Initiation into a dialysis-dependent life: an examination of rites of passage

Martin-McDonald et al explore the conceptual and empirical application of the rites of passage model in contemporary health care for those who are dialysis dependent. The findings illustrate the three stages of rites of passage, separation. liminality, and reincorporation. A commentary and response are provided.

Sustained low-efficiency dialysis with filtration (SLEDD-f) in the management of acute sodium valproate intoxication

Hemodialysis is only infrequently used in drug overdosage situations. The efficacy of hemodialysis to remove the drug depends upon the pharmacokinetics and pharmacodynamics of the drug. At normal therapeutic concentrations, valproic acid is predominantly protein bound and therefore removal by hemodialysis is limited. In an overdose situation, protein binding is rapidly saturated and therefore the substantially larger quantities of the free drug can rapidly cause toxicity. Slow low-efficient daily diafiltration (SLEDD) has not previously been utilized in a drug overdose situation. We report the effective use of SLEDD to remove high toxic concentrations of valproic acid in an overdose situation. Slow low-efficient daily diafiltration also prevented the rebound phenomenon that can occur as the excess drug is released from its protein-bound stores. Hybrid dialysis therapies deserve further evaluation in the management of other poisonings where extra-corporeal therapy is indicated.

Benign recurrent intrahepatic cholestasis with secondary renal impairment treated with extracorporeal albumin dialysis

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive condition characterized by intermittent episodes of pruritis and jaundice that may last days to months. Treatment is often ineffective and symptoms, particularly pruritis, can be severe. Extracorporeal albumin dialysis (molecular adsorbent recycling system, MARS) is a novel treatment which removes albumin bound toxins including bilirubin and bile salts. We describe a case of a 34-year-old man with BRIC and secondary renal impairment who, having failed standard medical therapy, was treated with MARS. The treatment immediately improved his symptoms, renal and liver function tests and appeared to terminate the episode of cholestasis. We conclude that MARS is a safe and effective treatment for BRIC with associated renal impairment.

Central venous dialysis : an Australian survey

Aim: To explore the current central venous dialysis catheter (CVDC) nursing care practices in Australia. Method: A survey of dialysis units in Australia. Results: 66% return rate (48/73) Internal jugular is the main insertion site (75%) and the majority are tunneled (85%). Insertion was performed most commonly by radiologists (34%) followed by intensivists (24%) with one center reporting insertion by nursing staff. CVDCs were most commonly inserted in radiology (54%), followed by theatre (33%). Dressings were attended weekly (55%) or on dialysis days (45%). Chlorhexidine was the antiseptic solution of choice (54%) followed by povidine-iodine (37%). In 21% of centres Mupirocin was routinely applied in addition to the antiseptic solution. Transparent dressings were overwhelmingly favoured however most centres recommended alternatives related to patient need. 21% of units reported enrolled nurses undertaking dressings. All units reported the use of sterile gloves and sterile dressing packs. 10% reported different routine care for tunneled and non-tunneled. 40% of the units collected data on infection rates per catheter days. General opinion (39%) was identified as the reason to base CVDC protocols while descriptive studies (25%), RCTs (23%) and guidelines (18%) were also reported. Conclusion: There are significant variations in the Australian nursing practice related to the care of CVDCs. Although there is still practice based on general opinion there is evidence that changes in practice in the past 8 years may be associated with knowledge derived from research.

The Australian and New Zealand dialysis workforce

Aim: To capture a "snapshot" of the current Australian and New Zealand dialysis workforce in order to contribute to the future renal workforce challenges.

Methods: A web-based survey of dialysis managers (n=221) were asked fifteen questions relating to demographics, age, full-time equivalent information, workforce designation, post-registration qualifications, subjective perceptions of staffing levels, staffing strategies and future dialysis research recommendations

Results: In Australia in 2008 there were 2433 registered nurses, 188 enrolled nurses and 295 dialysis professionals (technicians) and 327 registered nurses (RNs), 8 enrolled nurses (ENs) and 64 dialysis professionals in New Zealand. There were significant variations in staff/patient ratios, workforce profiles and post-registration qualifications. There is a significant association between staff/ patient and home dialysis ratios. A high proportion of renal staff worked part-time, particularly in Australia. The dialysis workforce reflects the aging nature of the general nursing population in Australia and New Zealand. The majority of dialysis nurse managers perceived they had sufficient staff.

Conclusion: Workforce variations found in this study may be useful to identify future workforce challenges and strategies.

