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International Journal of Nursing Studies 49 (2012) 1320–1324

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International Journal of Nursing Studies


journal homepage: www.elsevier.com/ijns

Ultrafiltration rate as a nursing-sensitive quality indicator in


haemodialysis
Magnus Lindberg a,b,c,*, Mette Spliid Ludvigsen d
a
Department of Nephrology and Haematology, Gävle Hospital, Gävle, Sweden
b
Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
c
Department of Health and Caring Sciences, University of Gävle, Gävle, Sweden
d
Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark

A R T I C L E I N F O A B S T R A C T

Article history: Nursing quality indicators are widely used to demonstrate nurses’ contributions to health
Received 15 January 2012 care. Some studies in nephrology settings have addressed nursing quality, but indicators
Accepted 23 February 2012 reflecting the nursing process quality in haemodialysis are lacking. This paper argues for
considering ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis.
Keywords: Strategies and qualifications for considering ultrafiltration rate as a nursing quality
Haemodialysis indicator are established and discussed. It is argued that the indicator is associated with
Nursing care nursing practice, linked to both morbidity and mortality, and is within the scope of the
Patient safety
nurse’s responsibility. It is also argued that the indicator could be influenced by other
Quality indicator
factors than nursing care. Thus, further studies are needed to investigate the association
between ultrafiltration rate and patient safety. The introduction of the ultrafiltration rate
as a duty specific quality indicator is a coveted measure of nursing care quality in
haemodialysis settings.
ß 2012 Elsevier Ltd. All rights reserved.

What is already known about the topic? 1. Introduction

 Quality indicators are widely used in healthcare services Nurses are the principal caregivers in dialysis settings
but progress has been slow in developing indicators in and the care profoundly affect the lives of dialysis patients.
nursing care. The goal of each dialysis session is to remove retained fluid,
 Nursing quality indicators must be measurable at electrolytes and waste products (Machek et al., 2010) and
reasonable costs, be reliable and valid. the aim of the nursing care is to ensure that the treatment
 Nursing-sensitive quality indicators assessing the pro- is safe and evidence-based (Ballantine and Barcellos, 2004;
cess aspect of haemodialysis treatment are lacking. Murphy, 2006). Careful assessment and planning by the
nurse can prevent the most common complications in a
What this paper adds
dialysis (Bradshaw et al., 2011; Chamney, 2007; Dasselaar
et al., 2007). In case of unplanned events (Abuelo, 1998;
 The introduction of ultrafiltration rate as a nursing-
Davenport, 2006; Davenport et al., 2008) the role of the
sensitive process quality indicator in haemodialysis and
nurse is to ensure early recognition and prompt interven-
a critical discussion about its application in practice.
tion to protect the patient from harm (Ballantine and
Barcellos, 2004; Dasselaar et al., 2007; Murphy, 2006). One
complication that is both frequent and disabling is
* Corresponding author at: Gävle Hospital, Department of Nephrology
and Haematology, SE 801 87 Gävle, Sweden. intradialytic hypotension. Intradialytic hypotension
E-mail address: magnus.lindberg@lg.se (M. Lindberg). mainly occurs as the consequence of a rapid ultrafiltration

0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2012.02.018
M. Lindberg, M.S. Ludvigsen / International Journal of Nursing Studies 49 (2012) 1320–1324 1321

