Kidney disease has affected more than 20 million Americans and incidence rates are projected to continue increasing by 2% annually.1 This disease results in catastrophic physical signs and symptoms and multiple complications for patients to manage. As a result, patients with end-stage renal disease (ESRD) are subject to increased incidence of hospitalization compared with the average person. Additionally, these patients experience frequent hospitalizations that may be related to not achieving effective clinical outcomes while at home.
The relevancy of this clinical concern was identified at a Central Florida hospital. During organizational leader discussions a consistent theme emerged; patients with ESRD on dialysis had an increased rate of hospital readmission. Wingard et al. found that 20% of Medicare patients are hospitalized within 30 days of discharge compared with 36% of patients with ESRD who were readmitted during the same period.2 Evidence demonstrates a 30% annual rise in hospitalization rates resulting from complications associated with ESRD.2
This article will discuss an evidence-based practice (EBP) change through implementation of an educational program to improve knowledge of patients with ESRD concerning specific kidney disease outcome quality initiative (KDOQI) guidelines in order to reduce 30-day hospital readmissions.
“Evidence-based practice is the conscientious and judicious use of the current best evidence combined with the clinician's expertise and the patient's preferences or values in making decisions about patient care.”3
Literature evidence was searched and appraised to identify and support a solution to the defined clinical question of, “In patients with ESRD, does knowledge of KDOQI guidelines impact 30-day hospital readmission rates?” An educational intervention was a sound solution for improving patient knowledge of clinical practice guidelines and decreasing 30-day hospital readmission rates for this population. The expected outcomes for the intervention were to: (a) Improve patient knowledge of KDOQI practice guidelines; and (b) Decrease organizational ESRD hospital 30-day readmissions.
The overwhelming mortality, morbidity rate, and economic burden of caring for patients with ESRD were the focus of the Institute of Medicine (IOM) where an IOM committee convened to discuss areas of significance pertaining to the care of patients with ESRD.
Topics discussed were:
(1) 5-year survival rate
(2) variations in outcomes
(3) healthcare consequences.
The IOM needed care recommendations based on ESRD costs topping $15 billion annually. The financial impact on private and governmental sectors was apparent by the increasing cost. In an effort to decrease rising healthcare costs, improve patient outcomes, and standardize provider practice, the National Kidney Foundation (NKF) developed and published the first widely accepted KDOQI clinical guidelines.4
The KDOQI guidelines provided performance measures, a means to evaluate provider care, offered consistent educational criteria for patient teaching, and a method to measure evidence of outcomes. KDOQI guidelines were used by the Healthcare Financing Administration to gauge level of care for ESRD in 1997.5
The quality indicators measured included: mortality, hospitalization, transplantation, anemia, vascular access, dialysis adequacy, nutrition, BP, and quality of life.
Findings demonstrated that the implementation of measurable KDOQI guidelines improved morbidity and mortality, which was evidenced by improvement of urea reduction ratio (the reduction in urea as a result of dialysis) from 63% to 67%.5 Participants had an improvement of anemia status from 63% to 72%, which met the practice standard. The overreaching consensus of the findings was patients' quality of life was improved, validating decreased health costs and decrease in hospitalizations.
Increasing patient knowledge through education is a primary factor in improving patient survival, self-management behaviors, and outcomes for the ESRD population.6 A small quasi-experiment was conducted using patients (n = 27) receiving hemodialysis in an outpatient center. Patients were evaluated using a pre- and postknowledge survey, after being provided four 30-minute educational sessions based on ESRD care. Findings concluded that education provided a positive impact, preintervention mean scores of 15.27 compared with an increase score after educational intervention of 20.65, supporting education improves patients' ESRD knowledge.6
A similar study was conducted as a three group, quasi-experiment, with 85 Black participants. The study focused on the relationship of knowledge and adherence to patient outcomes. A presurvey was obtained at the initiation of the study. Patients received education based on the principles of ESRD: kidney function, diet, fluid restrictions, lab values, medication associated with dialysis, and treatment adherence. At the completion of the education program a postsurvey was obtained. The findings noted mean pretest knowledge scores of 65% and after the educational intervention mean knowledge scores increased to 71%.7 (See Survey tool.)
