Renal access coordinators' impact on hemodialysis patient outcomes and associated service delivery: a systematic review

Background
Renal access coordinators contribute specifically to dialysis access care for people with chronic and end stage renal disease. Since the introduction of renal access coordinators into Australia in the early 2000s, there have been anecdotal examples of associated improvements in patient outcomes and service delivery; however scant published quantitative evidence exists. Thus, the impact of the implementation of renal access coordinators has not undergone a rigorous review to date.

Objective
The objective of this systematic review was to critically appraise and synthesize the best available evidence related to the impact of renal access coordinators on dialysis patient outcomes and associated service delivery.

INCLUSION CRITERIA

Types of participants
This review considered studies that included renal access coordinators (noting variations of the titles) and adult hemodialysis patients (aged 18 years and over).

Types of intervention(s)
This review considered studies that evaluated the effectiveness of the renal access coordinator. This role typically consists of clinical and administration duties such as providing pre dialysis access coordination, access surveillance patient education and nurse education.

Types of studies
The types of studies considered within this review included experimental and epidemiological study designs. Thus randomized controlled trials (RCT), non-randomized controlled trials, and quasi-experimental, before and after studies, prospective and retrospective cohort studies were considered as were case control studies, analytical cross sectional studies and descriptive cross sectional studies.

Types of outcomes
Patient outcomes considered included: days to first vascular access complication (such as stenosis or thrombosis) and/or primary intervention (such as angioplasty or surgical intervention); percentage of central line insertions (negative); rate of arteriovenous fistula (AVF)/arteriovenous graft (AVG)/central venous catheter (CVC) at start of dialysis (incidence); prevalent rate of AVF/AVG/CVC; time to occlusion of AVF and time from referral to surgery. Service outcomes included: knowledge/up skilling of renal nurses; cannulation skills, ultrasound skills, knowledge of anatomy and physiology and other access related knowledge.

Search strategy
The search strategy aimed to locate published and unpublished studies, utilizing a three-step searching approach. Studies published in English from 1990 to October 2013 were considered for inclusion in this review.

Methodological quality
The studies were assessed by two independent reviewers using the appropriate standardized critical appraisal instruments from the Joanna Briggs Institute.

Data collection
Data were extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute, namely JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

Data synthesis
This review aimed to conduct meta-analyses of the findings: however, because of the limitations of the data found, this was not possible and so the findings are presented in a narrative format.

Results
Five studies were identified for inclusion in the review. No RCTs were found, therefore four of the five studies were pre-post intervention cohort studies and one was a prospective quality assurance report. Data were heterogeneous and thus did not allow for meta-analysis. All studies included multidisciplinary teams with variable emphasis on the renal access coordinator role. The pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the hemodialysis population and the quality assurance report measured the difference in patency rates between AVF and AVG. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusions
This review found insufficient data to make firm conclusions about the impact that renal access coordinators have on patient outcomes. The results of this review suggest an association between renal access coordinators and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs.

Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession

organisational culture, quality assurance, health care, state medicine, Great Britain, Health care reform, quality improvement

Do renal access coordinators make a difference? What is the evidence?

Background
Since the introduction of the renal access coordinator (RAC) role into Australia there have been only anecdotal examples of associated improvements in patient outcome and service delivery and scant published quantitative extant evidence exists.

Aim
To review the literature related to the impact of RACs on dialysis patient outcomes and associated service delivery, gauge the level of evidence available and identify gaps in the literature.

Method
A three stage Joanna Briggs Institute (JBI) systematic review process was used to collect and synthesise data. The review considered studies that explored and measured the RAC role in the adult haemodialysis context. All quantitative study designs were considered. Due to lack of homogeneity a narrative synthesis was undertaken.

Results
Five studies met the inclusion criteria for the review. All studies included multidisciplinary teams with variable emphasis on the RAC role. Four pre post intervention cohort studies measured incident and/or prevalent AVF, AVG and CVC rates in the haemodialysis population and the quality assurance report measured differences in patency rates between AVF and AVG and associated hospital length of stay. All discussed the role of central coordination as a contributor to the success of vascular access care.

Conclusion
The available reports do suggest an association between RACs and improved patient outcomes. These improved patient outcomes were apparent in an increase in incident and prevalent AVFs, and a decrease in the incidence and prevalence of CVCs. Both associations are correlated with a reduction in infection rates, length of hospital stay and healthcare costs
 

Effects of patient-, environment- and medication-related factors on high-alert medication incidents.

To measure the rate of medication incidents associated with the prescription and administration of high-alert medications and to identify patient-, environment- and medication-related factors associated with these incidents.

