NN&I - May 2010
National www.nephronline.comMay 2010 Nephrology News & Issues 13 LettersThe article by Tom Parker, MD, and Theodore Steinman, MD, "Changing the models and measurement of dialy- sis care" in the March 2010 issue of NN&I serves as an excellent review of some of the clinical parameters that must change if nephrology clinical outcomes are going to improve in the future. Quite possibly the authors were intending to use the article to spearhead a rallying call to their peers. However, with all due respect to these fine nephrologists, the article neglects to address a couple of inherent issues in nephrology that must change along with their mentioned clin -ical measurements and models. 1. Roles of the nephrology team: Specifically, where are the nephrology nurses? Nephrology nurses must step up to the table and fully contribute to the advancement of evidence-based care delivery. Nephrology should serve as the exemplar model of collaborative clinical practice. As such, committees must not be composed solely of neph-rologists. Many of the clinical changes proposed, and others that were not mentioned, at the State-of-the-Art meeting and in the summary article require participation and buy-in from primary care practitioners, nephrology nurse practitioners, nephrology nurses, nephrology dietitians and nephrology social workers. Being part of the pro-cess from the start enhances the likeli-hood of ownership by these profession-als in pursuing the necessary changes in clinical practice. All of these disci- plines must sit side by side with neph-rologists and work together to define their unique roles in shaping future care for patients with kidney disease. Since the physicians have taken the lead, the other members of the neph-rology health care team must proac -tively approach our nephrologists' col- leagues to engage in the dialogue. 2. Nephrology clinical staffing: We well realize the financial restraints of today's world, but it might behoove Drs. Parker and Steinman and the rest of the steering committee to recom -mend placing more professionals back in the dialysis clinics. Dialysis techni -cians have their role in patient care, but they cannot be held responsible for continuing clinical assessment, utiliz -ing adult learning principles for patient education, addressing the complexi -ties of the renal diet, nor evaluating patients for rehabilitation. At a mini -mum, these parameters require nurse practitioners, registered nurses, renal dietitians, and social workers, in addi-tion to community resources. 3. Patients suitable for dialysis: Finally, if the nephrology community is serious about changing the high mor -tality rate, particularly in the first year of dialysis, the excellent clinical prac -tice guideline, "Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis," developed by the Renal Physicians Association, must be accepted and utilized in every primary care setting, nephrology practice, and dialysis clinic through-out the United States. Efforts must be increased to provide quality treatment for only those who will benefit and pro -vide quality end-of-life care planning for those whom the burden outweighs the benefit of beginning or continuing aggressive treatment. Christy A. Price Rabetoy, NP Piney Flats, Tenn. Sally Burrows Hudson, MSN, RN, CNN Sunnyvale, Calif. Barbara Bednar, MHA, RN, CNN Naples, Fla. The authors' response: We agree with the thoughtful com-ments of our nursing colleagues. The intent of our article was to highlight the deficiencies in ESRD care. Major areas of concern, cardiovascular dis -ease, infection due to catheters and the first four months of care for the inci-dent patient, were emphasized because they contribute to the unacceptable high morbidity and mortality rate and costs. Identifying areas that need to be addressed without designing a spe-cific roadmap to achieve the necessary goals was our intent. Quality care requires a coordinated team approach and we support the collaborative effort noted in the letter. The days of team meetings at the bed-side, including the patient as an active participant in their own care, should return. Meaningful monthly dialysis rounds with the physician, nurse, tech-nician, social worker and dietitian can lead to better outcomes because sig-nificant time is spent with the patient. Dealing with issues that make a differ -ence, rather than achieving numbers that do not profoundly affect outcomes, will result from coordinated care. To be utilized in the care process when needed is the specialist access nurse. Those who attain further education in nursing, gaining degrees and certifica -tion, should be given greater leader -ship positions in the dialysis setting. Coordinated care should be initiated before the start of dialysis for patients identified as progressing towards ESRD. Rehabilitation goals should be estab -lished early, no later than the initiation of chronic dialysis. As part of improving care based on the best science, there should be twice a year nephrology team education sessions. We endorse ongoing assessment of the appropriateness of dialysis. As a team we need to focus on whether the patient is deriving overall benefit from the dialysis therapy. Compassionate care more than occasionally may translate into an examination of palliative care. Theodore I. Steinman, MD Thomas F. Parker III, MD National_NNI0510_4.indd 13 4/19/10 1:55:41 PM
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