Meeting The Fluid Management Conditions of Coverage Thru Crit-Line Monitor Use

1. Meeting The Fluid Management Conditions of Coverage Thru Crit-Line Monitor Use

2. TODAY’S PRESENTER 

3. Objectives Discuss the rationale for adding fluid management into the Conditions of Coverage (CfC)? Review the long-term complications of HD related to FVE and FVD State the conditions and interpretive guidelines related to fluid management Verbalize the CLM as the Gold Standard of fluid management to meet the CfC

4. Conditions of Coverage: Community Comments Volume mismanagement is the main cause for cardiac related morbidity and mortality rates Not referring to it was a “Serious Omission” that needed to be corrected. Fluid management cited as the current “Orphan in Quality Assessment”. It is the “Single Most important indicator” related to morbidity and mortality Without managing volume and its effects on the heart, there would be no patients.

5. Conditions of Coverage 494.80 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.

6. Conditions of Coverage: Community Comments CMS received several comments regarding §494.90(a)(1), “Dose of dialysis.” Some commenters suggested we include patient volume status ( measurement of body fluid removal) in the adequacy requirement

7. Conditions of Coverage: Community Comments Kt/V levels did not correlate with mortality or morbidity Dialysis adequacy monitoring needs to be modified to require facilities to “monitor fluid status.” Better methods of measuring intravascular volume and related blood pressure changes are needed

8. Conditions of Coverage 494.90 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”

9. “Protect the Pump ”

10. “Protect the Pump ”

11. “Protect the Pump”

12. “Protect the Pump”

13. Current Trend :Safe Occurrence of Intradialytic Morbidities (Ischemic events) during HD : Hypotension up to 50% Hypoxemia 50% Cramping 20% Nausea/ vomiting 15% Seizures up to 10% Angina 5% Myocardial Ischemia 22% TXs Dysrhythmias 50% of patients Cardiac arrest 7/100,000 TX Sudden death 25% of all deaths in HD population

14. Effects of Intradialytic Hypotension Tissue Ischemia / Hypoxia Adenosine release causing decrease in PVR Changes in Mental status / Seizures / Stroke Vision changes Silent cardiac ischemia / MI Ischemia / Infarct to the gut Decrease in Residual Renal Function Ischemia = decrease in URR

15. “Protect the Pump”

16. V640 : Patient Safety The facility must immediately correct any identified problems that threaten the health and safety of patients.

17. Current Trend: Effective Mortality rate remains >20% Average ESRD Treatment Life is 62 months CVD accounts for 50% >90% of patients are hypertensive 70% have Left Ventricular hypertrophy CHF was found in 40% of ESRD patients 60% remain in fluid volume excess post TX Two or more hypotensive episodes per week increase the death rate by 70% Residual Kidney function decreases with IDMs Hemoglobin “Time in range” remains difficult to maintain

18. “Protect the Pump”

19. Current Trend: Efficient Average BP meds 3 ( 5 not uncommon)? 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

20. The Dry Weight Issue

21. “Protect the Pump”

22. Quotes from Dr Charra “Need to Focus on Dry Weight” “Dropped the Ball with failure to Achieve and maintenance Dry Weights” “Control of Dry Weight = Control BP = Increase in Survival Rate”

23. Current Trend: Patient Centered UF Goal set by comparing pre-weight to EDW EDW generally incorrect UFRs exceed recommended 10ml/kg/ hr Plasma refill rates are different on different days depending on numerous patient variables UF Profiles are not individualized for each TX Standard 2 gram sodium diet still prevalent Facility Standard Dialysis bath / temperature Sodium modeling remains on the majority of patients

24. To avoid thirst, fluid gains and hypertension, the NKF-KDOQI Clinical Practice Guidelines state that increasing positive sodium balance by “sodium profiling” or using a high dialysate sodium concentration should be avoided.

25. “Protect the Pump”

26. Current Trend: Patient Centered Oxygen needs are rarely assessed Root causes for IDMs rarely assessed TX of IDMs consist of stopping UFR/ Normal saline/ Position change Staff feel they are doing “all they can do” Patients are labeled “noncompliant” if fluid gains are excessive Patients are blamed for the cause of crashing Staff/ Patients believe that if they “crash” they have reached their EDW

28. Dialysis Assessment Just because a patient “Crashes” It does NOT Mean they are “DRY”!!!

29. “Protect the Pump ”

30. V559: Adjusting the plan of care This requirement is not met/ not satisfied if: The patient's plan of care is not adjusted / individualized There is no evidence the IDT is working to address ongoing problems (e.g., uncontrolled hypertension, hyperkalemia, missed treatments, inaccurate or unattainable target weight The only reason documented for failure to achieve goal(s) is “patient non-compliance” or “non-adherence.”