Are vitamins A and D important in the development of food allergy and how are they best measured?

Food allergy has a dramatic impact on a child's (and their family's) quality of life and places a major financial burden on the community. It has been hypothesized that the increase in food allergy may relate to the concordant rise in prevalence of vitamin D insufficiency. More recently a second hypothesis has implicated vitamin A sufficiency in the development of immune tolerance. Together, these hypotheses have prompted investigation into the circulating levels of vitamins A and D in relation to food allergy prevalence. This review aims to examine the relationship between vitamins A and D and food allergy. The first part of this review presents the available epidemiological data which proposes a dramatic increase of food allergy and related anaphylaxis during the last two decades. There is some indirect evidence that variation in food allergy prevalence within countries might be linked with ambient ultra violet radiation exposure and thus potentially with vitamin D levels. Only a few studies to date have directly examined the relationship between measured serum vitamin D levels and either food sensitization or allergy. The significance of vitamin A in food allergy prevalence is only provided through a hypothetical association due to its role in the immune system. The second part of this review discusses the relevant aspects of the analytical methods to assess vitamin A and D levels in children. The primary methods utilized relate to measuring the main circulating forms of vitamins A and D in blood i.e. retinol and 25-hydroxy-vitamin-D3 respectively. Chromatographic separation coupled with mass spectrometric detection is considered the gold standard method for both vitamins. These analytical methods should be fully validated for the use in pediatric populations to ensure they are fit for their clinical purpose.

TESOL professional standards in the "Asian century": dilemmas facing Australian TESOL teacher education

Australian teacher education programmes that prepare teachers of English to speakers of other languages (TESOL) are confronting the nexus of two facets of globalization: transformations in the Asian region, captured in the notion of the "Asian century", and shifting conceptions of professionalism in TESOL in non-compulsory education. In booming Asian economies, English language learning is integral to the demand for high-quality education. This has produced increases in TESOL Teacher Education Programme (TTEP) enrolments of both domestic Australian students and international students from Asia. Growth in demand for TTEPs has necessitated that they cater to student diversity, and the intended contexts of practice. This demand has coincided with a concurrent movement towards professional standards for TESOL that, we argue, confronts complexities around quality, accountability, and professional identity and achieving conceptual and contextual coherence. Drawing on discourses of managerialism and performativity, this paper explores tensions between increased student demands for TTEPs, professional standards discourses which are part of the global policy discourses on teacher quality, and the achievement of programmatic conceptual and contextual coherence from the perspective of Australian TTEPs.

Evidencing learning outcomes: a multi-level, multi-dimensional course alignment model

This conceptual framework proposes a multi-level, multi-dimensional course alignment model to implement a contextualised constructive alignment of rubric design that authentically evidences and assesses learning outcomes. By embedding quality control mechanisms at each level for each dimension, this model facilitates the development of an aligned curriculum. The use of rubrics is a crucial theme for many higher education institutions owing to the binding requirement by universities to provide evidence to quality assurance agencies. The success of evidencing learning outcomes through rubrics, however, is only one piece of the puzzle. The other is the contextualised constructive alignment of intertwined factors. Despite the significance of embedding these factors, there has been little, if any, systematic framework in this area. The two key instrumental forces underpinning the conception of this model are: seeking external accreditation and the implementation of programme enhancement thus realising the strategic agenda for an Australian university.

Understanding toxicities and complications of cancer treatment: a data mining approach

Cancer remains a major challenge in modern medicine. Increasing prevalence of cancer, particularly in developing countries, demands better understanding of the effectiveness and adverse consequences of different cancer treatment regimes in real patient population. Current understanding of cancer treatment toxicities is often derived from either “clean” patient cohorts or coarse population statistics. It is difficult to get up-to-date and local assessment of treatment toxicities for specific cancer centres. In this paper, we applied an Apriori-based method for discovering toxicity progression patterns in the form of temporal association rules. Our experiments show the effectiveness of the proposed method in discovering major toxicity patterns in comparison with the pairwise association analysis. Our method is applicable for most cancer centres with even rudimentary electronic medical records and has the potential to provide real-time surveillance and quality assurance in cancer care.