Disciplines should ensure patients receive effective education prior to discharge from acute admissions. In an observational analysis the impact of hospitalization on biomarkers (serum hemoglobin, phosphorus, and albumin) of patients with ESRD was identified.
The evidence noted that these patients had a 40% higher risk for 30-day hospital readmission compared with 20% of other Medicare patients. The authors hypothesized that if recently hospitalized patients with identified high-risk domains such as anemia, nutrition status, infection, vascular access, target weight, mineral metabolism, mental status/depression, new dialysis initiations, and medication management received adequate education prior to discharge then an impact in hospital readmission rates would be realized.2
A retrospective survey of 80,578 outpatient hemodialysis patients in 1,500 facilities was reviewed.8 The study sought to evaluate the impact of patient knowledge of common core kidney disease indicators on repeat hospitalizations. Patients were included if they presented with an admission diagnosis of: volume overload; anemia; hypertension; weakness; and other conditions that correlate to KDOQI goals. Also considered were patients with a new hospital admission during the 30-day study period postdischarge.
Overall results of this study provided evidence that early posthospital evaluation of hemoglobin, nutritional status, and fluid balance, related to clinical practice guidelines, decreased the likelihood of repeat complication and readmission. Review of biomarkers, medication titration, and the interdisciplinary approach to attaining practice guidelines improved patient outcomes; whereas, an overall analysis showed 16% related to anemia, 6% related to vitamin D, and 25.7% related to dry weight management decreased risk of hospital readmission after management and intervention.8
The purpose of this EBP change was to develop and implement an evidence-based educational intervention to teach hospitalized patients with ESRD certain KDOQI goals to improve patient knowledge and decrease 30-day ESRD hospital readmissions. KDOQI comprises 15 guidelines with multiple subsets. Specific guidelines related to this EBP change educational program included:
- anemia (subset 4)
- adequacy of creatinine removal (subset 4)
- nutrition (subset 3.2)
- fluid intake (guideline 5).
Each of these topics was identified as key KDOQI aspects about which patients could be educated in order to decrease readmissions. Prior to implementation internal Institution Review Board exempt approval was granted.
To be included in the EBP change, patients must be admitted to the hospital with an ESRD diagnosis as either inpatient or observation admission status requiring either hemodialysis or peritoneal dialysis. Individuals included adults (18 years or older) of both genders and all ethnicities, who are proficient in reading, writing, and speaking English. Participants who were under the effects of anesthesia, involuntary admission (Baker Act), cognitively impaired, incarcerated, or patients with kidney disease diagnosis not requiring dialysis were excluded from participating in this EBP change initiative.
Setting—The EBP change was instituted at an 851-bed community, not-for-profit hospital in Central Florida. The hospital operates a 10-bed, acute Nephrology Unit that dialyzes approximately 12 patients daily and 280 monthly. Peritoneal dialysis is provided by Nephrology-trained nurses and accounts for approximately three treatments daily.
Implementation steps—As a part of the EBP change patients were assigned an independent ID number beginning with the number “1” increasing in numerical value as the number of participants increased (for example 1, 2, 3, and so on.). Informed consent and demographic information were obtained including gender, date of birth, last dialysis date, and dialysis modality. Once informed consent was obtained, the patient took a 15-minute electronic pretest using a laptop to access the Survey Monkey (SM) website (see ESRD knowledge test). Participants then received a 30-minute verbal education presentation by the Project Manager (PM) through a PowerPoint presentation. Information that was disseminated through the presentation specific to KDOQI guidelines associated with: Adequacy (related to blood cleansing); Hemoglobin (related woth effects of being low); Nutrition (related to serum phosphorus, albumin, and potassium); Fluid Intake (related to BP); and their Access site (related to signs and symptoms of infection).
