الفهرس 
MATERIAL AND METHODSOnly 14 pages are availabe for public view
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Abstract
ESRD has emerged as a major public health problem around the world. One of the main and lifesaving lines of medical interventions for patients with ESRD is HD. While HD has improved patients‘ care, questions remain regarding the quality of care provided to patients by dialysis facilities.
Nowadays, continuous improvement in quality and safety of the care provided to those patients has become a central topic in dialysis. Studies showed clearly that compliance to guidelines results in better outcome. In recent decades, several important advances have been made in the therapy of HD with the introduction of these international guidelines to ensure standardization and the delivery of optimum care. Accurate and appropriate measures of the quality of care provided by any health professional are essential to provide evidence that care is the best it could be. In patients receiving long-term HD, meeting multiple clinical measure targets is associated with a decrease in hospitalization and mortality rates.
This study aims to:
1. To assess the structure of HD units in comparison to the selected HD practice guideline.
2. To identify the degree of compliance of current practice of health care personnel to the selected HD practice guideline.
3. To evaluate the outcome of care provided for patient receiving permanent HD in terms of:
a. The attaining clinical performance measures (targets) for HD patient care
b. Hospitalization
c. Mortality
4. To determine the association between the attaining clinical performance measures for HD patient care with favorable twelve months outcome (hospitalization and mortality).
5. To estimate health-related quality of life of HD patients.
The study was conducted in HD units of the three Health Insurance hospitals in Alexandria, at 2013, including:
Gamal Abdel-Nasser hospital (665 beds), with 28 HD machines (17 for seronegative patients, 3 machines for hepatitis B virus (HBV) positive patients, and 8 machines for hepatitis C virus (HCV) positive patients).
Abou Kir Insurance Hospital (254 beds), which include 14 HD machines (10 for seronegative patients, and 4 for HCV positive patients).
Karmouz Hospital (301 Beds), with 17 HD machines (11 seronegative, and 6 for HCV positive patients).
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The study included prospective and cross sectional design.
The study sample consists of all patients receiving long-term HD in the study setting who are above eighteen years old and receiving regular three HD sessions per week. All medical records of patients who meet the selection criteria, all staff of HD units, and 159 HD sessions performed on the selected HD patients were observed.
As regards data collection; for the cross sectional study, patients were interviewed using structured, validated Arabic form of KDQoL-SFTM, version 1.3 questionnaire to ass their quality of life. HD guidelines were then selected. Then observation was conducted to collect data pertaining to the structure, patient care practices, and infection control practices based on the selected guidelines in the studied HD units. Structured staff interview to collect data about staffing, their qualifications and experiences, and healthcare staff/patients ratio was also conducted.
For the prospective part of the study, medical records of patients who meet the selection criteria were followed for one year to collect data about the primary cause of renal failure, laboratory tests results including hemoglobin, serum albumin, serum calcium, phosphorus, viral serology (HBV, HCV, HIV), then calculation of clinical performance measures targets attainment based on KDOQI.
The study revealed the following findings:
Compliance with structure measures:
For sub-items of the facility domain the average compliance with guidelines was 91.7% for administration standards, 85.7% for sterilization and disinfection areas, and 77.8% for physical standards, and 53.3% for nursing station.
Compliance with dialysis treatment area standards were less than 50 % in all hospitals (47.4%, 43.9%, 43.9% in Gamal, Abou Kir, and Karmouz hospitals respectively).
The average patients/physician/shift ratio ranged between 1.6 and 9.
Patients/staff nurse ratio ranged between 2.8 and 4.5.
For patients/nursing supervisors‘ ratio, it was ranging between 6.3 and 18.
Physicians with current BLS certificate ranging between 45.4% in Karmouz hospital, and 77.8% in Abu Kir hospital, and only 1 nursing supervisor in each hospital had current BLS certificate.
In Gamal Abdul-Nasser hospital, about 35.7% of nurses were BLS certified, while only 30.0% in Abou Kir hospital and 0.7% of Karmouz nurses are BLS certified.
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Compliance with process measures
For the patient care domain the highest compliance was with termination of dialysis and post-dialysis guidelines were 68.1% and 55.9% respectively. While the lowest compliance was with pre-dialysis preparation and dialysis monitoring (18.02%, and 25.8% respectively).
Hemoglobin monthly measurement according to guidelines was done only in 26.3% of patients. Compliance with measuring Albumin at least 4 times per year was achieved in less than half of patients (45.1%). On the other hand, compliance with measuring calcium and phosphorus was high (97.1%, and 97.7% respectively).
For infection control items, the highest score percentage was for compliance with AVF/graft or catheter care (72.1%), followed by environmental cleaning and disinfection (67.2%). On the other hand, compliance with using PPE (9.3%), and hand hygiene (27.9%) received the lowest percentage.
Outcome measures:
Hemoglobin target was attained in 14.3% of patients, albumin in 74.0%, calcium x phosphorus target in 78.3%, blood pressure target in 49.3%, and IV target in 99.1% of patients.
Only 1.3% had attained the whole five targets. While 2.7% attained one target, 27.6% attained two targets, 45.7% attained three targets, and 22.7% attained four targets.
The death rate was higher in Gamal Abdul Nasser Hospital (25.0%), compared to 14.5%, and 14.3% at Abou Kir and Karmouz hospitals respectively.
Median hospitalization per patient year was1, and the median hospitalization days per patient year was 5.0.
Mortality and hospitalization rates were highest among patients‘ attained two targets (32.3%, and 51.6% of patients‘ attained two targets respectively). Mortality and hospitalization were lowest among patients attained the four targets (5.9%, and 19.6% of patients attained four targets respectively).
The presence of cardiovascular comorbidity significantly increased risk of death by 3.7 times, hospitalization increased risk of death by 4.8 times, while reaching the target values of DBP decreased risk of death to 0.032.
the presence of cardiovascular comorbidity increased risk of hospitalization by 5 times, presence of diabetes mellitus increase risk of hospitalization by 3.7 times, and hypertension by 2.6 times. While reaching the target values of hemoglobin and albumin decreased risk of hospitalization to 0.296 and 0.202 respectively
The overall QoL score was 39.26. Attainment of more targets was significantly associated with better quality of life in all domains.
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Accordingly, the following recommendations are suggested:
selection, adoption, and distribution of evidence based guidelines to all HD unites.
Continuous monitoring and evaluating quality of care provided to dialysis patients.
Provision of adequate infection control facilities, with continuous monitoring of compliance with recommended guidelines.
Proper staff distribution to ensure adequate staff/patient ratio.
Further improvement is needed regarding anemia management, blood pressure control, calcium and phosphate metabolism, and continuous monitoring of dialysis adequacy.
Improve quality of care provided to HD patients through coordinated, multidisciplinary program.
Continuous education of HD staff, through organized in-service training to increase their knowledge and skills about the importance of improving QOL of HD patients.
Educational program for patients with ESRD should be initiated during the predialysis stage and continued after maintenance dialysis.
Psychosocial and nutritional support for HD patient.
Support from non-governmental organizations.
Future researches are recommended to determine the effect of each individual and combined targets attainment on HD patients.