Phosphorous Management Quality Improvement Module. PO4 Goal

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1 Phosphorous Management Quality Improvement Module PO4 Goal July 2009

2 Phosphorous Management Quality Improvement Module Table of Contents Components, Project Goals and Instructions 5 Section 1 Introduction 11 Section 2 QAPI Tools 19 Phosphorous Management Barriers Facility Self Assessment 21 QAPI Action Plan 25 Run Chart 27 Data Collection Tool 29 Section 3 Staff Activities 31 QAPI Team Members 33 Nurses, Patient Care Technicians, and Social Worker(s) 35 Dietitian(s) 37 Section 4 Patient Education 39 It Will Do Your Heart and Bones Good! (English/Spanish) 43 Phosphorous Report Card Know Your Numbers (English/Spanish) 51 Section 5 Evaluation 55 Section 6 Resources for Patients and Professionals 59 Resources for Patients 61 Resources for Professionals 63 Section 7 Additional Professional & Patient Educational Resources 65 *Will be mailed to facility October 2009! Section 8 Additional Professional & Patient Educational Resources 67 *Will be mailed to facility January 2010! Page 3 The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX July 2009

3 Phosphorous Management Quality Improvement Module Components Quality Improvement Tools and Resources Interdisciplinary Staff Education Resources Patient Education Resources Project Goals Provide technical assistance and education to Network #14 facilities to encourage and support facility-level quality initiatives that stimulate improvement in patient care, practice patterns, processes and outcomes for Phosphorous Management. Foster internal quality improvement at the facility level by assisting facilities in the development, implementation, maintenance and evaluation of an effective data-driven, interdisciplinary Phosphorous Management Quality Assessment and Performance Improvement (QAPI) Project that focuses on improved processes of care and health outcomes. Promote increased awareness and accountability among interdisciplinary treatment team members (including nephrologists, nurses, PCTs, dietitians, social workers and patients and their significant others) regarding their role in achieving optimal phosphorous outcomes. The ESRD Network of Texas, Inc. operates under Contract HHSM NW014C with the Centers for Medicare and Medicaid Services (CMS) as ESRD Network #14 (NW #14) which encompasses the state of Texas. The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX July 2009 Page 5

4 !!! ATTENTION!!! ESRD Network #14 Phosphorous Management QAPI Webinar Thursday - July 30, :00pm 3:00pm CST Donald Molony, MD - Professor of Medicine University of TX Health Sciences Center, Houston NW #14 Medical Review Board Chair-Elect Bobbie Knotek, BSN, RN, CNN NW #14 Quality Improvement Director Webinar Enrollment Instructions: Open Internet Explorer. Go to https://ifmcevents.webex.com. Locate the name of the event: Phosphorous Quality Improvement Project Click on the Enroll button to the right of the event title. Enter the required information. Immediately upon submission of this information you will receive an informing you that your enrollment is pending. If your enrollment is approved, you will receive an containing detailed instructions for joining the meeting. If your enrollment is declined, you will receive an explaining the reasons for your declined enrollment. If you experience any difficulties in enrolling or joining this event, please contact the IFMC WebEx Helpline at (515) WHO should attend? Facility QAPI Team Members Facility Administrator Nephrologists Peritoneal Dialysis Coordinators (if applicable) Dietitians Social Workers Corporate Quality Directors Webinar will be recorded Phosphorous mg/dl Webinar Information 125 Webinar phone lines will be available for Open Registration Facilities registering for Webinar will be limited to (1) phone line per facility Webinar will be recorded for future viewing by your nurses and PCTs Register early to reserve a place for YOUR QAPI team!

5 Phosphorus Management Quality Improvement Project Instructions To maximize your facility s benefit during the Phosphorous Management Quality Improvement Project we recommend you follow the module implementation instructions below. Step #1: Copy and distribute module (including cover letter) to Quality Assessment and Performance Improvement (QAPI) Team Members, facility Nephrologists, Dietitians, and Social Workers. Step #2: Complete and discuss the baseline Phosphorus Management Barriers Facility Self - Assessment Tool (Section 2) for June 2009 in your next QAPI meeting. During October 2009 QAPI meeting complete the barriers tool for September 2009 and discuss progress compared to baseline. During January 2010 QAPI meeting complete the barriers tool for December 2009 and discuss progress compared to baseline and 3 month results. If facility phosphorous management goal not obtained by March 2010, continue to complete and discuss the barrier tool in QAPI meetings. Step #3: Use the QAPI Action Plan (Section 2) to develop a facility specific QAPI plan addressing your facility s phosphorous management barriers. Review the QAPI Action Plan in monthly QAPI meetings, monitoring progress and completion of deadlines by assigned team members. Revise QAPI Action Plan as necessary based on progress to date. Step #4: Enter your facility s monthly phosphorous outcome data on Facility Run Chart (Section 2) and review/compare to previous outcomes in QAPI meetings. Step #5: Complete the Phosphorous Management Data Collection Tool (Section 2) on a monthly basis to track, trend and analyze patient s with phosphorous greater than 5.5 mg/dl. Step #6: Staff Education (Section 3): Distribute educational material instructions to QAPI Team members, Nurses, Patient Care Technicians, Social Worker(s), Dietitian(s), and all nephrologists practicing in facility to stimulate discussion and process/strategy development. We recommend all interdisciplinary team members complete designated educational activities no later than August 15, Place completed CE/CME Certificates in personnel training records. Step #7: Patient Education (Section 4): Make copies and distribute the following educational tools to all facility patients: o It Will Do Your Heart and Bones Good (English or Spanish) o Report Card (English or Spanish) Please ask your staff to review the Report Card with patients and assist as needed. Step #8: Complete the Evaluation Scan (Section 5) and fax to the ESRD Network at (972) Due Monday, August 31, Please note - CMS requires Networks to obtain a minimum response rate on all project evaluations, therefore if we do not receive your facility s evaluation, you will receive fax reminder(s) from us. Please look for Phosphorous Management QIP Module Part 2 to arrive at your facility in October Thank you for your support and participation! The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 9