(Caplin et al., 2011; Davenport et al., 2008; Yung, 2008). In necessary time for waste clearance and thus provide a
the decision-making process of whether to continue, better tolerance of ultrafiltration (Twardowski, 2007).
reduce or terminate ultrafiltration in ongoing haemodia- A quality indicator has more or less two main functions:
lysis, the nurse performs several assessments of the to indicate need for change and to evaluate change results.
patient, including vital signs such as blood pressure and Both of these functions are part of quality improvement,
relative blood volume. These assessments are important which is included in the daily routine for haemodialysis
for patient safety. The ultrafiltration rate is the outcome nurses (Gomez et al., 2011). Griffiths et al. (2008)
parameter of this complex decision-making process and recommend that particular indicators should reflect
the decision will determine if the patient completes the nursing contribution at three dimensions; safety, effec-
dialysis session normovolemic, hypovolemic or hypervo- tiveness and compassion. Ultrafiltration rate may be such
lemic (Flythe and Brunelli, 2011). an indicator as it is evidently related to patient safety and
Since there has been little attention to nursing-sensitive dialysis adequacy, i.e. effectiveness (Flythe et al., 2011;
quality indicators in dialysis facilities (Bodin, 2007; Movilli et al., 2007; Saran et al., 2006). The dimension of
Frauman and Gilman, 2001), the president of the American compassion (Griffiths et al., 2008), containing the element
Nephrology Nurses Association called for attention to this of patient experience, might also be attained since patients
issue in 2007 (Bodin, 2007). Moreover, Bennett and Neill are likely to be more satisfied with care if they are treated
(2008) urged nephrology nurses to apply individualized, without complications related to ultrafiltration rate
patient-focused care metrics and not only rely on the (Ballantine and Barcellos, 2004).
waste clearing service of the urea molecule as the quality
indicator for dialysis. Although there are some studies in 3. Rationale for ultrafiltration rate as a process quality
nephrology addressing nursing-sensitive quality indica- indicator
tors, such as nurse staffing levels (Thomas-Hawkins et al.,
2008), patient satisfaction (Gardner et al., 2007) and Excess fluid is very common in haemodialysis patients
patient outcome (Kleger and Fassler, 2010; Spiegel et al., and is associated with adverse outcomes such as hyper-
2010), indicators reflecting the nursing process quality in tension, increased vascular stiffness, cardiac failure, and
haemodialysis are lacking. In this paper, we will discuss the mortality (Kalantar-Zadeh et al., 2009). Thus, removal of
ultrafiltration rate as a nursing-sensitive quality indicator excess fluid during dialysis by intradialytic ultrafiltration is
and its significance for health care. the cornerstone of volume management in these patients
(Abuelo, 1998; Machek et al., 2010). The amount of fluid
ultrafiltrated during the subsequent dialysis session is
2. Ultrafiltration rate as a nursing-sensitive quality equivalent to the magnitude of weight gain between
indicator treatments with supplying fluids added during the
