Educating Hemodialysis Patients on Phosphorus Binders in Emergencies

Introduction and Project Overview

The clinical leadership competency framing this project requires effective transformational leadership practices that can motivate all stakeholders to become educated concerning the use of phosphorus binders in lieu of dialysis during emergencies (Cook, 2004). The patient population of interest is hemodialysis-dependent patients. The intervention is education and training on the use of phosphorus binders as a substitute for hemodialysis treatment during power outages or other emergencies, with the outcome measure being a successful return demonstration of how and when to use phosphorus binders. The timeline goal was to have 80% of 99 patients educated by August 30, 2015.

This project involves training selected clinical staff members to provide educational support services to hemodialysis-dependent patients concerning the use of a phosphorus-binding drug, Renagel, to prepare them for emergency situations when dialysis services are unavailable.

AIM Statement: By August 15, 2015, 80% of hemodialysis-dependent patients will be educated and prepared to use phosphorus binders in lieu of hemodialysis treatment during power outages or other emergency situations.

The use of phosphorus binders for hemodialysis patients is not new. The original binders were aluminum-containing compounds that were shown to be highly effective in lowering phosphorus levels; however, these original phosphorus binders resulted in multisystem toxicity and their use was therefore largely discontinued (Beyzarov, 2009). An alternative was found in calcium-containing binders, which were regarded as safer, but this intervention was found to cause accumulation of calcifications in multiple tissues, resulting in increased patient mortality — especially among patients with advanced-stage chronic kidney disease — and their use was also largely discontinued (Beyzarov, 2009).

Since its approval, the use of non-calcium-, non-aluminum-containing phosphorus binders gained increased acceptance by the healthcare community following the publication of results in Kidney International showing that patients treated with sevelamer experienced significantly lower mortality rates related to the control of coronary artery calcifications compared with patients treated with calcium-based phosphate binders (Beyzarov, 2009). These drugs represent potentially life-saving alternative treatments for hemodialysis-dependent patients during emergency situations when power is lost or dialysis equipment is otherwise inoperable (Lemieux & Chamberlin, 2015).

Clinical Rationale and Literature Review

A study by Sheikh, Maguire, Emmett et al. (2009) reports that phosphorus binding can assume various forms, including a chemical reaction between dietary phosphorus and the cation of the binder compound, adsorption of phosphorus ions on the surface of binder particles, or a combination of both processes. Until fairly recently, aluminum-containing antacids were used as phosphorus binders, but studies demonstrated that long-term use of aluminum compounds by patients with chronic renal failure is associated with a risk of serious aluminum toxicity, prompting a search for safer alternatives (Sheikh et al., 2009).

Emmett (2004) argues that the optimal approach for phosphorus maintenance in hemodialysis-dependent patients is to balance the net amount of phosphorus absorbed from the gastrointestinal tract to correspond to decreased kidney function. While chronic dialysis therapy can achieve this balance, it is very challenging to reduce dietary phosphorus to appropriate levels, and a wide range of phosphorus binders have been used for this purpose (Emmett, 2004).

More recently, non-calcium-, non-aluminum-containing phosphorus binders have been shown to be a considerable improvement over these two earlier interventions (Beyzarov, 2009). As Beyzarov reports, "The new binders were not systemically absorbed and provided phosphorus control without concerns of calcium or metal accumulation" (2009, p. 9). Kalantar-Zadeh (2013) notes that chronic kidney disease has been linked to an increased risk of cardiovascular disease and mortality associated with traditional cardiovascular risk factors such as diabetes and hypertension. Research also indicates a significant link between elevated serum phosphorus and mortality in dialysis patients, with hyperphosphatemia representing the highest risk of death in hemodialysis patients (Kalantar-Zadeh, 2013). Phosphorus binders therefore represent a valuable tool in controlling hyperphosphatemia (Kalantar-Zadeh, 2013).