6 Section 1 Introduction Page 11

7 Phosphorus Management End Stage Renal Disease Network of Texas, Inc. (NW #14) Quality Improvement Project Project Goals: Stimulate development, implementation, maintenance and evaluation of data driven, interdisciplinary Phosphorous Management Quality Assessment and Performance Improvement (QAPI) Projects that focus on improved clinical processes and health outcomes at the facility level Promote increased awareness, knowledge and accountability of interdisciplinary treatment team member roles in the optimal management of Phosphorous outcomes (i.e., nephrologists, nurses, PCTs, dietitians, social workers and patients and significant others) Background: National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) Bone Metabolism and Disease Guideline #3, Evaluation of Serum Phosphorous, describes the link between hyperphosphatemia and increased morbidity and mortality in the CKD population. Multiple observational studies performed between demonstrated significant increases in the relative risk of mortality with minimal elevations in serum phosphorous (i.e., mg/dl. increases), with increased mortality risk observed as serum phosphorous levels continued to rise. Based on these findings, current K/DOQI Guidelines recommend serum phosphorous levels be maintained between mg/dl for patients in Stage 5 CKD to maximize health outcomes. Although nephrology clinicians have been waging war against the bone and mineral metabolism disorders precipitated by hyperphosphatemia since the advent of chronic dialysis, many clinicians and patients were unaware until recently of the devastating vascular and cardiovascular morbidities associated with hyperphosphatemia. Researchers hypothesize that soft-tissue and vascular calcifications seen with hyperphosphatemia are caused by increases in the calcium-phosphate product or by actual calcification. These calcifications, seen in coronary arteries, cardiac valves and pulmonary tissues, lead to cardiac disease, the leading cause of death in patients with CKD. However, even though there is consensus throughout the nephrology community that prevention of hyperphosphatemia and maintenance of serum phosphorus levels within the normal range are critical components of ESRD care, patient non-adherence to diet and medications make phosphorous management one of the most difficult clinical indicators to adequately control. Based on: a) the numerous clinical research studies linking hyperphosphatemia with increased cardiovascular morbidity and mortality in the CKD population; b) the 2003 NKF-K/DOQI Bone Metabolism and Disease Guidelines and c) the less than optimal phosphorous management outcomes reported by Texas and the U.S. over time, Network #14 s Medical Review Board unanimously selected Phosphorous Management as the ESRD Network of Texas, Inc. Quality Improvement Project (QIP). The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 13

8 Data Analysis: Clinical performance measures (CPM) data supporting NW #14 quality improvement projects is collected and analyzed on an annual basis by Network #14 through the following process steps: 1. All Texas dialysis facilities (adult, pediatric, corporate, non-corporate, regional, etc.) provide clinical performance measure data for analysis via the Lab Data Collection Project. Large dialysis organizations (LDOs) provide data using electronic data transfer. All remaining facilities (non-ldos) provide CPM data directly to Network # LDO and non-ldo CPM data sets are merged, analyzed and aggregated at the facility and Network level. 3. Facility-specific aggregate data reports with Network #14 comparative data are provided to Texas hemodialysis and peritoneal dialysis facilities. 4. The Network #14 MRB reviews trended outcomes, current Network averages and Network distribution charts and recommends MRB Quality of Care Concern Cut-Points for each CPM that define the minimally acceptable standard of care for that indicator. 5. The Network #14 QI department utilizes the MRB Quality of Care Concern Cut-Points to identify, notify and intervene with outlier facilities in need of educational and quality improvement assistance. 6. This same process is used to identify high performing facilities that have achieved outcomes in the top 10% for an indictor for one and two consecutive years. During the Phosphorous Management Project, outlier facilities and high-performing facilities will receive the following interventions and/or recognitions: MRB Quality of Care Concern Cut-Points for Phosphorous Management will be used to identify, notify and intervene with outlier facilities in need of educational and quality improvement assistance. The MRB recommended that NW #14 utilize the following QOC Concern Cut-Point for Phosphorous Management to identify outliers for the Phosphorous Management QIP Greater than 40% of a facility s patients should be achieving a serum phosphorous level > 3.5 and < 5.5 mg/dl. Facilities with one and two year outlier status will receive a notification letter with this module and will be required to participate in Phosphorous Management QIP activities. All facilities are encouraged to actively participate in the Phosphorous Management QIP to improve facility phosphorous management outcomes, thus positively impacting patient quality of life, health and well-being and decreasing the risk of morbidity and mortality secondary to soft tissue and vascular calcification. Facilities achieving phosphorous outcomes in the top 10% for one year will be notified that they have achieved Recognized Status. Facilities achieving phosphorous outcomes in the top 10% for two years will be notified that they have achieved Benchmark Status and will be asked to share Best Demonstrated Processes and Practices with other Network #14 facilities The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 14