31. Current Trend: Timely Treatment of IDMs are reactive vs. proactive EDW is changed after event or admission for CHF UFR generally exceed plasma refill rate causing IDMs Number one cause of getting off early / skipping TX is IDMs or fear of them

32. Current Trend: Equitable Hospital days remain high: - 2 admissions; 14 days per patient per year - CV causes are increasing by 10% - Time in range effects the Relative Risk Extra normal saline, hypertonic, mannitol. Albumin, oral medications given for treatment and prevention on IDMs Patient are still receiving extra treatments for fluid removal Medicare budget is significantly impacted

33. “Protect the Pump ”

34. “Protect the Pump ”

35. V543:Dose of dialysis Defines EDW- and the inter/ intradialytic measures that will be used to evaluate the outcomes: A patient at their EDW should be: - asymptomatic and - normotensive - on minimum blood pressure medications - while preserving organ perfusion and - maintaining existing residual renal function

36. “Protect the Pump” Clinical Performance Measures (CPMs) for fluid management ( attaining Dry Weight) may include: Pre/ Post/ lowest BP Number of BP medications Hospitalizations related to fluid management Intra/ interdialytic morbidities Cardiac arrest, sudden death Reassessment of residual kidney function (RKF)? Dry Weight (plasma refill) checks if BVM available

37. QAPI: Measurement Assessment Tool (MAT)? V543 Dose of Dialysis: Management of volume status Value monitored: Euvolemic and Normotensive - BP 130/80 (adult)? - Lower of 90% of normal for age/ht/wt or 130/80 (pediatric)?

38. Learning from “history” Clyde Shields First long-term HD patient in the US, March 1960 Developed malignant HTN within a few months Treatment: aggressive ultrafiltration (UF)? Three times per week HD – 8-10 hours each Result: 11 years of dialysis in the 1960s “The key to treating HTN in dialysis patients is adequate control of the extracellular volume”.

39. The new conditions of coverage also elevate the importance of fluid management effects on: Anemia (V507; V547)? Nutritional status(V509; V545)? Access patency(V 551)?

40. 494.140 Condition: Personnel qualifications.V681 Staff education is now mandated to include specific competencies such as : Identifying and treating intradialytic morbidities Monitoring patients Equipment alarms

41. Crit-Line Monitor:The Gold Standard of Optimal Fluid Management

45. End – Section 1 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.

46. Additional Information 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

47. Section 2Crit-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.

57. Types of Hypoxia: Causes in ESRD

58. Factors to Consider:Source Arterial Blood: Internal Access ( Fistula /Graft) Mixed Venous Blood: CVC line 90 to 100% is considered normal for arterial sats (SaO2)? 60 to 80% for mixed venous sats (SvO2)?

60. Access: Catheter SvO2

61. Factors to Consider:Source The continuous monitoring of SvO2 is a sensitive Parameter of continuous Cardiac Output C. O. = Heart Rate x Stroke Volume

62. Seizure 1 hour 55 min into TX

64. The Guyton Curve

72. Blood Volume Monitoring and Post Dialysis Vascular Refill( Dry Weight Check) in 3 Different Patients.Arrows show end of ultrafiltration

73. Rodriguez Summary When used in combination with clinical assessment, the Crit-Line monitor results in: Optimization of Extracellular fluid status Reductions of intra and post dialysis morbid complications Improvements in patient well-being Potential reductions in hospitalization due to fluid overload “Provides an objective way of assigning Dry Weight”

74. V504: Blood Pressure and Fluid Management Needs ...”blood volume monitoring during hemodialysis should be available in order to evaluate body weight changes for gains in muscle weight vs. fluid overload”. - Mandated for pediatric patients - Imperative for adult patients

75. V504: Blood Pressure and Fluid Management Needs The comprehensive assessment should include evaluation of the patient’s: Plan of Care Medications Pre/intra/post and interdialytic blood pressures, Interdialytic weight gains Target Weight vs. Ideal Dry Weight Related intradialytic symptoms (e.g., hypertension, hypotension, muscular cramping)? Along with an analysis for potential root causes.

76. Root Causes of Intradialytic Morbidities Posture Low O2 saturation Medications / Antihypertensives Incorrect Ultrafiltration rate Hypotonic environment / Hypoalbuminemia Dialysate at body temperature or warmer: core body heating Splanchnic vasodilatation secondary to food ingestion Electrolyte/Acid-Base Imbalance Incorrect dialysis bath for individual patient Severe anemia (HCT <30) / Occult hemorrhage Unstable cardiovascular status / Arrhythmias / Pericardial tamponade / MI High Output failure related to high access blood flow rate (QA)? Septicemia Dialyzer reaction, Hemolysis and Air embolisim

77. Root Cause Analysis Thru The Crit Line Monitor Anemia Hypoxemia Oxygen carrying capacity Hypervolemia Hypovolemia UFR is incorrect: too fast / too slow Patient is at dry weight Position effects Effects/ need for hypertonic; replacement fluid Low cardiac output ( SvO2 ) Effects of eating

78. Administration’s Next Step Assign a Fluid Manager to each facility Provide necessary technology Incorporate competency based fluid management & CLM training in orientation and annual in-services Educate patient / families on fluid management Ensure use of monitors each shift Approve Hema Metrics “ Recommended Guidelines” for CLM use Order / reinforce “Dry Weight / Refill Checks” PAGE 1

79. Administration’s Next Step Round / Review profiles and tracking tools with staff Assess Medications on ongoing basis Reassess protocols for Sodium Modeling, Eating, use of Oxygen and Thermal Control Review hospitalization diagnosis for accuracy Analyze Root causes of IDM with staff Add Fluid Management into the facility QAPI program PAGE 2

80. Potential Quality Indicators Hospitalization rate : Hospitalization Causes Intradialytic events: Number / Type / Cause Incidence of Hypoxemia Access Morbidity Anemia Management : Hemoglobin variability Albumin levels Dry Weight changes PAGE 1

81. Potential Quality Indicators Reduction in BP meds Left ventricular mass index (echo) Morbidity/ Mortality Economics Quality Of Life Patient Satisfaction Skipped Treatments / Early sign offs PAGE 2

82. End – Section 2 Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management, and how the Crit-Line will assist you in achieving the new mandates.

83. Additional Information 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