treatment session. The fluid is removed directly from
The theoretical underpinnings of developing and the intravascular space and lost fluid is counterbalanced by
applying quality indicators in health care rest upon the resorption of interstitial fluid. When the fluid removal rate
work of the healthcare theorist Donabedian (1980). All exceeds resorptive capacity, the intravascular space
healthcare systems consist of three elements: structures contraction can be induced causing symptoms of hypo-
(e.g. staff, equipment, appointment systems, and other volemia (cramping, hypotension, and syncope) (Charra,
resources), processes (e.g. organisation and delivery of 2007; Flythe et al., 2011; Twardowski, 2009). Hypotensive
care, prescribing, interactions between professionals and episodes related to ultrafiltration rate may be misinter-
patients, etc.), and patient-related outcomes (such as preted by renal nurses as an indication that the patient is
mortality, morbidity and patient satisfaction). A quality hypovolemic and therefore cause clinical responses of
indicator is an explicitly defined and measurable item premature termination of the dialysis session or abandon-
referring to the structures, processes or outcomes of care ment of further ultrafiltration. Such misinterpretations
(Campbell et al., 2003). A nursing-sensitive indicator thus result in 25–50% of haemodialysis patients to have chronic
reflects nurse delivered care and its outcome in patients. fluid overload (Flythe et al., 2011). Chronic fluid overload is
Nursing-sensitive outcomes are those that are relevant, defined as an expansion of extracellular volume above
based on nurses’ scope and domain of practice, and for normal (Kalantar-Zadeh et al., 2009). The number of
which there are empirical evidence linking nursing inputs hypotensive events may, however, be decreased by timely
and interventions to the outcomes (Doran, 2003). intervention by the nurse responsible for the treatment
The ultrafiltration rate is determined by both the (Ballantine and Barcellos, 2004; Bradshaw et al., 2011).
amount of fluid that must be removed and the time during Emerging empirical evidence suggests that rapid
which this fluid is removed. Both of these determining ultrafiltration rate adversely influence health and survival
factors are influenced by nursing care. The amount of fluid among haemodialysis patients (Flythe et al., 2011; Movilli
to be removed can for instance be reduced by tailored et al., 2007; Saran et al., 2006). The morbidity and mortality
nursing interventions focusing on adherence behaviour risks begin to increase at an ultrafiltration rate of 10 ml/h/
(Lindberg et al., 2011; Welch and Thomas-Hawkins, 2005). kg body weight (Saran et al., 2006). A Swedish national
Further, by using a patient-centred nursing care approach registry study (Lindberg et al., 2009) demonstrated,
(Doss et al., 2011) and/or nurse–patient negotiation however, that 15–23% of the adult haemodialysis patients
(Polaschek, 2003), the dialysis session time and thus the were ultrafiltrated at rates exceeding 10 ml/h/kg between
time of ultrafiltration can be extended beyond the 2002 and 2006. Some patients were exposed to a three
1322 M. Lindberg, M.S. Ludvigsen / International Journal of Nursing Studies 49 (2012) 1320–1324