9 # of Facilities Distribution of HD Facilities by Percent of Patients with Phosphorous > 3.5 and < 5.5 mg/dl ESRD NW #14 of Texas 2009 Quality of Care Project (4th Qtr 2009) 2009 M R B C ut P oin t < 40 % of P at ie nts w ith P O 4 > 3.5 to < 5.5 mg/d l % of Facility's Patients with Serum PO4 > 3.5 and < 5.5 Distribution of Hemodialysis (HD) Facilities by Percent of Patients with Serum Phosphorous > 3.5 and < 5.5 mg/dl ESRD NW # Quality of Care Project (4 th Qtr 2008 data) Percent of Facility Patients With Phosphorous < 3.5 and < 5.5 mg/dl Outlier Facilities # Facilities % Facilities Total % The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 15

10 # of Facilities Distribution of PD Facilities by Percent of Patients with Phosphorous > 3.5 and < 5.5 mg/dl ESRD NW #14 of Texas 2009 Quality of Care Project (4th Qtr 2009) M R B C ut P o in t < 4 0 % o f P a t ie nt s w it h P O 4 > 3.5 t o < 5.5 mg /d l % of Facility's Patients with Serum PO4 > 3.5 and < Distribution of Peritoneal Dialysis (PD) Facilities by Percent of Patients with Serum Phosphorous > 3.5 and < 5.5 mg/dl ESRD NW # Quality of Care Project (4 th Qtr 2008 data) Percent of Facility Patients With Phosphorous < 3.5 and < 5.5 mg/dl Outlier Facilities # Facilities % Facilities Total % The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 16

11 Opportunities for Improvement: Using 2009 Quality of Care Project results from the Lab Data Collection Project data (4 th quarter 2008 data); the following opportunities for improvement in Phosphorous Management have been identified for Network #14: 48% of Texas patients failed to meet the NKF K/DOQI Guideline recommendations for serum Phosphorous levels between mg/dl. Utilizing the MRB QOC Concern Cut-Point for Phosphorous Management: o 42 HD and 33 PD facilities have been identified as one-year outliers. o 5 Facilities have been identified as one-year outliers for both HD and PD. o 7 HD and 8 PD facilities have been identified as two-year outliers. Tools & Resources: Tools and resources for the NW # Phosphorous Management Quality Improvement Project have been divided into three implementation phases. Each implementation phase, targeting the different aspects of phosphorous management, will include Quality Assessment and Performance Improvement (QAPI) Team tools and resources, professional education and resources (targeting physicians, dietitians, nurses, PCTS and social workers), patient education tools and NW #14 Patient Advisory Committee (PAC) approved patient education posters to hang in your facility. All QIP components will be posted on the ESRD NW #14 website under This mailing includes Part I Phosphorous Management QIP tools and resources. Part II will be mailed to your facility in October 2009 and Part III will be mailed in January All components will be sent to you in copy-ready black and white format, with three-hole punch. We recommend you start a Phosphorous Management QIP notebook with Part I and then add Parts II and III when they arrive at your facility. This will make it easier for you and your facility staff to access the information. If you have questions or comments about the tools and resources provided for this QIP, please contact Bobbie Knotek at or or Angie Wieler at or Partners/Acknowledgements: We are proud of the quality care delivered in Texas and appreciate the dedication and efforts of the professionals that work to achieve desired outcomes for Texas patients. NW #14 relies on collaboration with the nephrology community and would like to acknowledge our project partners: NW #14 ESRD Providers. Medical Review Board and Executive Committee members. NW #14 Patient Advisory Committee (PAC) members. Texas Department of State Health Services Surveyors. Every surveyor will receive the Phosphorous Management QIP Modules Parts I-III. The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 17

