?
The APN Difference
First,
the patients would soon realize that this nurse would provide
continuity of care and communication, telling patients things “that
they didn’t want to bother the doctor with” or that they didn’t feel
comfortable telling the doctor. Second, the staff may feel better
supported with their assessments and questions about patients. APNs
would support the clinical staff through situational education and
demonstration of enhanced critical thinking. The staff frequently
referred questions to me with about symptoms or other patient
problems that they did not have the education or the experience to
handle. My presence in the dialysis unit enabled me to raise staff
knowledge and confidence in handling problems.
But nephrologists have to make rounds in the dialysis unit, don’t they?
Not according to John Bower, MD, one of the founding fathers of home
and incenter dialysis. He states that, “it is an area of hemodialysis
that should not have fallen into the hands of nephrologists in the
first place” (Bower, 2004, p. 12). He goes on to say that nurses can do
a much better job because they see so much more of the patient and can
provide the much-needed emotional support as well as the best patient
education. He further opined that the major role of the nephrologist
should be to manage the patients’ comorbid conditions and make the
appropriate referrals. This is exactly the scenario that I envision for
the facility-based APN. But how realistic is this idea? Would it lead
to better patient outcomes? And how would you justify the necessary
funding for this position?
A
recent report entitled “APNs: Improved Outcomes at Lower Costs” (Sofer,
2004) highlighted the results of a study showing that older patients
hospitalized with heart failure stayed healthier for longer periods
following discharge if they received comprehensive transitional care
from specially trained APNs. Not only were these patients at a
significantly reduced risk of rehospitalization and death than those in
the control group, but the cost of care per patient was also
significantly less. Thus, based on this data, in an ESRD disease
management environment hiring APNs in this role within dialysis
facilities could be extremely cost-effective as they improve the
quality and quantity of life for those patients at highest risk.
Consider for example, the work of Pupim and colleagues (2003), which
showed that those patients beginning maintenance hemodialysis with
uremic malnutrition had significantly more hospitalizations and longer
stays while in the hospital, resulting in higher costs (Pupim, Evanson,
Hakim, & Ikizler, 2003). Staff RNs and technicians do not have the
time nor the expertise to give these incident, high-risk patients the
intense comprehensive care that they require to improve their
physiologic status. A full time APN, in collaboration with the
nephrology team, including the patient, would. In addition, this
position would be ideally suited to deliver the holistic care that our
patients need incorporating both the rehabilitation and the palliative
care facets of a long term chronic illness. The beauty of this
role is that APNs combine the expert nephrology nurse experience with
medical care management thereby freeing the physician to manage acute
and comorbid pathology.
ANNA: A Proactive Approach
You may well point out that this thesis is
based on the premise that globally capitated ESRD disease management is
a reality rather than a possibility. However, the reality is that the
American Nephrology Nurses’ Association (ANNA) is proactive in
anticipation of ESRD disease management as evidenced by the:
- publication of the ESRD Disease Management position statement (ANNA, 2004);
- nomination
of two highly qualified nurse candidates to the CMS advisory board for
the ESRD Disease Management Demonstration Project;
- inclusion
of criteria for the nephrology advanced practice nurse in nephrology
nursing standards and nursing care guidelines; and
- explanation
of nephrology APNs qualifications and scope of practice for policy
makers at the Centers for Medicare and Medicaid Services.
Perhaps
the next step is to propose to CMS that a parallel ESRD demonstration
project using the APN as the primary caregiver in the dialysis unit be
undertaken to compare outcomes.
A Role Model for Staff Nurses
There
is one further reason that APNs in the dialysis unit makes good patient
care, as well as business, sense – they would serve as excellent role
models for staff nurses. The role of the APN epitomizes the potential
of the experienced and expert nephrology nurse. With graduate education
mandatory for entry into advanced nursing practice, the APN
demonstrates both evidence-based nursing interventions as well as
implements routine medical acts such as evaluating laboratory studies
and trends, medication prescription and adjustment, and dialysis
prescription, etc. Inexperienced, novice staff RNs need strong role
models and these APNs would provide frequent reminders of what is
possible when nurses invest in higher education to reach their full
potential as expert nephrology nurses. Our patients deserve no less!
References
American
Nephrology Nurses’ Association. (ANNA). (2004). ESRD disease management
position statement. Retrieved November 29, 2004 at www.annanurse.org
Bower, J.D. (2004). Letter to the editor. Nephrology News & Issues, 18(5), 12.
Pupim,
L.B., Evanson, J.A., Hakim, R.M., & Ikizler, T.A. (2003). The
extent of uremic malnutrition at the time of initiation of maintenance
hemodialysis is associated with subsequent hospitalization. Journal of
Renal Nutrition, 13(4), 259-66.
Sofer, D. (2004). APNs: Improved outcomes at lower costs. American Journal of Nursing, 104(9), 19.
Lesley C. Dinwiddie, MSN, RN, FNP, CNN
ANNA President
Cardinal Chapter
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