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Towards Home-based Dialysis Therapy-�The Dawn Of A Successful Programme In Negeri Sembilan��Dr Dheepa Ramasamy�Department of Nephrology, HTJS

National QA Convention 2017

Team Members

Dr Dheepa Ramasamy
Dr Lily Mushahar
Dr Sudhaharan Sivathasan
Dr Asiah Usamah
Dr Bhawani Thangaratnam
Sister Fuziah Zakaria
SN Juliana Yunus

National QA Convention 2017

1. Selection of Opportunities for Improvement

National QA Convention 2017

List of QA Problems

SCALE : High 8-10 , Medium 4-7 , Low 1-3

Problem Identification

National QA Convention 2017

Refined Topic

National QA Convention 2017

Towards Home-based Dialysis Therapy-�The Dawn Of A Successful Programme In Negeri Sembilan

Home-based Dialysis Therapy

National QA Convention 2017

Home-based Dialysis

Home hemodialysis

HD machine at home
Not offered in Malaysia currently

Defined as dialysis therapy that can be done at home

Peritoneal Dialysis

Requires a PD catheter (Tenckhoff)
Uses pt’s own peritoneum
30 mins/ exchange
4 exchanges per day
Clean area, water, electricity

Situational analysis

Peritoneal dialysis (PD) was first introduced in Malaysia in 1981.

Although effective, the national penetration rate for PD in Malaysia remains low at 10-14% of all modes of RRT over the last decade.^1,2

1. 22^nd Malaysian Dialysis and Transplant Registry, 2015

2. Morad Z, Lee DG, Lim YN, Tan PC: Peritoneal dialysis in Malaysia.

Perit Dial Int 25:426–431, 2005

National QA Convention 2017

Advantages of PD over HD

Patient survival
Technique survival
Preservation of residual renal function
Improved quality of life
Cheaper costs
Less infection rates (including hepatitis and HIV) and hospitalisation
Better transplant outcomes
Accessible to patients in remote areas without HD facility
Less bodily disfigurement (no AV fistula)

HD

PD

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PD Utilisation Across The Globe

12%

PERITONEAL DIALYSIS UTILIZATION AND OUTCOME: WHAT ARE WE FACING?

Wai-Kei Lo, Perit Dial Int June 2007 vol. 27no. Supplement 2 S42-S47

National QA Convention 2017

Outline of Problem

Although peritoneal dialysis as a home-based dialysis therapy has several advantages over in-centre HD, its uptake remains poor in many countries including Malaysia.

This is due to several barriers including patient and staff factors, biasness towards HD, poor knowledge, delay in PD catheter insertion and lack of support.

National QA Convention 2017

Reason for selection- Seriousness (S)

Patient’s safety concerns
Evidence shows that PD confers equal or better survival compared to HD, and preserves residual renal function
Less hospitalisations and infections including hepatitis, HIV
Better transplant outcomes

Patient’s quality of life and satisfaction
Ability to travel
Empowering autonomy

- the patient is “in charge”

More flexibility and freedom
Higher employment rates

National QA Convention 2017

Seriousness (S)

Cost
Does not require centres ,machines or staff
Lower overhead
Require 3-4 times less erythropoietin than HD patients
Overall cost per patient per year is less than HD

National QA Convention 2017

Budget Impact Analysis

National QA Convention 2017

If PD prevalence in Malaysia increases from 8% to 38%

in 2018, cumulative 5-year savings is predicted to be

RM 23.93 million!

PD prevalence (2014)	PD prevalence (2018)	Cumulative 5-year savings/loss
8%	18%	RM 7.98 million
8%	28%	RM 15.96 million
8%	38%	RM 23.93 million
8%	4%	(RM 3.19 million)

Reason for selection

Measurable (M)
PD utilisation rate amongst ESRD

patients can be measured

Appropriateness (A)
Care of dialysis patients is part of the core business in Nephrology.
A study to improve rate of PD utilisation will give a good impact on patient care, quality of life and healthcare costs.

National QA Convention 2017

Reason for selection

Remedial Measures (R)
Strategies to improve PD uptake amongst ESRD patients can be devised and implemented

Timeliness (T)

- Socially, politically, ethically acceptable

Remediable measures can be implemented to produce better outcomes within a reasonable time frame.