12 Medical Review Board (MRB) Members Ruben Velez, MD Chairman Dallas Robert Hootkins, MD Immediate Past Chair Austin Donald Molony. MD Chair-Elect Houston Clyde Rutherford, MD Corpus Christi Mohanram Narayanan, MD Temple Navid Saigal, MD Live Oak Mazen Arar, MD San Antonio Stuart Goldstein, MD Houston Ingemar Davidson, MD Dallas Jacqueline Lappin, MD Houston Camille May, RN, CNN Dallas Deborah Heinrich, RN, CDN Austin Trish White, RN, CNN Gainesville KayLynne Duran, RN Laredo Mary Beth Callahan, ACSW/LCSW Dallas Joyce Hernandez, LMSW San Antonio Jennie Lang House, RD, CSR, LD Midland Jane Louis, RD, CSR, LD Galveston Anna Gonzalez San Antonio Dianne Thomas Dallas ESRD Network of Texas Board Members Executive Committee (EC) Members Melvin Laski, MD Chairman Lubbock Dionicio Alvarez, MD Vice Chairman El Paso Ruben Velez, MD MRB Chairman Dallas Amy Hackney DeSoto Larry S. McGowan, II BS College Station Laura Yates, RN, CNN Harlingen Charles Orji, MD Tyler Leigh Anne Tanzberger Sugar Land Richard Gibney, MD Waco Patient Advisory Committee (PAC) Members Jennifer Kane Co-Chair Houston Leigh Anne Tanzberger Co-Chair Sugar Land Jorge Garcia Immediate Past Chair McAllen Anna Gonzalez San Antonio Dianne Thomas Dallas Maury Booth Fort Worth Frances Carroll Lubbock Gigi Cooper Houston Felipe Enriquez Hereford Amy Hackney DeSoto Danny Knight Waxahachie Gloria Lang-Jones San Antonio Ana Rodriguez Kyle David Swearingen Stephenville The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 18

13 Section 2 QAPI Tools Page 19

14 Phosphorous Management Barriers Assessment HD, PD Check ( ) All Treatment Barriers Present in Facility That Are Impacting Optimal Phosphorous Management in your Facility Patient- Related Barriers Don t know what phosphorous number should be Don t understand or get confused about how many binders to take each time Don t understand or get confused about when to take binders Forget to take binders with every meal and snack Forget to bring binders along when eating out Diet consists mainly of fast foods high in phosphorous Believes dialysis can remove phosphorous and they don t need to take binders Don t want to take binders because of side effects Don t consider binders a high priority compared to other problems they are experiencing Binders are too expensive and patients can t afford to buy them Don t understand that itching is caused by a high phosphorous Don t know high phosphorous can cause heart disease and heart attacks Don t know high phosphorous levels can make their bones break Feel good now, don t believe high phosphorous complications will happen to them Other: Areas Identified as Issues and Actions to Address them: Month/Year Month/Year Month/Year Comments ESRD Network of Texas, Inc McEwen Road, # 350 Dallas, TX Ph: Fax: Page 21

15 Phosphorous Management Barriers Assessment HD, PD Lack of Resources for Patient Education about Phosphorous: Month/Year Month/Year Month/Year Comments What phosphorous is and why it s bad to have a high phosphorous How binders work How and when to take binders Patient s role in controlling phosphorous Phosphorous content in fast foods and how to make good fast food choices Hidden phosphorous in foods and how to read labels to look for hidden phosphorous Other: Nephrologist-Related Barriers Doesn t consider phosphorous control a priority compared to anemia, adequacy, vascular access Doesn t reinforce benefits of taking binders with patients when making dialysis rounds Others Explain: Facility-Related Barriers Phosphorous Management team not in place QAPI program does not monitor phosphorous management QAPI team not involved in developing/supporting phosphorous management process improvements Dialysis staff not educated in how to reinforce phosphorous education provided by dietitian and nephrologist Lack of staff awareness of benefit of patient adherence to binder regimen Lack of adequate training for nurses and PCTs on phosphorous management Inadequate communication between facility staff, dietitian, nephrologist and patients Others Explain: ESRD Network of Texas, Inc McEwen Road, # 350 Dallas, TX Ph: Fax: Page 23

16 FACILITY: CONTACT: Goal: Optimize % of patients in target range (PO ) PROBLEM STATEMENT: (Ex) High incidence of patients outside of target range (Ex) PO4 management not a consistent part of QAPI review ROOT CAUSE(S): (Ex) Lack of communication between interdisciplinary team (Ex) High incidence of patient non-adherence ACTION PLAN 1. Designate staff member(s) in dialysis facility responsible for PO4 monitoring. 2. Assemble multi-disciplinary PO4 management QAPI team in dialysis facility. 3. Investigate and track PO4 status of all patients by: (1) reviewing lab data; (2) verifying prescribed binders; (3) assessing adherence to binder(s) regime; (4) soliciting reasons for non adherence from the patient and (5) setting specific goals for the month. 4. Review monthly at QAPI meeting. 5. Investigate and track all patients not meeting PO4 goals. 6. Address values outside of target range using best practice models. 7. Review /Revise Plan. Developed by NW # 9/10: Distributed by NW # 14 April 2009 QAPI ACTION PLAN Phosphorus Management HD and PD (circle one) RESPONSIBLE TEAM MEMBER START DATE ESTIMATED COMPLETION DATE ACTUAL COMPLETION DATE TEAM MEMBERS: Medical Director Nurse manager Facility nurses Dietitian Social worker Nephrologists COMMENTS (STATUS, OUTCOMES, DISPOSITION, ETC.) Page 25