times higher ultrafiltration rate than this cut-off. Conse- process quality indicator are still unresolved. National or
quently, nursing care during ongoing haemodialysis can be international implementation of the ultrafiltration rate
optimised. performance measures in registries such as the Swedish
Renal Registry and the Danish Nephrology Registry will
facilitate quality improvement as well as new research
4. Strategies for ultrafiltration rate as a process quality
opportunities.
indicator
The validity of the ultrafiltration rate as a nursing-
4.1. Why do we need a nursing-sensitive process quality sensitive process quality indicator needs to be evaluated
indicator in a haemodialysis setting? before implementation into clinical practice. Traditional
methods for these tests (content, construct, and predictive
Prevention of healthcare-related infection/pneumonia, validity) should be tested. It should also be investigated
pressure ulcers and falls is considered to be key quality whether the ultrafiltration rate indicator is sensitive to
indicators in nursing care. Especially prevention of change, sensitive to discriminate, and to meaning. It is
pressure ulcers are widely considered as a nursing- necessary to develop systems to monitor the indicator
sensitive indicator (Van den Heede et al., 2007). These systematically and develop systems for education and
indicators are equally important for nursing quality also in training of nurses and other relevant staff. The Model for
the dialysis setting, although the procedures are not Improvement (Langley, 2009) could be a relevant tool for
reflected in the specific nursing of haemodialysis patients. this process.
Specific nursing-sensitive quality indicators for the dialysis According to Griffiths et al. (2008), a good nursing
setting need to be developed. Moreover, a specific quality quality indicator should fulfil a number of criteria. Firstly, it
indicator is needed to enable evaluation of quality is important that the indicator is measurable using existing
improvement strategies of nursing care in the dialysis data and at a reasonable cost. Data regarding ultrafiltration
setting. Thus, this paper argues for using ultrafiltration rate volume and treatment time is routinely registered in the
as a nursing-sensitive quality indicator. Ultrafiltration rate patient record. Depending on if the dialysis centre uses a
is a clinical parameter already in use in dialysis although paper-based record or an electronic patient record, the
not used as a quality indicator. availability of these data will vary. In paper-based records
it will often be time consuming and costly to collect and
4.2. Who would be able to use this indicator and what would process the existing data. Furthermore, the system used for
the indicator do? electronic recording of patient data will determine how
easy data can be collected and processed. Centres using
Target users of the ultrafiltration rate indicator are automated documentation of each performed dialysis
patients, professionals, purchasers, inspectorate, policy session will have fast and continuous access to ultrafiltra-
makers and scientists. This indicator may serve as a basis tion rate data, while centres using other types of electronic
for quality improvement in the organisation as comparison record may need to develop or have access to applications
can stimulate and motivate change. Moreover, it may serve extracting data from the record and further process it
as a reward for perceived performance among haemodia- before indicator data will be available. Automated
lysis nurses. It may also be used as a part of regulation in documentation is provided by some dialysis equipment
the single organisation, e.g. of minimum standards. manufacturers. Consequently, ultrafiltration rate data are
Further, patients in haemodialysis would in the long-term available but depend on the system used in clinical
be able to ask for documentation for the quality of their practice the assessment of ultrafiltration rate as a quality
haemodialysis treatment and compare with international indicator could be more or less easy to display. Secondly,
standards. The indicator could serve as a pre- and post- the indicator must be sensitive to nursing and there should
measurement in scientific effect studies. Decision-makers be substantial variability associated with nursing practice
could use the indicator to identify areas of need for future (Griffiths et al., 2008). A disadvantage in applying
investment as part of pay for performance schemes (e.g. ultrafiltration rate as a process quality indicator is that
Quality and Outcomes Framework, in the UK, which one of the two determining factors, amount of excess fluid,
reward GP practices for how well they care for patients) or is influenced by several other factors than nursing care. The
to assist decisions on purchasing (e.g. contracts). amount of fluid to be removed during a dialysis session
mainly depends on the patient’s fluid intake behaviour
4.3. How will ultrafiltration rate as a nursing-sensitive (Abuelo, 1998). It also depends on psychological factors
quality indicator be operationalized? (e.g. depression and self-efficacy; Lindberg et al., 2010);
social factors (e.g. encouragement and support) (Kara et al.,
The moral and ethical reasons for dialysis providers to 2007; Yokoyama et al., 2009) as well as medical factors
focus on prevention of dialysis-related adverse effects such as prescription of diuretics, urine volume, and blood
might promote implementation of the indicator. An sugar levels (Abuelo, 1998). Since the urine production
important consideration is to show the usefulness of usually falls to insignificant amounts within the first 18
the indicator in the clinical haemodialysis setting. We are months of haemodialysis treatment (Abuelo, 1998; Rot-
currently planning a pilot project to shed light on the role tembourg, 1993), the amount of fluid that must be
of ultrafiltration rate as a nursing-sensitive process removed might increase by dialytic vintage. Although
quality indicator at one hospital. The issues of imple- the fluid intake behaviour is primarily the responsibility of
mentation of the ultrafiltration rate as a nursing-sensitive the patient, the performance of a safe removal of excess
M. Lindberg, M.S. Ludvigsen / International Journal of Nursing Studies 49 (2012) 1320–1324 1323

