Implementation of Body Composition Monitoring in a Satellite Haemodialysis Unit: Benefits

IMPLEMENTATION OF BODY COMPOSITION MONITORING IN A SATELLITE HAEMODIALYSIS UNIT: BENEFITS REALISED AND LESSONS LEARNED Elizabeth Lindley1,2, Elizabeth Baines3, Eimear Coughlan4, Sheila Hull4,Christine Jowsey4, David Keane1,2 and Russell Roberts4 1Renal Medicine & Medical Physics, Leeds Teaching Hospitals NHS Trust; 2NIHR Devices for Dignity Healthcare Technology Co-operative; 3NHS Technology Adoption Centre, Manchester; 4Renal Medicine, Bradford Teaching Hospitals NHS Foundation Trust INTRODUCTION: Body composition monitoring using bioimpedance spectroscopy has been shown to improve outcomes in haemodialysis patients (e.g. Machek NDT 2010). The ability of BCM to give an objective measure of hydration can be used to justify its adoption in hub units treating patients who are too unstable or complex to dialyse in the community. The potential for use of BCM in the satellite setting is less clear as the patients are usually well known to the multidisciplinary team (MDT) who review their fluid management. This project was carried out to evaluate the impact of introducing BCM in a rural satellite unit operating 8 stations. METHOD: Prior to the evaluation, the staff ensured that all patients had an up-to-date height and target weight assessment. Three training sessions covering background, measurement and interpretation were provided in month 1, together with operating procedures and patient leaflets. Changes in fluid management were discussed by the MDT in month 2 and recorded in month 3. Complicated cases and logistical issues were reviewed during support visits in months 4 and 8. RESULTS: 31 patients (84% white, 55% male, 23% diabetic) were reviewed at the MDT. 22 (71%) patients had a change in target weight following their initial BCM measurement. 14/22 target weight changes were increases (median 1.1 kg, range 0.5 to 2.0 kg). In two cases, fluid removal was stopped as their residual kidney function was sufficient to maintain their fluid status. None of the target weight increases led to an undesired increase in blood pressure. 8/22 target weight changes were planned decreases (median 1.0 kg, range 0.5 to 2.5 kg). Seven patients were able to achieve the planned reduction. Two patients, who were overloaded but symptomatic, had changes in their medication. A hand-to-hand BCM post-dialysis showed that dehydration was the likely explanation for severe cramp in a patient with marked leg oedema. In the follow up visits, discussions included the use of vector analysis (BIVA) and haematocrit changes to confirm dehydration, and the use of BCM to maintain an acceptable fluid status in patients for whom comfort is more important that strict volume control. Problems occurred when one of the staff trained to interpret BCM retired and it became clear that at least two competent users are required, even in a small unit. Less experienced staff were tending to delay weight adjustment until BCM had been carried out, rather than using it for confirmation. DISCUSSION: Following the evaluation, the clinical team responsible for the unit are confident using BCM as an integral part of the assessment of volume status. While it is essential to ensure that staff do not become over-reliant on the BCM, it can provide essential information when there are conflicting clinical indications. Common scenarios for requesting a BCM include where a patient is struggling to reach the target weight that appears to be clinically appropriate and where a patient is hypertensive despite having no clinical signs of fluid overload. Volume is often the culprit in the latter 2131

scenario and a BCM can be useful to demonstrate this to the patient as well as staff members. CONCLUSION: Introducing BCM did prompt a significant number of target weight changes in this well managed patient cohort and BCM is now a part of routine clinical care. On-going support from experienced users should be available after the initial training especially in small units where unusual cases are seen less frequently.