17 Facility Name: Provider/CCN#: - Phosphorous Management %of Patients with PO4 > 3.5 & < 5.5 mg/dl % % Facility Patients Meeting Goal Facility Total Patient Census # of Patients with Results US CPM Average 52 TX QOC Average 50.5 MRB Cutpoint < 40 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec ENTER YOUR FACILITY NAME & PROVIDER NUMBER IN THE BOX. Then enter the data in the appropriate box as requested. Be sure to add this to your QAPI Meeting Minutes. Page 27

18 Phosphorous Management Data Collection Tool Quarterly Tracking Document Month 1 Month 2 Month 3 Patient Name Name of PO4 Binder Binder Frequency & Dose Taking Binder as Rx d Yes or No Serum PO4 & Date Name of PO4 Binder Binder Frequency & Dose Taking Binder as Rx d Yes or No Serum PO4 & Date Name of PO4 Binder Binder Taking Frequency Binder as & Dose Rx d Yes or No Serum PO4 & Date Developed 04/09 ESRD Network of Texas, Inc McEwen Road, #350 Dallas, TX Ph: * Fax: We recommend using this tool to assess and track status of patients with phosphorous greater than to 5.5 mg/dl. Page 29

19 Section 3 Staff Activities Page 31

20 Phosphorous Quality Improvement Project July 2009 QAPI Team & ALL Nephrologists Educational Opportunity Hypertension, Dialysis, and Clinical Nephrology (HDCN) Web site Using Teamwork for Effective Management of CKD and Mineral and Bone Disorders The Importance of Phosphate and Choice of Phosphate Binders in CKD CE/CME Activity for 1.25 Contact Hours Available online at Instructions on next page. 1. Please have the following facility personnel complete this educational offering: Medical Director Administrator Clinical Manager/Head Nurse Social Worker(s) Dietitian(s) Chief Technician ALL Nephrologists practicing in the facility 2. Have all members listed above complete the educational offering, file a copy of the CE/CME certificate in the personnel training records, and ensure documentation and full reporting in QAPI meeting. Page 33 The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX

21 Phosphorous Quality Improvement Project July 2009 QAPI Team & ALL Nephrologists Educational Opportunity Hypertension, Dialysis, and Clinical Nephrology (HDCN) Web site Instructions To complete Using Teamwork for Effective Management of CKD and Mineral and Bone Disorders The Importance of Phosphate and Choice of Phosphate Binders in CKD, you need to go to the Hypertension, Dialysis, and Clinical Nephrology (HDCN) website (www.hdcn.com) and do the following: 1. Go to On the LEFT side click on Subscribe New Users (Free or Key). You must Subscribe before you can access the presentation. Once you have completed this, then, on the Right side click on: FREE: ANNA Accredited CE Program 2. On the page that opens, it will be the first program. 3. Click on the title: Using Teamwork for Effective Management of CKD and Mineral and Bone Disorders The Importance of Phosphate and Choice of Phosphate Binders in CKD, go through the presentation. 4. Take the test at the end of the presentation. 5. Print the CE/CME certificate. Click on Subscribe New Users Click on FREE ANNA CE! File copy of certificate in personnel training records, document and report completion in QAPI meeting! The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 34

22 Phosphorous Quality Improvement Project July 2009 Nurses, Patient Care Technicians & Social Worker(s) Educational Opportunity Hypertension, Dialysis, and Clinical Nephrology (HDCN) Web site Achieving and Maintaining a Phosphate Balance in the Patient with CKD CE/CME Activity for 1.25 Contact Hours Available online at Instructions on next page. 1. Please have the following facility personnel complete this educational offering: All Nurses All Patient Care Technicians Social Worker(s) 2. Have all members listed above complete the educational offering, file a copy of the CE/CME certificate in the personnel training records, and ensure documentation and full reporting in QAPI meeting. The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 35

23 Phosphorous Quality Improvement Project July 2009 Nurses, Patient Care Technicians & Social Worker(s) Educational Opportunity Hypertension, Dialysis, and Clinical Nephrology (HDCN) Web site Instructions To complete Achieving and Maintaining a Phosphate Balance in the Patient with CKD, you need to go to the Hypertension, Dialysis, and Clinical Nephrology (HDCN) website (www.hdcn.com) and do the following: 1. Go to On the LEFT side click on Subscribe New Users (Free or Key). You must Subscribe before you can access the presentation. Once you have completed this, then, on the Right side click on: FREE: ANNA Accredited CE Program 2. On the page that opens, it will be located towards the bottom of the list of programs (you will need to scroll down). 3. Click on the title: Achieving and Maintaining a Phosphate Balance in the Patient with CKD, go through the presentation. 4. Take the test at the end of the presentation. 5. Print the CE/CME certificate. Click on Subscribe New Users Click on FREE ANNA CE! File copy of certificate in training records, document and report completion in QAPI meeting! The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 36