fluid during a dialysis session is the nurse’s responsibility. available to the nurse during the session. Accordingly,
A patient-centred care approach (Doss et al., 2011) the fourth qualification that a good quality indicator should
necessitates that the treatment is adjusted to the needs be able to inform remedial action seems to be met as
of each patient and the ultrafiltration rate indicator will timely and informative data are available.
thus reflect the nursing in each treatment session. Another As a fifth qualification, the indicator should be recognised
disadvantage is the likelihood that the longer dialysis as important by nurses, managers and the public (Griffiths
session required for decreasing the ultrafiltration rate et al., 2008). Whether this is the case for ultrafiltration rate
(Twardowski, 2007) might be impossible due to the requires further investigation. It is important that the
department’s capacity. Maybe the patient does not agree management acknowledges that rapid ultrafiltration rate
to extend the session. A too busy scheduling of patients in adversely influences cardiovascular health and survival
need for dialysis will prohibit the nurse to adjust the among haemodialysis patients and that the nursing culture
treatment time and thereby force the nurse to either might need to be altered during quality improvement work.
abandon the treatment goal of getting the patient Before implementation of publicly available feedback
normovolemic or put the patient at risk for ultrafiltra- systems such as traffic light systems (Griffiths et al.,
tion-related complications. Despite these disadvantages, 2008) for national quality data we do not believe that the
we believe the ultrafiltration rate could serve as a process ultrafiltration rate indicator could be considered important
quality indicator of nursing care during haemodialysis. by the public. Since nurses hold a moral and ethical position
Moreover, the lack of capacity and its importance to in their performance of care they have to respect autonomy,
dialysis treatment outcomes could be highlighted by the non-maleficence, beneficence, and justice in relation to the
process quality indicator. patient. The sixth qualification is that the indicator should be
Thirdly, a good process indicator should be supported by recognised as being the responsibility of nursing staff
links to important outcomes (Griffiths et al., 2008). (Griffiths et al., 2008). Historically, recordings of fluid intake
Ultrafiltration rate emerges as a strong candidate because and output have been discussed in the nursing literature as
empiric evidence demonstrate associations between ultra- one of the major duties for nurses caring for patients with
filtration rate and both morbidity and mortality (Flythe renal failure. This dates back to 1915, decades before
et al., 2011; Movilli et al., 2007; Saran et al., 2006). haemodialysis treatment became available in the 1960s
However, further studies are needed to determine the (Hoffart, 2009). Fluid and hydration status is acknowledged
optimal ultrafiltration rate. Saran et al. (2006) and Flythe as the number one key area in the roles and responsibilities
and Brunelli (2011) suggest that it should be less than of nurses caring for a patient undergoing haemodialysis
10 ml/h/kg while Movilli et al. (2007) propose a maximum treatment (Chamney, 2007). The introduction of the
ultrafiltration rate of 12.4 ml/h/kg. Thus, a likely safe but so ultrafiltration rate as a quality indicator would thus be
far unproven ultrafiltration rate would be below 10 ml/h/ expected to serve as a coveted measure of nursing care
kg because a more rapid rate adversely influences health quality in haemodialysis settings.
and survival among haemodialysis patients (Flythe and
Brunelli, 2011).
5. Conclusion and future directions
Since many haemodialysis patients are unable to
receive a kidney transplant they receive haemodialysis
In this paper, we have argued for introducing ultrafiltra-
for many years. Nurses involved in the dialysis process
tion rate as a possible nursing-sensitive process quality
often provide care to the same patient for a lengthy period
indicator in haemodialysis care and briefly reviewed
of time and thus develops a relation with the patient. The
evidence on its application in nursing practice. The
human body utilizes a host of compensatory mechanisms
ultrafiltration rate as an indicator may need to be
to maintain blood pressure despite changes in blood
supplemented by other nursing-sensitive indicators in the
volume. These mechanisms are highly individual and
haemodialysis setting in the future. Systematic approaches,
mediated by each patient’s cardiac and co-morbidity
such as agencies, literature on indicators, trials and guide-
status. Some patients experience a gradual decline in
lines should be employed as means to develop new
blood pressure with an increase in heart rate while others
indicators. We hope this paper will stimulate discussion
experience an abrupt fall in blood pressure, a decreased
about nursing quality indicators in haemodialysis settings
heart rate as well as nausea and vomiting (Steuer and
as well as lead to further research. Applying ultrafiltration
Comis, 1996). Consequently, knowing the patient’s typical
rate as a nursing-sensitive quality indicator in haemodia-
pattern of response during haemodialysis is of key
lysis settings is safe, effective, and compassionate.
importance to dialysis nurses as it facilitates their clinical
decision-making process of whether to continue, reduce or
terminate the ultrafiltration. Apart from knowing the Acknowledgements
patient, the dialysis nurse also needs focused training and
experience because dialysis nursing requires enhanced This collaborative work was promoted by the European
skills to recognize the severe fluid and electrolyte Academy of Nursing Science. It was funded by the County
imbalances the patients can experience during treatment. Council of Gävleborg (ML), Faculty of Medicine Uppsala
Alteration of the ultrafiltration rate is an important tool for University (ML), and the Department of Renal Medicine
the nurse to prevent or manage side effects related to Aarhus University Hospital (MSL).
haemodialysis. The current ultrafiltration rate is instantly Conflict of interest: No financial or other relationships
displayed on the dialysis machine and thus always exists that might lead to a conflict of interest.
1324 M. Lindberg, M.S. Ludvigsen / International Journal of Nursing Studies 49 (2012) 1320–1324

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