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Problem Statement

There is poor utilisation of peritoneal dialysis as a form of long term RRT among patients with end-stage renal failure in Negeri Sembilan (EFFECTS)

The problem is a result of poor knowledge, lack of a dedicated team to manage PD, and a delay in insertion of Tenckhoff catheters, causing patients to lose interest (POSSIBLE CAUSES)

A study is needed to identify the major factors that contribute to poor uptake of PD and devise a long-term strategy that can improve PD utilisation rate.

(WHY WE WANT TO DO THIS STUDY)

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2. Key Measures for Improvement

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Study Objectives

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General Objective
To improve our PD utilisation rate to 40% within three years (2013-2015) and to ensure these patients remain on peritoneal dialysis.
Specific Objectives
To determine factors that contribute to poor PD uptake
To identify weakness of pre-dialysis education sessions
To formulate strategies and carry out remedial measures to improve PD uptake and ensure patients remain on PD
To reassess effectiveness of remedial measures implemented

Indicator and Standard

National QA Convention 2017

Indicator= PD utilisation rate

PD utilisation rate = number of incident PD patients per year x 100%

total number of incident dialysis patients per year

Standard= PD utilisation rate >40%

Evidence to support choice of measures

PD utilisation rates are high in some parts of the world, with excellent outcome

Mexico, Hong Kong- 80%

New Zealand, Finland, Sweden- 30% to 40%

- Evidence shows with proper quality initiative

programmes, PD utilisation rates can be increased

successfully

Global Trends in Rates of Peritoneal Dialysis

Arsh K. Jain, Peter Blake, Peter Cordy, Amit X. Garg

J Am Soc Nephrol. 2012 March; 23(3): 533–544.

National QA Convention 2017

Poor utilisation of PD

Lack of confidence

Poor knowledge

Delayed Tenckhoff insertion

Biasness towards HD

No dedicated team of doctors/ nurses/ social worker

Lack of support

Readily available HD centres

Opinions of family/friends/doctors

Inadequate pre-dialysis education

Misconceptions and myths

No dedicated OT time

Long waiting time for surgery

No financial reimbursement

No family involvement

Unsuitable home/work place

Burden to caregiver

No autonomy

Dependency on surgeons and anaesthetists

Insufficient staff, resources,funding

1

2

3

Patient presents to

Nephrology Clinic

Assessment of patient

a. History

b. Physical examination

c. Investigations

d. Insert IJC if urgent HD needed

Advanced CKD

Continue follow-up

Pre-dialysis education

CAPD/HD visit

YES

NO

Follow-up care

RRT Counselling

Advanced CKD

YES

NO

A

B

C

Process of Care

Pre-dialysis education

CAPD/HD visit

Assess for suitability of CAPD,

Surgery date given

NO

Opt for CAPD

Refer vascular surgeon

for AVF creation

Hemodialysis or conservative management if no decision on RRT

YES

Passed assessment

Counsel for HD

Refer vascular surgeon, appropriate treatment

YES

NO

C

D2

E

D1

Home visit/ reimbursement

D

D1

Home visit/ reimbursement

Patient remains in PD programme

E

Optimised for surgery

Appropriate steps to treat and ensure patient optimised

NO

YES

Tenckhoff catheter insertion

CAPD training

F

G

Follow-up

H

Model of Good Care

STEP	PROCESS	CRITERIA	STANDARD
A	Diagnosing patients with advanced CKD/ ESRD	All cases referred to our nephrology clinic or as inpatient are assessed by a nephrologist and determined if they have advanced CKD or ESRD via a) History-taking b) Clinical examination c) Laboratory and radiological examination If urgent dialysis is required, temporary hemodialysis is commenced via an internal jugular vein or femoral cathether	100%
B	Counselling them on preparation for renal-replacement therapy (RRT)	Patients and family members are given adequate information regarding their condition, and counselled on the importance of preparing for RRT	100%