24 Phosphorous Quality Improvement Project July 2009 Dietitian Educational Opportunity Hypertension, Dialysis, and Clinical Nephrology (HDCN) Web site Education Helps ESRD Patients Cut Phosphorous Levels FREE CE/CME Available online at Instructions on next page. 1. Please have the following facility personnel complete this educational offering: Dietitian(s) 2. Have the member(s) listed above complete the educational offering, file a copy of the CE/CME certificate in the personnel training records, and ensure documentation and full reporting in QAPI meeting. The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 37

25 Phosphorous Quality Improvement Project July 2009 Dietitian Educational Opportunity Med Page Today Website This educational presentation emphasizes the importance of educating patients about hidden phosphorous in fast food and grocery store products. When patients are aware of high phosphorous and hidden phosphorous foods they are more likely to maintain recommended serum phosphorous levels decreasing their risk of cardiovascular morbidity and mortality. The Dietitian s role in teaching patients how to identify high phosphorous foods and hidden phosphorous foods is critical to the patient s ability to make healthy choices that improve their quality of life. This educational presentation is available online at: The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 38

26 Section 4 Patient Education Page 39

27 Phosphorous Quality Improvement Project July 2009 Patient Educational Materials 1. This section is dedicated to patient educational materials specific to phosphorous management which are ready for copying and distribution. Please make copies of the 2 educational tools in this section (listed below) and distribute to All Patients! It Will Do Your Heart and Bones Good! (English & Spanish) Phosphorous Report Card (English & Spanish) 2. Please ask your care team members (nurses, patient care technicians, dietitians, social workers, nephrologists) to: Review the Phosphorous Report Card with every patient on a monthly basis and provide any assistance your patients may need in filling in their numbers on the report card. Help your patients compare their phosphorous numbers from month to month. 3. We strongly recommend the following actions be completed prior to staff discussing phosphorous outcomes with your patients: Ask your Dietitian to present a brief phosphorous project orientation to all staff members. Ensure your care team members have completed the recommended discipline specific education. 4. Don t forget to document the education you provide to your patients in their Medical Record. Implementation of phosphorous project patient educational activities should be documented and reviewed during monthly QAPI meetings. The End Stage Renal Disease Network of Texas, Inc. (#14) 4040 McEwen Rd. #350 Dallas, TX Page 41

28 It Will Do Your Heart and Bones Good! Even if you think you ve heard absolutely everything there is to know about phosphorous from your dietitian and kidney doctor, do yourself (and your body) a favor - read this article it really will do your heart and bones good! Every year the Network picks a project to work on that will improve care for Texas patients. For , the Network is working with facilities and patients to come up with ideas to help patients with high phosphorous numbers learn more phosphorous control. The Network chose phosphorous because in 2007, only 58% of Texas patients had a phosphorous number in the safe range (between ). That means that 42% of Texas patients (over 32,000 patients) are still living dangerously! A high phosphorous level doesn t just make you itch it can cause a heart attack, broken bones and even amputations of your fingers, toes, feet and legs. PO What should MY phosphorous number be? Your phosphorous number should be between mg/dl. Most people on dialysis have a phosphorous number that is too high! 5.5 PO 4 What is Phosphorous? Why does everyone worry when my phosphorous is high? Phosphorous is a mineral your body uses to make bones. When your kidneys were healthy, they helped your body get rid of phosphorous that wasn t being used to tune up your bones and keep them healthy and strong. But because your kidneys don t work right anymore, the phosphorous that you get from the food you eat, is trapped in your body with no way out. Your body only needs a small amount of phosphorous to tune up your bones. The rest of the trapped phosphorous builds up and hurts your body! How does Phosphorous hurt my body? Phosphorous loves calcium. When there is extra phosphorous in your body it looks for calcium. If there isn t enough calcium in your blood or tissues, it pulls calcium out of your bones. This makes your bones weak and causes bone pain. When your phosphorous stays high for days or even weeks, your bones get weaker and weaker. Because your bones are weak, they can break very easily. I will always remember a young woman on dialysis who broke several ribs every time she sneezed or coughed because of her weakened bones. Finally, when the pain caused by her bone disease got so bad she couldn t live with it, she stopped dialysis. To make things worse, when your body has extra phosphorous, it also sends a phosphorous balancing hormone (PTH) to your bones. This hormone pulls more calcium from your bones, making them even weaker. High phosphorous hurts more than just bones! It also hurts other parts of your body. When phosphorous and calcium meet in your body, they turn into sharp phosphorous-calcium crystals. These crystals move through your body scratching tissues and causing damage to blood vessels, skin, heart, lungs and eyes. Won t dialysis remove extra phosphorous? NO - dialysis only removes very small amounts of phosphorous. The only way to control phosphorous is with diet and phosphorous binders. Page 43