Education was conducted as a one-on-one session, with time allotted for questions and answers, at the end of the presentation. Then the participant completed a computerized posttest, through SM, to evaluate the patient's knowledge improvement. After the posttest, participants received a KDOQI fact sheet, which listed specific KDOQI clinical goals.
Once education was complete, the PM entered each participant into an electronic database (Midas) to track if the patient was readmitted to the hospital within 30 days of discharge. Patients were enrolled, by medical record number, and entered into the organizational-secured patient information database (Midas). Demographic information (gender, date of birth, and age) was prepopulated from the Midas system based on the individual's admission information and medical record number. The PM added dialysis and the date of last dialysis treatment to enrollment database.
Plan for project evaluation
Outcomes were selected to assist in evaluation of project effectiveness and potential improvement of future educational interventions. The first outcome of patient knowledge of KDOQI clinical practice guidelines was evaluated by a knowledge survey tool, which was developed by the PM for use in this EBP change. The pre- and posttest includes 13 multiple-choice questions. Expected respondent scores ranged from 0%-100% based on number of correct responses. The survey tool content was validated by an expert panel of nephrologists, a renal clinical nurse specialist (CNS), and a certified kidney dialysis nurse. A means comparison for overall aggregated respondent correct survey scores was used to comparatively evaluate both pre- and postsurvey tools. A paired t-test was used to determine statistical significance evidenced by a p ≤ 0.05 for overall knowledge improvement.
The second outcome to be evaluated was 30-day ESRD hospital readmissions. Readmission was defined as: any admission 30 days or less after receiving the educational intervention. As a result of the knowledge increase the second outcome of a 5% decrease in 30-day hospital readmissions among patients with ESRD receiving dialysis during the implementation period of May 6 through June 8, 2013 was projected. Internal comparative data were obtained for a defined 6 months period prior to project implementation (June 1 to December 31, 2012). The implementation period ESRD hospital readmission rate was then compared with preproject 30-day ESRD hospital readmission rate. The implementation period ESRD 30-day readmission rate was also compared externally to the United States Renal Data System (USRDS) average readmission rate of 33.41% for 2012.1 The USRDS is a compilation of reported national data regarding ESRD patient outcomes. The difference in the rates was used to ascertain outcome success for a decrease in 30-day ESRD hospital readmissions.
Participants included in the ESRD EBP change initiative were selected from a group of patients on a Nephrology Unit. The convenience sample of all hemodialysis and peritoneal dialysis patients was screened and invited to participate based on meeting inclusion/exclusion criteria. There were 46 patients who agreed to participate in the EBP change educational program; however, 5 participants were unable to complete the program due to clinical status deterioration (n = 41). Of those 41 participating patients 41% (n = 17) were male and 59% (n = 24) were female. All 41 (100%) were hemodialysis patients with no patients receiving peritoneal dialysis. An additional 63 patients were screened for inclusion, but weren't included for various reasons. Thirty-nine (61.9%) participants screened were excluded due to severity of illness; 13 (20%) were non-English speaking; and 11 (17%) of those screened declined to participate without reason.
A primary reason for undertaking an EBP change for this population was to improve patient knowledge of aspects of the KDOQI guidelines. The respondents pretest mean for correct responses was 34.78%; posttest mean for correct responses was 68.6%. Further analysis was performed to ascertain the percentage of knowledge increase for the patient group by subtracting the pretest score from the posttest score and dividing by the posttest score [(68.6–34.78)/68.6=% improved knowledge score]. A robust 49.3% improvement in participants' knowledge was observed posteducational intervention.
A statistical significance was established as evidenced by a p ≤ 0.05. Statistical significance was correlated using descriptive statistics (paired 2 tailed t test) to obtain a p value. Findings noted p = 0.001, yielding a statistically significant indicator (p ≤ 0.05) that the delivered educational intervention influenced a positive patient outcome of improved knowledge. (See The ESRD knowledge test.)