STEP	PROCESS	CRITERIA	STANDARD
C	Refer for CAPD/HD visit (pre-dialysis education)	All patients with advanced CKD (along with family members) are referred for both CAPD and HD visits, where are they are given detailed pre-dialysis education regarding both modes of RRT This pre-dialysis education comprises of audio-visual explanation, live demo, exposure to other patients undergoing CAPD/HD, brochures	100%
D	Preparation to start RRT D1 D2	Once the patient has opted for either CAPD/HD, the process of RRT preparation truly begins If HD is chosen, the patient is referred to a vascular surgeon for creation of AVF If CAPD is chosen, the patient is assessed for Tenckhoff insertion and a suitable date for surgery is given	100%

Model of Good Care

STEP	PROCESS	CRITERIA	STANDARD
E	Home visits and reimbursement	Home visits are done by our trained PD nurses who will assess the home environment and recommend necessary adjustments (if needed). Essentials are a clean corner in the house, storage space for PD fluid and a clean water supply. Application for financial reimbursement by SOCSO/ Baitulmal/ JPA are done, according to eligibility	100%
F	Tenckhoff catheter insertion	Tenckhoff catheters should be inserted (ideally within 4 weeks of decision for CAPD), either by surgeon or nephrologist. If the insertion is anticipated to be difficult, i.e in patients who are obese or with previous scars in the abdomen, the case is referred to the surgeon, and to be done under general anaesthesia using laparoscopic insertion technique.	100%

Model of Good Care

STEP	PROCESS	CRITERIA	STANDARD
G	Training	CAPD training is commenced after 10-14 days of catheter insertion Patients (or assistants) are trained for about 5-7 days until they are confident to carry out the dialysis at home by themselves.	100%
H	Follow-up	Follow-up monitoring is done via phone calls or visits to the CAPD unit, where patients will be assessed to ensure the dialysis process is smooth and efficient. Scheduled clinic visits to see the nephrologist are given every 3 months.	100%

Model of Good Care

3. Process of Gathering Information

National QA Convention 2017

Inclusion
Patients aged >18, who have been diagnosed to have ESRD requiring RRT

Exclusion
Patients who are contraindicated for PD

(disabled without caregiver, unsuitable

abdomen, poor hygiene)

Inclusion and Exclusion Criteria

National QA Convention 2017

October 2012- December 2012

1. Record review of all dialysis patients

- PD utilisation rate

- Mean waiting time for surgery

2. Audit compliance to MOGC

- random sampling of 40 CAPD patients

3. Survey (questionnaire)

- knowledge on CAPD amongst patients

- Factors that influenced choice of PD in

patients given pre-dialysis education

Assessing the Problem

National QA Convention 2017

Data collection sheet
Borang A – Audit on compliance to MOGC
Borang B- Questionnaire on knowledge of peritoneal dialysis among patients
Borang C- Questionnaire on factors influencing choice of renal replacement therapy in patients with advanced CKD
Patients’ clinical records

Sampling Tools

National QA Convention 2017

Data Collection Sheet

National QA Convention 2017

Clinical Audit Form

National QA Convention 2017

4. Analysis and Interpretation

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Pre-intervention Results

PD

HD

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Mean waiting time for Tenckhoff insertion in 2012 was

81.48 ± 17.12 days

Due to delay in surgical appointment, lack of dedicated OT time, delay in anaesthetist clearance, no ICU back-up (high-risk cases) and cancellations

Long waiting time for surgery

National QA Convention 2017

Overall compliance 72.5% (29 out of 40 audits had full compliance to MOGC)
Areas that need improvement were identified:

- effective pre-dialysis education (78.3%)

(detailed explanation, audiovisual presentation,

patients’ experience, live demo, brochures)

- waiting time for surgery <4 weeks (40.5%)

- home visits (76.7%)

Compliance to MOGC

National QA Convention 2017

Factors that influenced choice of PD:

Detailed explanations by nurses (82.3%)
Audiovisual presentations (84.6%)
Sharing of experiences by existing PD patients (90.2%)

Pre-dialysis education

National QA Convention 2017

5. Strategy for change

National QA Convention 2017

0�

Donabedian’s Model For Change

(Structure- process- outcome)