29 Why is it so hard to control my Phosphorous number? Phosphorous control is hard because our food is full of phosphorous. Almost everything we eat contains phosphorous. Some foods are naturally full of phosphorous. Many foods have added phosphorous that helps to keep the food fresh (phosphorous preservatives). Common foods with a lot of Phosphorous are: Processed foods Breakfast cereals Dark sodas Chocolate Cheese Milk Ice Cream Beef and Chicken livers Organ meats Whole grain products Talk to your facility s dietitian to find out how to get the protein and vitamins you need and still keep your phosphorous number between A BIG reason phosphorous is hard to control is because people don t like to take phosphorous binders. The pills are big, you have to take lots of them, you need to have them with you when you eat and if you forget to bring them with you and don t take them close to a meal the binders won t work! A patient even wrote an article for the National Kidney Foundation s Family Focus newspaper called - Top 10 Reasons for NOT Taking Phosphate Binders. Just for fun, read his Top 10 Reasons and ask yourself how many of these reasons YOU have used! 1) OOPS, I forgot! No big deal anyway! 2) Nothing ever happens if I forget to take my binders! 3) I ll take my binders later when I get back home. 4) The doctor can fix whatever goes wrong, right? 5) No one is ever going to know, so who really cares? 6) Nobody is watching whether I do or don t take my binders. 7) I feel okay right now, so why do I need to take phosphate binders? 8) It s a major inconvenience for me to take my binders when I eat. 9) My friends don t take binders, so why should I? 10) The binders are so expensive, I can t afford them. The patient who gave these reasons was trying to get other patients to listen to him. He admits that it is very easy to make excuses not to take phosphorous binders. But, he also said, Deciding to take binders with every snack and meal is without a doubt one of the most important decisions a person with kidney disease can make. And - if YOU don t believe that, no one can make it seem important to you. Try these tips for taking your binders: Take the binders your doctor ordered for you (don t change how many you take without checking with your doctor) Take your binders 5 10 minutes before or after your meal If your Phosphorous stays high (and you really are taking your binders), try taking the binders during your meal Take your binders with you everywhere you go that way you ll have them if you get hungry and want to eat something! Take binders with every snack Remember, when you don t take your binders you are hurting your heart and bones! ESRD Network of Texas, Inc McEwen Road, #350, Dallas, TX Phone Page 45

30 Esto es Bueno para Su Corazón y Huesos! Incluso si usted piensa que usted ha oído absolutamente que todo allí debe saber sobre fosforoso de su nutricionista y doctor de riñón, hágase (y su cuerpo) un favor - leya este artículo esto realmente hará su corazón y huesos un bien! Cada año la Red escoge un proyecto de trabajar en esto mejorará sienten cariño por pacientes de Tejas. Para , la Red trabaja con facilidades y pacientes para someter ideas de cómo ayudar a pacientes con números fosforosos altos a aprender más control fosforoso. La Red eligió fosforoso porque en 2007, sólo el 58 % de pacientes de Tejas tenía un número fosforoso en la variedad segura (entre ). Esto significa que el 42 % de pacientes de Tejas (más de 32,000 pacientes) todavía viven peligrosamente! Un nivel fosforoso alto no le hace sólo picar esto puede causar un ataque cardíaco, huesos rotos y hasta las amputaciones de los dedos, dedos del pie, pies y piernas. PO Que debia MI numero de fosforosos? Su numero deber entre mg/dl. Pasientes tienen un numero de fosforosos que mas alta! 5.5 PO 4 Qué es Fosforoso? Por qué se preocupa cada uno cuándo mi fosforoso esta alto? Fosforoso es un mineral que sus usos del cuerpo usa para hacer huesos. Cuando sus riñones eran sanos, ellos ayudaron a su cuerpo a deshacerse de fosforoso que no era usado para sintonizar sus huesos y guardarlos sanos y fuerte. Pero porque sus riñones no trabajan el derecho más, el fosforoso que usted consigue del alimento que usted come, es "atrapado" en su cuerpo sin salida. Su cuerpo sólo necesita una pequeña cantidad de fosforoso para sintonizar sus huesos. El resto del fosforoso "atrapado" aumenta y hace daño a su cuerpo! Cómo hace Fosforoso daño a mi cuerpo? Calcio "de amores" fosforoso. Cuando usted tiene fosforoso de más en su cuerpo esto busca el calcio. Si no hay bastante calcio en su sangre o tejidos, esto saca el calcio de sus huesos. Esto hace sus huesos débiles y causa el dolor de hueso. Cuando sus fosforosas permanecen altas durante días o hasta semanas, sus huesos se hacen más y más débiles. Como sus huesos son débiles, ellos pueden romperse muy fácilmente. Siempre recordaré a una mujer joven en la diálisis que rompió varias costillas cada vez que ella esternudaba o tosia debido a sus huesos debilitados. Finalmente, cuando el dolor causado por su enfermedad de hueso se hizo tan malo ella no podía vivir con ello, ella paró la diálisis. Para colmo de desgracias, cuando su cuerpo tiene fosforoso adicional, esto también envía una hormona "de equilibrio" fosforosa (PTH) a sus huesos. Esta hormona tira más calcio de sus huesos, haciéndolos aún más débiles. Daños fosforosos altos hacen más daño no solo a sus huesos! Esto también hace daño a otras partes de su cuerpo. Cuando fosforoso y calcio "se encuentran" en su cuerpo, ellos se convierten en cristales de calcio fosforoso agudos. Estos cristales se mueven por su cuerpo que rasguñan tejidos y causan daño a vasos sanguíneos, piel, corazón, pulmones y ojos. No quitará la diálisis fosforoso adicionales? NO - la diálisis sólo quita muy pequeñas cantidades de fosforoso. El único modo de controlar fosforoso es con dieta y carpetas fosforosas. Page 47