However, the posttest overwhelmingly supported the patients' understanding of the difference in treatment modality and 95.12% of patients selected the correct response. Data analysis revealed robust findings of an increase in patients' knowledge, through the improved percent of correct aggregated responses on the posttest, supporting the educational intervention improved patient knowledge. Evaluation of each test item yielded positive postintervention results with the exception of question 8a related to signs of infection. There was no identifiable correlation as to why the question yielded a lower score posteducation.
The second defined outcome was a decrease in 30-day ESRD hospital readmissions. An internally set benchmark of a 5% decrease in 30-day ESRD hospital readmissions compared to data evaluated 6 months prior to project implementation was established. According to quality-improvement analysis, conducted between June 1 through December 31, 2012, organizational internal ESRD 30-day hospital readmissions were 36.1% compared with the 34.3% 30-day ESRD hospital readmissions reported in the USRDS annual report of incidences of hospitalized dialysis patients.1
Participating patients were followed for 30 days postdischarge after receiving the educational intervention. Final analysis yielded 78.04% (n = 32) of patients weren't readmitted within 30 days after receiving the educational intervention, while 19.5% (n = 8) of patients were readmitted within 30 days. A comparison to preproject data of 36.1% (June 1 to December 31, 2012) ESRD 30-day hospital readmissions versus 19.5% ESRD 30-day hospital readmissions, postintervention implementation, represents a reduction and a 45.9% decrease in 30-day ESRD patient readmission rate, which was considerably improved over the expected 5% reduction. Comparative to the USRDS national 30-day hospital readmissions of 34.3% the EBP implementation period readmissions was significantly lower at 19.5% postintervention. (See Readmission rates.)1
Organizational implications related to these positive findings present unique opportunities to improve clinical practice for this population, discharge preparation and teaching process, and change leadership strategies for expected ESRD readmissions. Identification of a clinical concern and gleaning the evidence for recommendations offered an opportunity to improve patient care, mentor, and facilitate the nursing process. EBP engages the clinician in exploration of scientific methods and scholarship. Synthesis of the evidence for the purpose of developing improved practice is a skill acquired through education and experience.
This ESRD EBP change highlighted the prospect of collaborating within the clinical practice setting to integrate an educational intervention into the discharge process for patients with ESRD.
Recommendations to convert the educational program to an online format provided organizational leadership the potential to share clinical education with community leaders, patients, and families. Further opportunities exist for collaboration with the NKF and American Kidney Fund to address the impact of KDOQI guidelines on healthcare reimbursement standards and practice standards regarding ESRD. Standardizing surveillance for patients with kidney failure leads to early identification of disease progression. Creating emphasis on best practices for the kidney failure population also has tremendous financial implications, related to appropriate stewardship of healthcare resources.
Limitations of the project
The purpose of implementing the ESRD EBP change was to gain access to chronically ill patients and bridge a knowledge deficit based in expectation of improving ESRD 30-day hospital readmissions. The first limitation was that the organizational technology infrastructure denied access to web-based systems to play the educational video. Computers that were available in the patients' rooms weren't equipped with speakers to hear audible education programs. Identification of these limitations required that the computer-based program to be administered with the PM personal computer. This identification also facilitated conversation with Information Technology for potentially allowing Internet access to websites that are frequently used for educational interventions. Additionally, an infection control concern developed related to using one laptop computer to transport between patients. The concern was discussed with the organization's infection control department and a hospital-approved disinfectant was used to clean the laptop between patients.
Secondly, the time constraint of implementing an EBP change in 9 weeks potentially limited access to patients who needed to have exposure to the provided education. Time constraints limited the amount of time that was spent with each participant and hindered more frequent follow-up interactions. The implementation would've been better served instituting multiple educators to reach all patients admitted with a kidney diagnosis. That would ensure personalized education based on the individual's educational and care needs. Due to the project design a group educational program wasn't utilized, but this educational method could be considered to reach a larger number of participants with fewer educators. This limitation could be overcome with these future recommendations for implementing the education material.