Dialysis residential care : a future dialysis service model

People with chronic kidney disease are ageing and have increasing co-morbidities. The current delivery of renal replacement therapy, dialysis and transplantation, needs to adjust to changing patient needs. This paper proposes a potential future service delivery model featuring a dialysis residential care facility and a care coordination focus. The residential care facility would be composed of four levels of care; high, hostel, independent and outpatient. The paper argues that this model may result in decreased morbidity, improved patient quality of life and may prove cost effective. Patients' nutritional status, medication adherence and transport efficiency may be improved. We propose this model to stimulate further debate in order to meet the needs of current and future chronic kidney disease patients.

How a culture of exercise benefits patients on dialysis

It is widely known that patients on dialysis benefit from exercise. Here, Paul Bennett points out that patients can increase the amount and the quality of exercise if the dialysis centre they are attending has a culture of exercise. He describes the elements required to maintain such a culture.

Satellite dialysis nursing : technology, caring and power

Aim. This paper is a report of an exploration of nurses’ perceptions of the quality of satellite dialysis care and how aspects of power that influenced quality nursing care.

Background. In Australia, the majority of people living with established kidney failure undertake haemodialysis in nurse-run satellite dialysis units. Haemodialysis nurses provide the majority of care, and their perceptions of what constitutes quality nursing care may influence their care of the person receiving haemodialysis.

Method. A critical ethnographic study was conducted where data were collected from one metropolitan satellite dialysis unit in Australia over a 12-month period throughout 2005. The methods included non-participant observation, interviews, document analysis, reflective field notes and participant feedback.

Findings. Three theoretical constructs were identified: ‘What is quality?’, ‘What is not quality?’ and What influences quality?’ Nurses considered technical knowledge, technical skills and personal respect as characteristics of quality. Long-term blood pressure management and arranging transport for people receiving dialysis treatment were not seen to be priorities for quality care. The person receiving dialysis treatment, management, nurse and environment were considered major factors determining quality dialysis nursing care.

Conclusion. Aspects of power and oppression operated for nurses and people receiving dialysis treatment within the satellite dialysis context, and this environment was perceived by the nurses as very different from hospital dialysis units.

The Australian and New Zealand dialysis workforce study in the international context

Background: Given increasing demand for renal replacement therapy, this study sought to identify of key workforce issues facing dialysis units, based on a “snapshot” of the current workforce.

Methods: A web-based survey of all dialysis unit managers in Australia and New Zealand, in October 2008, about their workforce.

Results: A significant minority of dialysis staff in most regions were not registered nurses. Many renal registered nurses worked part time. Staff/patient ratios in dialysis units varied significantly by region, reflecting the relative prevalence of home therapies. Most dialysis units were generally adequately staffed. The proportion of registered nurses with specific renal qualifications varied significantly by region.

Conclusion: The changing character of the workforce in the dialysis unit in the future will require clarification of the relationships between different categories of dialysis staff. Specialty education for nurses needs to be oriented to equipping staff to be effective in their changing work environment.

Being a parent on dialysis : a literature review

Aim
This literature review explored the extant literature to further our understanding of the experience of being a parent on dialysis.
Methods
Keywords used to search the literature were haemodialysis, hemodialysis, chronic kidney disease, end stage renal disease, parent and experience. Databases searched included CINAHL, Medline, Wiley/Blackwell, EBSCOHost, Web of Science, Pubmed, and ProQuest. Years included were 1999 to 2009. Seventeen primary research articles (sixteen qualitative, one mixed methods) met the search criteria with only one on parents undergoing dialysis.
Findings
The experience of the parent on dialysis has rarely been explored in the literature. Related research has indicated important themes including: restricted lives; relationships; adjustment; consequences and future outlook.
Conclusions
More should be known about challenges that face parents who receive dialysis. This review established an urgent need for further research to determine the experiences and needs of this population to provide empirical, person-centred nursing care.

Advanced vascular access workshop for dialysis nurses : a three-year review

There is increased awareness regarding the benefits of ultrasound for vascular access surveillance and guided cannulation in haemodialysis. However, finding time to train staff whilst working within the clinical setting is challenging. In 2009 a workshop was introduced in Victoria to provide a platform for nursing staff to learn advanced skills in surveillance and cannulation in a safe, supportive environment. The workshop covered topics such as: assessment and cannulation; surgical perspectives in vascular access; radiological perspectives in vascular access; surveillance and monitoring; cannulation competency package; antegrade/antegrade cannulation; and introduction to ultrasound plus five hours of practical sessions. Feedback from the workshop over the past three years has been positive, and staff have benefited from the both the theoretical and clinical components of the workshop. The success of this workshop highlights the demand for continuing education within the renal workforce.