31 Por qué es tan difícil controlar mi número Fosforoso? El control fosforoso es difícil porque nuestro alimento esta lleno de fosforoso. Casi todo lo que comemos contiene fosforoso. Alguna comida es naturalmente llena de fosforoso. A mucha comida le han añadido fosforoso que ayuda a guardar el alimento fresco (preservativos fosforosos). La comida común con muchos de los Fosforosos es: comida Tratada cereales de Desayuno sodas Oscuras Chocolate Queso Leche Helado Carne de vaca y hígados de Pollo carnes de Órgano productos de grano Enteros Dirigir al nutricionista de su facilidad para averiguar como conseguir la proteína y vitaminas usted necesite y todavía guarde su número fosforoso entre Una razón GRANDE fosforosa es difícil de controlar es porque a la gente no le gusta tomar píldoras fosforosas. Las píldoras son grandes, usted tiene que tomar muchos de ellos, usted tiene que tenerlos con usted cuándo usted come y si a usted se le olvida traerlos con usted y no tomarlos cerca de una comida las píldoras no trabajarán! Un paciente hasta escribió un artículo para el periódico de Foco de Familia de la Fundación de Riñón Nacional llamado - 10 Motivos Primarios de no Tomar Píldoras de Fosfato. Sólo para la diversión, lea sus 10 Motivos Primarios y pregúntese cuántos de estos motivos USTED ha usado! 1) AY!, me olvidé! Ningún a de todos modos! 2) Nada alguna vez pasa si me olvido de tomar mis píldoras! 3) Tomaré mis píldoras más tarde cuando regrese a casa. 4) El doctor puede fijar qué se equivoca, verdad? 5) Nadien sabra, y quién realmente se preocupa? 6) Nadie mira si tomo o no tomo mis píldoras. 7) Me siento bien ahora, entonces, por qué tengo que tomar píldoras de fosfato? 8) Esto es una molestia principal para mí tomar mis píldoras cuando como. 9) Mis amigos no toman píldoras, entonces, por qué debería yo? 10) Las píldoras son tan caras, no puedo permitírmelas. El paciente que dio estos motivos trataba de conseguir a otros pacientes que lo escucharan. Él confiesa que es muy fácil hacer excusas para no tomar carpetas fosforosas. Pero, él también dijo, La decisión de tomar píldoras con cada bocado y comida es sin una duda una de las decisiones más importantes que una persona con la enfermedad de riñón puede hacer. Y - si USTED no cree que, nadie pueda hacerlo parecer importante para usted. Intentar estas puntas para tomar sus píldoras: Tomar las píldoras su doctor ha pedido para usted (no cámbiese cuántos usted toma sin comprobar con su doctor primero) Tomar sus píldoras con cada bocado dentro de 5 10 minutos antes o después de su comida Si sus Fosforosas permanecen altas (y usted realmente toma sus píldoras), trate de tomar las píldoras durante su comida Traer sus píldoras con usted en todas partes usted va aquel modo que usted los tendrá si a usted le da hambre y quiere comer algo! Tomar sus píldoras con cada bocado Recordar, cuándo usted no toma sus píldoras usted hace daño a su corazón y huesos! ESRD Network of Texas, Inc.4040 McEwen Road, #350, Dallas, TX Phone Page 49

32 Patient Name PO Phosphorous Report Card Know Your Numbers ** 5.5 PO 4 If you have questions or need help writing your numbers, ask your nurse to help you. Test Name Normal Number* Phosphorous** mg/dl June 2009 My Phosphorous Number July August September Number of days when most of the foods I chose were low PO 4 foods instead of high PO 4 foods Number of days I took my binder pills with all meals and snacks at the right time (5 to 10 minutes before or after eating the food OR during the meal)** Number of dialysis treatments that didn t remove enough PO4 (I missed a treatment or had a short treatment) None! None! * The numbers are based on the National Kidney Foundation KDOQI Guidelines for Bone Metabolism and Disease. ** Check the Phosphorous Quick Facts! sheet to learn more. ESRD Network of Texas, Inc.4040 McEwen Road, #350, Dallas, TX Phone Patient Toll Free Number Page 51

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