Avedis Donabedian. Evaluating the Quality of Medical Care. The Milbank Quarterly,

Vol. 83, No. 4, 2005 (pp. 691–729)

Problem

Poor utilisation of PD

Solution

Identify factors that contribute to the problem
Devise remedial measures

Methods

Effective pre-dialysis education
Dedicated PD team
Nephrologist initiated Tenckhoff catheter insertion

Outcome

Increased PD utilisation
Better clinical outcomes for ESRD patients
Cost savings

National QA Convention 2017

Unbiased, detailed explanation by trained PD nurses
Misconceptions dispelled
All advantages and disadvantages of HD & PD clearly laid out
Audio-visual presentations
Sharing of experiences by existing PD patients
Live demo
Brochures

Effective Pre-dialysis Education

National QA Convention 2017

Audiovisual presentation

National QA Convention 2017

Nephrologists
Trained medical officers
Trained PD nurses
Pharmacist
Dietitian
Social worker

Dedicated PD team

National QA Convention 2017

Home Visit Assessment

National QA Convention 2017

“Mak Angkat” Programme

A dedicated nurse is assigned to each

patient throughout the duration of

PD treatment

This “Mak Angkat” is responsible for :

Training

Ensuring compliance

Troubleshooting problems

Follow-up visits

National QA Convention 2017

Physicians In OT!!

Peritoneoscopy method Tenckhoff catheter

insertion by nephrologists has been shown

to improve PD utilization and increase the

PD population growth rate in other parts

of the world

It is safe, minimally invasive and requires

only sedation and local anaesthesia

Can be completed in 30 minutes or less

We have been given one slot per week at

the daycare OT- 3 to 4 cases per session

Asif, P. Byers, F. Gadalean, and D. Roth, “Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program,” Seminars in Dialysis, vol. 16, no. 3, pp. 266–271, 2003.

National QA Convention 2017

Pre-dialysis education
PD ‘preferred’ approach

3. Patient selection

4. Personnel management

5. Peritoneoscopy method

catheter insertion

6. Purse management

7. Para-clinical support and services

8. Prescribing the right PD therapy

9. Prevention of complications

10. PASSION for PD

Our Strategy: 10 ‘P’s In A Pod

National QA Convention 2017

6. Effects of change

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Increase in PD Utilisation Rate

ABNA 14.9%

ABNA 5.3%

ABNA 27.3%

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Number of prevalent PD patients

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Distribution of prevalent PD patients

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11.5%

9.6%

9.2%

20.2%

6.1%

5.5%

38.1%

More than 50% reside in remote areas with scarce HD facilities

Tenckhoff catheter insertion

National QA Convention 2017

Total (by nephrologist) in 2015: 67
Primary Failure ( unable to use at first trial 10- 14 days ): 3 (4.5%)
Complication within 10 days but functioning :

Leaking 4 (7.4%)
Exit site infection 2 (2.9%)
1^o Peritonitis 1 (1.5%)

No complication : 57 (85.1%)

Outcome: Tenckhoff catheter

National QA Convention 2017

Outcome: Tenckhoff catheter

National QA Convention 2017

Dialysis therapy should be accessible to all
Home-based dialysis therapy, i.e. PD, is a convenient and safe alternative to HD
With this QA study, barriers were broken and PD utilisation rates improved dramatically
The key to our successful PD program:
Effective pre-dialysis education
A dedicated PD team
Nephrologist -initiated Tenckhoff insertion

Lesson Learnt

National QA Convention 2017

7. The Next Step

National QA Convention 2017

We aim to set up individual PD units in district hospitals in Negeri Sembilan

And look into automated peritoneal dialysis (APD) with telemedicine/ remote monitoring system

Mission Possible

National QA Convention 2017

H

A MOVE TOWARDS SPECIALISED HEALTH CARE

CLOSER TO PEOPLE

Conclusion

National QA Convention 2017

HOME- BASED PERITONEAL DIALYSIS

Through Innovation and Quality

Hemodialysis Adequacy

High erythropoietin use in HD patients

CRBSI in hemodialysis patients

Poor uptake of home-based dialysis

Nutrition in hemodialysis patients

THANK YOU

National QA Convention 2017