Dialysis readmission rates improve with patient education

When it comes to quality improvement, the simplest procedural changes can sometimes make the greatest impact on patient experiences and outcomes.

Dialysis is part of UF Health Jacksonville’s daily operations. Patients may be hospitalized for unrelated issues but require their regular dialysis treatment while recovering, whereas others may become hospitalized after missing a treatment. Patients who are not hospitalized have dialysis appointments three times a week. What they all have in common, typically, are the catheters through which they receive treatment.

A catheter is placed in the chest or neck and has two ports — an exit port where blood is pumped out to undergo a cleansing process in the dialysis machine and returns through an entrance port on the other side. When catheters become infected, they lead to central line-associated bloodstream infections, which require treatment in the intensive care unit.

“There is evidence supporting that catheter usage is linked to a higher morbidity and mortality rate,” said Anne Marshall, nurse manager of dialysis services with UF Health Nephrology – Jacksonville.

There is an ideal solution, one Marshall and colleagues are trying to promote to every UF Health patient who requires dialysis: a vascular access. Ultrasound technology is used to map a patient’s vascular system in the arm, and a surgical procedure fuses a vein and artery together. This fistula can then be accessed using two needles, one to withdraw blood and the other to return it to the body when cleaned.

Some patients resist vascular access placement because of the many steps and appointments involved and the surgery required.

“The main initiative is to get the catheters out,” Marshall said. “We do a lot of education with our patients.”

Dialysis staff have also taken steps to streamline the process of obtaining a vascular access for their patients. The first step was adding vascular consultation and vessel mapping to the dialysis order set in Epic.

“We added vessel mapping onto the Epic dialysis order set, so while they’re receiving inpatient treatment, they can get their mapping done,” Marshall said. “We also added it to the case management checklist, so we can ensure vessel mapping is complete before moving them to an outpatient chair.”

Completing the mapping during the patient’s stay eliminates the need for one more appointment after discharge. When they report for dialysis, treatment is overseen by a vascular access coordinator who can maintain a continuity of care.

“The vascular access coordinator picks up where we leave off and can set up appointments and make sure patients get their surgeries scheduled,” Marshall said.

The outpatient unit also has a vascular access task force that specializes in maintaining the integrity of vascular accesses. Some patients are at a higher risk for clotting or collapsing of the access, and the task force is able to insert needles into them successfully.

Integrating the process by providing patients with mapping while they’re on campus, coordinating appointments and hiring experienced nurses and technicians has made a difference for dialysis patients who depend on this service for survival.