Avaliação do grau de contribuição das normas de garantia da qualidade ISO-9000 no desempenho competitivo das empresas

Este trabalho avalia o grau de contribuição da implementação de um sistema de garantia da qualidade, em conformidade com as normas de garantia da qualidade (ISO 9001, 9002 e 9003), na competitividade das indústrias. Para o desenvolvimento do tema, discute-se inicialmente as normas da série ISO 9000, identificando-se sua origem, os objetivos, a aplicação e os requisitos existentes, bem como a forma e o impacto de sua implementação. Posteriormente, analisa-se a competitividade no sentido amplo, identificando-se os fatores determinantes da competitividade, tanto no nível interno como externo às empresas, definindo-se as estratégias genéricas de competição bem como as principais dimensões selecionadas para a obtenção do sucesso no curto, médio e longo prazos. A partir de então, analisa-se a forma como as normas ISO 9000 influenciam os fatores determinantes da competitividade, para posteriormente avaliar o impacto recaído sobre as principais dimensões de competição. O trabalho se encerra com o relato das conclusões sobre o tema proposto, obtidas a partir do confronto das observações colhidas ao longo do trabalho com os resultados de pesquisas existentes.

Desdobramento da qualidade em serviços : o caso da biblioteca de engenharia da UFRGS

O presente trabalho introduz o estabelecimento de um modelo para garantia da qualidade, particularmente aplicado ao segmento de prestação de serviços por bibliotecas. O estudo a ser apresentado baseia-se na utilização de um método de planejamento em específico, o Desdobramento da Função Qualidade (QFD), selecionada para viabilizar a análise da qualidade demandada pelo cliente, das características de qualidade críticas, dos serviços críticos e dos recursos críticos. Este trabalho discute o sistema de garantia da qualidade, cuja implantação está em curso, e que é parte integrante do modelo de gestão a ser adotado pela Biblioteca da Escola de Engenharia da Universidade Federal do Rio Grande do Sul. A análise a ser apresentada utiliza o QFD incorporando um conjunto de matrizes que facilita e garante o fluxo de informações através de todas as suas etapas de desenvolvimento.

Aplicação do qfd nas consultas eletivas do plantão médico da Santa Casa de Porto Alegre

O presente trabalho apresenta um caso de adaptação e aplicação de um modelo de garantia da qualidade à área de consultas médicas eletivas da Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA). O caso a ser apresentado utiliza um método de planejamento da qualidade específico, o QFD – Desdobramento da Função Qualidade, selecionado para identificar e solucionar as causas que levaram a resultados indesejados no Serviço Consultas Eletivas do Plantão Médico da Policlínica Santa Clara do Complexo Hospitalar da Irmandade Santa Casa de Misericórdia de Porto Alegre, RS. Este trabalho é parte integrante do Programa de Gerenciamento da Rotina (TQC), em andamento na ISCMPA desde 1997, e vem a ser a primeira utilização de ferramenta específica para o planejamento da qualidade na Instituição. Os resultados obtidos com a aplicação do QFD ao Serviço Consultas Eletivas do Plantão Médico demonstraram uma significativa melhoria no índice de satisfação dos clientes.

Germinação de sementes e otimização de técnicas de micropropagação de umbuzeiro (spondias tuberosa, arr.) anacardiaceae

The brazilian-plum (Spondias tuberosa, His) is a tropical fruit tree that has been consolidated in the market for agribusiness processing, due to its characteristic flavor of fruit. Accordingly, studies to optimize the propagation of plants are necessary for production of seedlings with agronomic and quality assurance measures. This study aimed at determining the efficient techniques for uniform seed germination, as brazilian-plum seed present mechanical dormancy, and establish optimal culture media for multiplication of shoots from the in vitro micropropagation. Firstly, in a greenhouse at the Universidade Federal do Rio Grande do Norte, was evaluated the influence of different methods of breaking dormancy in the emergence of seedlings of brazilian-plum and speed of germination (IVG) of seeds. After 60 days of cultivation, it was found that splay in the distal portion of the seed was the best treatment, with rates of 85.33% in germinability and 3.415 of IVG, compared with the treatment of seed-soaking in water for 12h + humus and the control group. Subsequently, new sources of seedling explants were obtained in studies of tissue culture. Laboratory of Plant Biotechnology that the university, was used stem apex, nodal segments and internodes in search of decontamination with various concentrations of calcium hypochlorite [Ca(OCl)2] and micropropagation, inoculating them in half WPM (1980) with various concentrations of 6-benzylaminopurine (BAP). We used 10 sample units with three replications for different concentrations of [Ca(OCl)2], BAP and explants type. After thirty days, which was observed for the control of contamination, during the establishment in vitro, concentrations of [Ca(OCl)2] between 0.5% and 2.0% were effective in combating exogenous contamination of the apex. In nodal segments and internodes, concentrations of [Ca(OCl)2] between 1.0% and 2.0% and 1.5% and 2.0% were respectively, sufficient to reduce the percentage of losses in these infestations explants. For micropropagation, the culture medium supplemented with 0.1 mg.L-1 BAP promotes better development of multiple shoots per explants from nodal segment. However, success does not get to shoot training in internodal segment