Patients must be assessed for the appropriateness of the dialysis prescription, blood pressure and fluid management at §494.80(a)(2), which encompasses intradialytic symptoms and issues, such as cramping, as well as dialysis adequacy.
Volume control, important to blood pressure management and cardiac health , is an essential component of dialysis care that requires ongoing attention from the care team.
Therefore, we are incorporating it into the “dose of dialysis” plan of care element.
Under the “Patient plan of care” condition, we have modified §494.90(a)(1) to read, “The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status ”
“ Protect the Pump ” The principal goal of these conditions is to improve cardiovascular outcomes by optimizing fluid management practices and strategies during hemodialysis
“ Protect the Pump ” Fluid Management is a - High Risk - High Volume - Problem Prone - High Cost Aspect of Care that must be clearly included in the Quality Assessment and Performance Improvement Plan (QAPI)
“ Protect the Pump ” Change concepts: Medical injuries and medical errors: V634(vi) “ Occurrences such as treatment prescription errors, intradialytic morbidities (IDMs) ….should be identified, reviewed and trended. “ Intradialytic morbidities” is any adverse symptom that occurs during the dialysis treatment to include but not be limited to seizures, chest pain, hypotension and cardiac arrest .
CVD is a major cause of hospital admissions for patients on hemodialysis, accounting for 49% of chronic and 40% of acute admissions
Pulmonary edema being the most common admitting diagnosis
Extra treatments for Fluid removal - UF only continue
IDMs are considered an acceptable/ expected side effect
Recovery time following typical HD is >1 day
The Dry Weight Issue Prevalence of Patients on Antihypertensives Cary, 2002 80-90% 2002 75% 1997 10% 1970
“ Protect the Pump ” Change concepts: V543 Dose of Dialysis The ultrafiltration component of the hemodialysis prescription should be optimized with a goal to render the patient euvolemic and normotensive. A patient at their EDW attains normotension for most of the interdialytic period, while avoiding orthostatic hypotension or postural symptoms either during or after dialysis. With successful fluid management, the number of medications a patient needs for blood pressure control may be able to be reduced.
Clinical Studies compiled over 5 years have documented:
70% Reduction in Intradialytic Morbidity
50% Reduction in Anti-hypertensive medications
48% Reduction in Hospitalizations due to Fluid
> 45% Reduction in Hospitalizations due to
Access Complications (See Howard, et al.)
55% Reduction in Left Ventricular Hypertrophy
Crit-Line’s Clinical Impact in Fluid Management
Meeting the new Conditions of Coverage with the Crit-Line Monitor (CLM) : Protect the Pump CLM IMPACTS : Hypotension, Hypertension, CHF, Myocardial Infarction, Organ Ischemia Stroke, Sudden Death Quality of Life Costs Financial Costs
Quality of Life Costs Patient Recovery Time, AMA’s, Rehabilitation Potential Financial Costs Hospitalizations/Hospital Days Medications/IV Solutions to TX SX Medications to TX Hypertnesion OUTCOME MEASURES BP’s (Hi/Low/Medications), Dry Weight/ECV/TBW, Residual Renal Function, Inter/Intradialytic Symptoms, Sudden Death, Left Ventricular Mass Index (Echo), Hospitalizations/Morbidity/mortality/Economics/QOL, Hemoglobin Variability
Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management. To learn how the Crit-Line Monitor can help you meet these new conditions, please select Section 2 of this presentation.
Please call 1-800-546-5463 if you would like additional information or would be interested in evaluating Crit-Line at your clinic
Additional information can also be found at www.hemametrics.com
Section 2 Crit-Line Monitor a tool for compliance with Conditions of Coverage.
Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management. In this section, you will learn how the Crit-Line Monitor can help you comply with these new conditions.
HYPOXEMIA DURING HEMODIALYSIS Blocks the release of norepinephrine from sympathetic nerve terminals Blocks the release of norepinephrine from sympathetic nerve terminals Releases adenosine Releases adenosine This tissue ischemia effect maybe the reason that anemic patients are prone to hypotension. . This tissue ischemia effect maybe the reason that anemic patients are prone to hypotension . TISSUE ISCHEMIA TISSUE ISCHEMIA TISSUE ISCHEMIA
90 to 100% is considered normal for arterial sats (SaO 2 )
60 to 80% for mixed venous sats (SvO 2 )
Time (hours) Oxygen Saturation Sleep Apnea Profile Sleep Complimentary Oxygen Delivery Issues 0 2 Delivery 20+ % of HD patients have intradialytic hypoxemia and up to 70% are sleep apneics. 0 1 2 3 4 80 85 90 95
Evidence of implementation of the plan of care for this aspect would include:
Treatment records reflecting attaining the target weight at the end of each treatment
Documentation acknowledging the target weight was not attained with an assessment of the reason for not attaining it, and a plan to correct this issue.
Blood Volume Monitoring and Post Dialysis Vascular Refill( Dry Weight Check) in 3 Different Patients. Arrows show end of ultrafiltration Hours Hours BV reduction: 16% No Vascular Refill BV reduction: 12% Vascular Refill BV reduction: 6% SLT Vascular Refill Rodriguez et al Kidney Int 68:854,2005