Timely education regarding the clinical practice standards for patients with ESRD, leads to improved patient knowledge and a decreased 30-day ESRD hospital readmission rate. Identification of a clinical problem with readmission rates inspired exploration of the literature. Review of the literature evidence supported the recommendations to improve the care of patients with ESRD through an educational program focused on specific KDOQI guidelines (anemia, adequacy, nutrition, and fluid intake) in order to decrease readmission rates.
Key findings from the intervention linked the significance of the impact of patient knowledge to improved clinical outcomes. There was significant improvement in patient knowledge of the KDOQI guidelines and a decrease in the 30-day ESRD hospital readmissions. The overwhelming impact of the EBP change has significant potential to affect quality of life and healthcare costs. As healthcare continues to operate under increasingly challenging financial climate, interventions that focus on keeping the patient in the community and avoiding costly readmissions are a valid platform for long-standing practice change.
Additionally, the exploration into the best clinical practices highlights remarkable statistics related to patients with kidney disease. The chronicity of kidney disease warrants focus on education, as early education has also been shown to allay progression of chronic kidney disease to ESRD. The populations at large need access to clinician-staffed facilities that offer education on kidney disease regardless of financial status. It is essential to continue to actively improve the education process of patients with chronic kidney disease.
The ESRD knowledge test
The ESRD knowledge test denotes the patient's aggregated answer selections as a percentage of correct responses, by question, as a comparative analysis. A review of individual questions yielded only one question, (8a [signs of infection]) with 100% correct responses on the pretest. Similarly, question 8a yielded only 95.12% correct responses on the posttest. This represents the only negative percent difference found on the posttests. The lowest score was question 13, which assessed if the patients could appreciate which modality of dialysis they participated in and what the recommended kinetic (measure of how well the blood is cleared of nitrogenous waste products such as urea). A lack of peritoneal dialysis participants in this project represents the 0% correct response to question.13
ESRD knowledge test
- Choose the number that best describes what your red blood cell count (hemoglobin) should be.
- greater than 11
- less than 11
- between 5 and 6
- I don't know the answer to this question.
- How do you know that your blood is being cleansed well?
- Check your Kt/V level.
- Check your hemoglobin level.
- How would you feel if your red blood cell count (hemoglobin) is low? Choose all that are the right answers.
- chest pain
- short of breath
- How would you feel if your Kt/V is low? Choose all that are the right answers.
- My mouth will taste like metal.
- I will feel sick to my stomach.
- I can't think straight.
- Your phosphorus level should be?
- greater than 5.0
- less than 3.5
- I don't know what it should be.
- Your protein level should be?
- greater than 5.0
- less than 3.5
- I don't know what it should be.
- According to a standard, which is the best access for a dialysis treatment?
- AV fistula
- AV graft
- catheter in chest wall
- What are signs of infection of your dialysis access? Choose all that are the right answers.
- pus around your access site
- Which foods are the best sources of protein (albumin) for a dialysis patient? Choose all that are the right answers.
- lean meats
- low-fat yogurt
- What are symptoms of a high phosphorous level in your blood?
- dry skin
- numbness in legs and/or arms
- When should you take you phosphate binders?
- 30 minutes before meals
- 30 minutes after meals
- with my meal
- I don't know when I should take my binders.
- Your clearance level should be which of the following for hemodialysis patients?
- My Kt/V should be greater than 1.3.
- My Kt/V should be less than 1.3.
- My Kt/V should be greater than 1.2.
- I am not a hemodialysis patient.
- Your clearance level should be which of the following for peritoneal dialysis patients?
- My Kt/V should be greater than 1.2.
- My Kt/V should be less 1.2.
- I am not a peritoneal dialysis patient.
Note. Evidence-based test, developed by Drs. Michelle Lee and Brad Sherrod on specific KDOQI guidelines related to adequacy, nutrition, hemoglobin, fluid Intake, and access.