Running late = speed it up

Ask Our Experts Dr. John Agar, Nephrologist
1

Hello Dr Agar,

I have 2 questions for you tonight if you please but will post them as different topics as they are not related and will give others a chance to read/reply as they wish and again I appreciate your time in reponding to these. So here we go for the first one.

I went to see the Neph today as a 4 weekly scheduled appointment, whilst I was there the Renal Nurse and I had a conversation about dialysis. without going into too much detail we talked about the schelue for dialising (thrice wekly) and i said there was a possibility that at times I could be, due to work commitments, on the odd occasion be late. I asked what would happen then would they turn me away?
She said that they would then ‘speed up the treatment’. Considering that the treatments are usually 3 hour sessions, and baring in mind how you advocate ‘slower, longer and more often’ is best, I’m wondering if this would be good practice and is it normal for dialysis units to do this?

Is there not a greater risk of cramping, fainting and or other ‘damage’ or not removing/over removing wastes that need to go? Is this normal precitce for Renal units and what do you do in Australia?

Thank you for your time Dr Agar.

Yours

Shaymon

2

Hi Shaymon,

I’m sure Dr. Agar will pop in and answer this. But I’m alarmed to hear that treatments are “usually 3 hours”–when research shows clearly (and US expert nephrologists agree) that anything less than 4 hours is unwise, and even 4 hours is a minimum. In the Dialysis Outcomes and Practice Patterns (DOPPS) international study of 22,000 people, researchers found that when treatments were at least 4 hours, people had a 30% better chance of survival. And, each extra 30 minutes improved survival by another 7%. (Saran R et al, Kidney Int. 2006 69:1222-28).

3

I think you knew what I would answer when you posed this question, Shaymon, as I know that you are already aware of my strong views about time and frequency, and that we should never contract treatment time but, rather, wherever possible encourage treatment lengthening.

But again, you knew I’d say that!

I agree fully with Dori’s response and I can only but echo her ‘What, only 3 hours? … and, that is your routine scheduling? … and, in 2011, and in the UK?’

I rather think you are pulling my leg !

To answer your question … no, I don’t think we would ever speed up a treatment though I am aware that some units may respond this way. However, I could never regard it as ‘good practice’ to do so.

Here, our mean conventional facility-based HD treatment time is now out to about 270 minutes x 3 (minimum) per week. DOPPS records Australia as being second only in treatment time to the Japanese and with significantly longer treatment times than the other DOPPS-surveyed nations.

On the subject of DOPPS (I, II, III and IV), there is one anomaly which, to us (in ANZ) is hugely important but is of little relevance, impact or influence on the data in in another DOPPS country … and that is: DOPPS only includes patients drawn from facility care!

Why do we care so much, yet no-one else cares a jot?

Well … of the total Australian dialysis population ~10,500, ~31% of all our dialysis is done at home. At home, about 2/3rds is PD and 1/3rd is HD [home PD 20-21%, home HD 10-11%].

As NZ has an even higher percentage on home HD than does Australia, across all of ANZ (Note: DOPPS combines us), 13-14% of the combined Australian and New Zealand HD population are excluded from DOPPS analysis! This means that our most fistula’ed, best performing, lowest morbidity, longest and most frequently dialysing patients do not appear in the DOPPS data. To us, this is a huge issue - as our ‘best’ patients are not in the DOPPS data at all! They are purposefully excluded. Now, that matters little if your home HD is <1% of all dialysis (eg: US) … but it makes a big difference to our ANZ data! And, it wrankles us, like a burr under our saddle.

This also means that our overall mean dialysis times would be, comparatively, even longer than the current DOPPS data suggests - if our home patients were included. This is especially so if you consider that the vast majority of ANZ home-based HD patients now prefer and select long, 8-9 hour, overnight nocturnal schedules and almost all our Australian ~1,000 home HD patients now do a minimum of alternate daily (or, rather, nightly) dialysis with a national home HD frequency mean of about 4 runs per week.

Even the thought of a facility-based therapy set at 3 hours is anathema to me - let alone a further ‘shortening’ of it.

To further shorten the session by ‘speeding up’ the dialysis seems …

(a) more a punishment than a solution
and …
(b) would likely be counterproductive anyway, as the staff are more likely then to have to deal with the patient going suddenly ‘flat’, cramping, requiring saline or resuscitation

… and thereby only increasing work load and lengthening, not shortening the sessional time.

If one of our patients is occasionally a ‘little’ late – and all units understand that that happens, especially with working patients, city traffic, etc – then our rosters are, I think, structured to be flexible enough to in-build these ‘glitches’ into the service we give. Our staff would simply extend the treatment at the finish end of the session, stay later, do ‘whatever’ - and get on with it.

However, I certainly understand how a regularly ‘late’ attendee can disrupt the logistics of working schedules and become a rostering nightmare for unit managers. While most units do try to cater for the needs of all, dialysis units try to run set nursing rosters and most have 2 or more scheduled treatment sessions each day. A chronic late attendee can really become a problem.

We try to work with any such ‘problem’ patient to nut out out a better schedule where an on-time arrival can be more assured.

But … shorten the session? … no!

4

Hello Dr Agar,

Thank you for this reply and as always your time too. Here you have made a good and important point and that was to question my information to you, and this did make me think if I had the original information right, (I hate it when people do that to me, but of course you were right to do so. I include Dori in this too ) so just to make sure I just phoned the dialysis unit to check what I had said was correct.

I have just got off the phone to them. My question was to them “what is the duration of a dialysis session for in centre heamodiaysis session?”
The reply was “to start with it is 3 hours. Then after that depending on blood results 3-4 hours”

You are right Dr Agar I do know your stongly held views on duration of dialysis and from all the posts it has never wavered and I have no doubt that Alice rock would be worn by the weather to sand before you change it. I too like to get my information correct before I ask such an imprtant question hence me asking the Dalysis unit the above question tonight. And I have also qustioned myself on this; did I hear correctly and did I ask the right questions?

I did think that when I was told that the sessions would be shortened that it was perhaps not the best way to go about things but giving the information suppiler some grace it was during a rather, lets call it a ‘lively’ discussion, and perhaps I may have been slightly provocative in my questions too, but if you don’t ask you never find out these things. Of course I am no expert and have no experience of actual dialysis at the moment but the time is encrouching fast, so I’d rather be prepared.

I also understand what you say about the perpetual tardy patient, they must cause all sort of issues not just the running and staffing of the units, but all the other issues that could manifest health wise so I guess its a case of you scratch my back and I’ll scratch yours, life goes on and jelly never sets in the sun.

You have as always been sagacious and helpfull beyong asking…thank you.

Yours

Shaymon