Patient Complexity: Back to Basics

The Patient, the Information, the Treatment

Use your SENSE(s).

Modern dialysis care gives us access to an extraordinary amount of information. We have blood results, dialysis adequacy measurements, treatment trends, blood pressure readings, access flows, machine data, medications, electronic records and clinical guidelines.

All of this information is valuable. But none of it replaces the patient sitting in front of us.

As Clinical Technologists, we work at the intersection between the patient, the information and the treatment. Our role is not simply to operate dialysis technology or follow a prescribed treatment plan. We continuously assess how the patient is responding, recognise changes, interpret clinical information and use our judgement to determine when something needs to be investigated, adjusted or escalated.

And when a patient becomes complicated, sometimes the most important thing we can do is go back to basics.

Start With the Patient

Before looking at the machine, the monthly blood results or the latest report, look at your patient.

How did they walk into the unit today? Are they walking comfortably or are they stopping to catch their breath? Do they look different from their normal presentation? Are they alert and engaging normally? Are their shoes tighter than usual? Are their ankles swollen? Are they coughing? Are they unusually tired? Is their breathing different? Do they tell you that they 'feel fine', while everything you are observing suggests otherwise?

A comprehensive clinical assessment should never become a tick-box exercise. Vital signs matter, but so does the clinical picture surrounding them.

A blood pressure of 160/90 mmHg does not mean exactly the same thing in every patient. A 3 kg interdialytic weight gain does not have the same significance in every patient. A haemoglobin of 9.5 g/dL, potassium of 5.8 mmol/L or change in access pressures needs to be interpreted within the context of that individual patient.

Patients are not one size fits all. The numbers help us understand the patient. They should never replace our assessment of the patient.

Use Your SENSE(s)

Clinical Technologists are trained to assess, observe, interpret and respond. Much of good clinical care begins with using the skills we already possess.

S - See the patient

Observe before you intervene.

Look at respiratory effort, skin colour, oedema, mobility, level of consciousness, vascular access, general appearance and behaviour. Compare today's patient with the patient you know.

Often the first indication that something has changed is not a laboratory result. It is simply the thought: 'This patient does not look like they normally do.' That observation matters.

E - Engage and listen

Ask questions - and listen carefully to the answers.

How have you been since your last treatment? Have you been short of breath? Have you been eating normally? Any nausea, vomiting or diarrhoea? Are you taking your medication? Did you miss any doses? How much fluid have you been drinking? Have you noticed swelling? Any problems with your access? Have you been admitted to hospital or seen another doctor?

Patients often provide the missing piece of clinical information if we take the time to ask. Sometimes an apparently unexplained change in blood pressure, weight, potassium or fluid status becomes understandable after one conversation.

N - Notice the trends

One abnormal number may be important. A pattern is often even more important.

This is where clinical information becomes powerful. Look beyond today's reading and ask:

• What has this patient's blood pressure been doing over the last two weeks?

• Are we repeatedly failing to achieve dry weight?

• Is the patient's interdialytic weight gain increasing?

• Has haemoglobin been gradually declining?

• Are phosphate or potassium levels repeatedly elevated?

• Has dialysis adequacy deteriorated?

• Are arterial or venous pressures changing?

• Has treatment tolerance changed?

• Are we repeatedly giving interventions during dialysis that were previously unnecessary?

  
  

Trend the information. A patient who repeatedly finishes dialysis above dry weight despite increasing ultrafiltration is telling us something clinically important. A patient whose blood pressure has slowly increased over several treatments is telling us something. An access with gradually worsening pressures is telling us something. Our responsibility is to recognise the story that the information is beginning to tell.

S - Synthesise the information

Clinical decision-making should not happen in silos.

Weight is connected to blood pressure. Blood pressure may be connected to fluid status. Fluid removal is connected to treatment time and cardiovascular tolerance. Poor clearance may relate to treatment time, blood flow, access function, dialyser performance or adherence. Anaemia may relate to iron availability, inflammation, blood loss, nutrition, dialysis adequacy or erythropoietin treatment.

The purpose of collecting information is not simply to document it. It is to bring the pieces together.

Ask yourself: What is happening to this patient, and what information supports my assessment? This is the difference between recording clinical information and using clinical information.

E - Evaluate the treatment

Once we understand the patient and the information, we must evaluate whether the current treatment is still appropriate.

The dialysis prescription was created for the patient at a particular point in time. Patients change. Their residual renal function may decline. Their weight changes. Their cardiovascular tolerance changes. Their medications change. Their nutritional status changes. Their vascular access changes. Their lifestyle changes. Their clinical condition changes.