Isakova et al. (2009) evaluated a prospective cohort study of 10,044 incident hemodialysis patients using Cox proportional hazards analyses to analyze one-year all-cause mortality among patients receiving or not receiving phosphorus binders. These researchers compared patients beginning treatment with phosphorus binders during the first 90-day period following initiation of hemodialysis with patients who were left untreated during the same period (Isakova et al., 2009). They found that treatment with phosphorus binders is independently associated with improved survival among incident hemodialysis patients and concluded that phosphorus binders represent a valuable tool in treating patients with chronic kidney disease.

De Francisco (2008) argues that while numerous researchers have evaluated the efficacy of phosphorus binders in decreasing serum phosphate levels and uniformly found the intervention effective, there remains a paucity of research concerning its efficacy compared to other phosphorus-chelating agents. The few available studies indicate that phosphorus binders and calcium compounds are equally efficacious after one year of treatment; however, phosphorus binders demonstrated additional beneficial effects, including a lower incidence of hypercalcemia, a minimal decrease in serum calcium levels, lower incidence of low PTH levels, lower LDL cholesterol, and a significantly lower percentage in the mean absolute score of calcium within the coronary arteries and aorta (de Francisco, 2008). Phosphorus binders also decreased C-reactive protein values compared to calcium compounds (de Francisco, 2008). It should be noted, however, that phosphorus binders should not be used for patients with chronic kidney disease who are not actively receiving hemodialysis, because the drug can induce metabolic acidosis (de Francisco, 2008).

Kotter's Eight-Step Change Model applies directly to the development of this educational project on phosphorus binders for hemodialysis-dependent patients. Kotter's model is best viewed as a vision for the change process and for avoiding major errors during that process (Mento, Jones & Dirndorfer, 2002). The model calls attention to the key phases in any change process. Each phase is described below as it applies to this project.

1. Establish a sense of urgency. The development of this project was based on an urgent need for change. Following national earthquakes, hurricanes, and general power outages, it was found that hemodialysis-dependent patients did not have an alternate solution available during emergency situations.

2. Create a guiding team. A core team of educators was established to move from patient to patient, provide education, and answer questions — forming change agents with credibility, authority, and skill to assist in the change process.

3. Develop a change vision and strategy. Part of the education process is ensuring that each patient understands the need for phosphorus binders when an emergency occurs and they cannot access dialysis treatments.

Methodology: Kotter's Eight-Step Change Model

4. Clearly communicate the change vision. Education is delivered both in group settings and one-on-one with patients. A well-trained team of educators shares the same vision so that consistent education is provided to every patient.

5. Empower the individuals involved in the change process. This is the central goal of the project — to empower patients with the knowledge they need when nursing staff are unavailable. Providing booklets and medication alone is not sufficient to ensure patient survival during a power outage or earthquake when dialysis is inaccessible.

6. Generate short-term successes. This step had not yet been fully developed at the time of writing, but plans were under discussion to celebrate patient successes.

7. Consolidate gains and continue change. This is part of a long-term plan to incorporate phosphorus binder education into all future patient education programs.

8. Make change stick. Anchoring new behavior into organizational culture ensures the intervention is sustained over time.

The model provides a key lesson: the change process proceeds through a series of phases that require considerable time. Any mistakes occurring in any phase can have an adverse impact on the momentum of the entire change process (Mento et al., 2002). It is through recognizing adverse momentum that clinicians can identify needs for adjustment, and each adjustment creates a stronger anchor for a long-term plan of action.

The project will be implemented in a series of steps: (1) conducting project management and training for CNL students; (2) holding core staff meetings over a period of ten weeks; (3) purchasing phosphorus binders; (4) conducting staff education over the same ten-week period; (5) creating printed educational materials such as brochures and leaflets; and (6) conducting follow-up patient evaluations concerning knowledge levels about the proper use of Renagel when dialysis services are unavailable during emergency situations.