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Article Excerpt
Nurses are ideally positioned to coordinate the patient education efforts of the nephrology team. Patient-centered education, a primary component of nursing practice and the right of every patient, incorporates customized and ongoing reinforcement of the key components of patient self-care that are known to improve patient outcomes and quality of life. In its optimal form, patient education involves a close partnership among the nurse, the patient and family, and other members of the medical team. By using their combination of medical training, psychosocial skills, and compassion in patient education, nurses achieve professional fulfillment and offer patients a comprehensive, life-altering service.
Providing effective education and comprehensive care is perhaps most urgent and challenging when patients begin dialysis. Data have consistently shown that the risk of mortality is higher during the first 90 days after renal replacement therapy is initiated, making it crucial to convey potentially life-saving information to patients as soon as possible (Bradbury et al., 2007; Hakim, 2008; Khan, Catto, Edward, & MacLeod, 1995; United States Renal Data System, 2008). However, patients who are suddenly faced with the prospect of chronic, thrice-weekly dialysis sessions are often emotionally overwhelmed and may not be ready to focus on the large amount of information that is sometimes provided by well-meaning healthcare professionals. In addition, new patients are often placed into the usual pattern of care provided for all patients in the clinic, without systems in place to address their unique needs.
This article provides an overview of the RightStart program, a teamdriven effort focused on improving morbidity and mortality rates during the first 90 days of dialysis. The program provides patients with education, encouragement, and support in conjunction with intervention strategies to ensure timely implementation of best practices, including a focus on achieving goals as recommended by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI[TM]) guidelines (Wingard et al., 2007).
What Is Known about Early Mortality in Patients on Dialysis?
Analyses have consistently revealed a higher rate of early mortality in patients receiving dialysis in the United States than in other parts of the world. A representative study conducted by the Dialysis Outcomes and Practice Patterns Study (DOPPS) assessed 1-year mortality rates in Europe, Japan, and the United States. Among 16,720 patients followed for up to 5 years, the adjusted risk of early mortality among patients starting dialysis in the United States was 33% higher than it was in Europe (P< 0.0001) and nearly three times higher than it was in Japan (P < 0.0001). Moreover, these differences were not explained by demographics or comorbid conditions (Goodkin et al., 2003).
While the reasons for this increased risk of mortality among U.S. patients on dialysis are still being elucidated, studies of early mortality rates have consistently shown a significantly higher risk of death within the first few months. One of the earliest studies (Khan et al., 1995) was a retrospective, single-center evaluation of 495 patients who started dialysis between 1971 and 1993 and were followed for up to 22.5 years. This analysis showed that 12% of all patients died within the first 90 days of initiating dialysis, for an annualized rate of about 48 deaths per 100 patient years.
A subsequent analysis by End Stage Renal Disease Network 6 (Georgia, North Carolina, and South Carolina) tracked 15,245 patients who were incident to dialysis from January 1989 through December 1992 to determine short-term mortality. This analysis was one of the first to report declining rates of mortality over the first year of dialysis. The annualized rate was 24 deaths per 100 patient years, but approximately one-third of all deaths during the first year of dialysis occurred within the first 90 days (Soucie & McClellan, 1996).
More recently, DOPPS assessed early mortality rates among 4,802 patients who initiated hemodialysis between 1996 and 2004. In this analysis, the risk of mortality in the first 120 days was 27.5 deaths per 100 person years, compared with 21.9 deaths per 100 person years from day 121 to day 365 (P = 0.002). Overall, 46% of all deaths in the first year occurred during the first 120 days. Significantly, while most of those deaths could be contributed to causes such as cardiac, vascular,...
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