Therefore, treatment plans must also be reviewed. We should routinely ask: Is this treatment still achieving what we expect it to achieve? If not, why not?

A dialysis machine can deliver exactly what has been prescribed and the patient can still be inadequately treated. That is why the Clinical Technologist remains an essential part of the process. We do not only ask whether the machine completed the treatment. We ask whether the treatment achieved the clinical objective for this patient.

The Patient + The Information + The Treatment

The Patient: What am I seeing, hearing and assessing? What has changed? What is the patient telling me?

The Information: What do the observations, pathology results, treatment records and trends show? Is this an isolated finding or part of a developing pattern?

The Treatment: Is the current treatment still suitable? Is it achieving the intended outcome? Does something need to be reviewed, changed or escalated?

Good clinical decision-making happens where these three elements meet.

Do Not Treat a Number in Isolation

Dialysis gives us many targets: dry weight, blood pressure, Kt/V, URR, potassium, phosphate, haemoglobin, ferritin, transferrin saturation and PTH. These parameters are important because they help guide good care. But achieving a target should never become more important than understanding the patient.

Consider dry weight. If a patient's prescribed dry weight is 70 kg but they have consistently completed dialysis at 72 kg for several weeks, repeatedly experience hypertension and now present with oedema and increasing breathlessness, simply continuing to record 'dry weight 70 kg' does not manage the patient.

We need to ask why the target is not being achieved. Is the treatment time sufficient? Is ultrafiltration tolerance limiting removal? Has fluid intake increased? Has true body weight changed? Is there cardiac dysfunction? Has the patient missed treatments? Do we need additional dialysis? Does the nephrologist need to reassess the treatment plan?

The number is the starting point. Clinical reasoning determines what we do with it.

Know What Is Normal for Your Patient

One of the greatest advantages dialysis teams have is continuity. We often see our patients three times a week. That means we are uniquely positioned to notice subtle changes before they become major clinical events.

We know who normally arrives talking and laughing. We know who normally walks into the unit without difficulty. We know the patient whose blood pressure normally sits around a particular range. We know how a patient's access normally feels. We know who usually tolerates three litres of ultrafiltration without difficulty and who becomes symptomatic after two.

That knowledge is clinically valuable. Never underestimate the importance of being able to say: 'This is not normal for this patient.' It should trigger us to reassess.

Clinical Judgement Also Means Knowing When to Escalate

Going back to basics does not mean managing everything ourselves. Good clinical judgement includes recognising the limits of our role and knowing when a patient requires senior clinical review, nephrologist input or emergency medical care.

Assessment should lead to action. If something is abnormal: Assess it. Interpret it. Document it. Act on it. Escalate it when necessary. Then close the loop.

Do not assume that because something was reported, it was resolved. Was the nephrologist informed? Was feedback received? Was the prescription changed? Was the medication adjusted? Was the patient referred? Was the change implemented at the next treatment? Did the patient's condition improve?

Clinical care is not complete until the loop has been closed.

Technology Supports Clinical Care - It Does Not Replace It

Our profession has evolved alongside increasingly sophisticated dialysis machines, electronic medical records and clinical reporting systems. These tools improve patient care enormously. But technology should enhance clinical judgement, not replace it.

A dashboard may identify that a patient's haemoglobin is falling. A report may show that dry weight has not been achieved for six treatments. A dialysis machine may show increasing venous pressures.

The system gives us information. The clinician must decide what that information means for the patient. That is where our professional responsibility lies.

Back to Basics

When faced with a complicated patient, it can be tempting to immediately search for a complicated solution. Sometimes the better approach is simpler.

Go back to the patient. Look. Listen. Ask. Examine. Review the history. Review the trends. Understand what has changed. Look at the treatment. Ask whether it is working. Then put the pieces together.

Clinical excellence does not come from knowing every number by heart or treating every patient according to exactly the same formula. It comes from understanding the person behind the numbers.

As Clinical Technologists, we have the privilege of spending many hours alongside our patients. We see them repeatedly, often over many years. This gives us an opportunity - and a responsibility - to recognise change, advocate for our patients and ensure that the treatment we deliver remains appropriate for the person receiving it.

The patient. The information. The treatment.

Use your SENSE(s).

Because sometimes the most sophisticated clinical tool available to us is still a skilled healthcare professional who knows their patient, recognises when something has changed and is prepared to act on it.