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Background
Targeted Facilities
Possible Contributing Factors
Materials Distributed
Data Monitoring & Feedback
In response to an opportunity for improvement identified through the 2006 Clinical Performance Measures (CPM) Project (2005 data), Network 5 implemented a project to improve the adequacy of delivered dose of hemodialysis. The project enlisted the participation of 31 dialysis facilities, each of which...
- had an adequacy measure (Percent of Hemodialysis (HD) Patients with Mean spKt/V =1.2 ) below 88%, as measured by the 2006 eLlab data (4th calendar quarter 2006),
- were unable to demonstrate improvement to >90% during the 3rd calendar quarter of 2007, and
- had a patient census of >30.
Excluded were all nursing home facilities, military operations, acute care hospitals, and prison units.
To affect change, the Network employed a multi-pronged quality improvement strategy that included gathering facility-specific quality improvement plans; data collection, monitoring, and feedback; the provision of web-based training on adequacy of hemodialysis; and the provision of adequacy tools and technical assistance, upon request.
Project participants improved Percent of HD Patients with Mean spKt/V = 1.2 from an average of 84.5%, measured through eLab data during the 4th calendar quarter of 2006, to an average of 91.7% in September 2008, thereby exceeding the project goal of 90%. Facilities used process changes, patient education, and staff education to achieve improvement.
Background
Annually, Network staff review the Clinical Performance Measure (CPM) data to how the results will be used to guide Network activities during the coming year. A CPM Work Plan is developed, incorporated into the Network Quality Improvement Work Plan (QIWP), and is submitted to CMS as a contract deliverable. During 2007, the Medical Review Board (MRB) chose to focus the CPM Work Plan on Hemodialysis Adequacy. With a baseline measure of 89% of patients having attained/maintained a Kt/V level of 1.2 or greater, drawn from the 2006 CPM Project (Oct - Dec 2005), the MRB set a goal for 90% of patients to attain/maintain a Kt/V of 1.2 or greater by 4th Quarter 2007.
Targeted Facilities
Due to data lags and other obstacles, targeting of facilities proved challenging. The 2006 CPM data were collected in the 4th Quarter of 2005 and only included a small fraction of patients served in the Network 5 community. Consequently, no facility-specific estimates of adequacy were available. Network staff identified a partial solution, which was using data from the 2006 Lab Data Collection Project (E-lab), which was drawn from 100% of eligible facilities. However, these data were also not as current as preferred. The Network targeted facilities having 30 or more patients using the Elab data and a Kt/V rate of less than 1.2. To overcome the data time lag barrier, selected facilities were permitted to document and submit three (3) additional months of current Kt/V results to the Network office. Network staff analyzed the data and facilities with 90% of patients attaining/maintaining a Kt/V rate of 1.2 or greater during this time period were released from the project. Nursing home, military, acute care hospitals, and prison facilities were also excluded.
Possible Contributing Factors
Several opportunities for improving adequacy were identified and include:
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issues related to the dialysis prescription
-
the proper delivery of the prescription
-
dialyzer surface area
-
dialyzer reuse/TCV is 80% or greater of original measured value
-
length of treatment
- blood flow rate
- dialysate flow rate
- type of vascular access
- in the case of an AVF, fistula needle size and type
- access re-circulation
- nutritional prescription and status
- proper blood draw technique
- processing of blood sample used to measure adequacy
- testing of residual urine output
- reducing treatment time and missed treatments
- patient education, specifically regarding hypotension and cramping
Materials Distributed
Network assistance was provided through WebEx training along with continued follow-up. The following materials were also provided to each participant:
Data Monitoring & Feedback
Facilities submit monthly Kt/V data to the Network office for review. The Network is monitoring performance and is using the data to report to the MRB and target technical assistance efforts.
This will continue through Fall 2008. Final analysis is pending.
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