Feb 27, 2014
IMPLEMENTATION OF ELECTRONIC MRD- A FEASIBILITY STUDY IN A TERTIARY CARE HOSPITAL
Exactly, as shared by one of the follower of my blog for use of students all over- Thanks a lot! if you wish I will put your name here any time!
As the medical care gets more and more complex and as the stock of
information enlarges the physicians need new technologies to help them cope and
be more efficient. This makes essential the use of information technology and
need for a digital to allow capture of patient data that can then be processed
and mined for insights into better treatment for patients.
With
the many advances in information technology over the past 20 years,
particularly in healthcare, a number of different forms of electronic health
records (EHR) have been discussed, developed, and implemented.[1] The electronic medical record (EMR) is the tool that promises to provide
the platform from which new functionality and new services can be provided for
patients.
Around the globe, there
has been a significant improvement in the healthcare industry standards and use
of various tools to define quality. Quality of patient information is one such
tool which helps the health care organizations provide excellence in the
industry. But, there are many misconceptions about various terminologies and
concepts of use of information technology and electronic medical records.
Electronic Medical Record: “An application
environment composed of the clinical data repository, clinical decision
support, controlled medical vocabulary, order entry, computerized provider
order entry, pharmacy, and clinical documentation applications. This environment
supports the patient’s electronic medical record across inpatient and
outpatient environments, and is used by healthcare practitioners to document,
monitor, and manage health care delivery within a care delivery organization
(CDO). The data in the EMR is the legal record of what happened to the patient
during their encounter at the CDO and is owned by the CDO” by HIMSS
A feasibility study is an evaluation and
analysis of the potential of the proposed project which is based on extensive
investigation and research to give full comfort to the decisions makers.
Feasibility studies aim
to objectively and rationally uncover the strengths and weaknesses of an
existing business or proposed venture, opportunities and threats as presented
by the environment, the resources required to carry through, and ultimately the
prospects for success.
In its simplest terms,
the two criteria to judge feasibility are cost required and value to be
attained. As such, a well-designed feasibility study should provide a
historical background of the business or project, description of the product or
service, accounting statements, details of the operations and management,
marketing research and policies, financial data, legal requirements and tax
obligations.
Till late fifties in
India, there was no awareness among the hospital clinicians as well as
administrators and usually the Medical records departments that have come up
were not planned as a part of total health care.
Various Organizations
face various problems with medical records they are:
- Incomplete
records, for which the physicians are asked to complete causing
duplication of work
- Inadequacy
of space, causing the decentralized storage of records
- Frequent
requests of changing patient’s name
- Loss
of records
Despite of above problems
been faced for a long time there is no Information technology coming in, in
spite of the availability of many efficient Electronic medical records systems.
It was thus decided to conduct a study of the medical records department of
ABC a hospital, to understand the barriers and facilitators of
Implementation of EMRs.
While it is important
to determine what is “in the EMR” it is also critical to understand what is not
considered part of the EMR. Gartner has put forth a model for the Healthcare
environment which contains all of the IT systems needed to run healthcare
organizations.
AIM
AND METHODOLOGY OF THE STUDY
The study was intended
to find the feasibility of Electronic Medical records in a tertiary care
hospital.
The study was based on
the Observations of the policies and procedures, the cost estimation and Closed
End Questionnaire from the medical professionals with the sample size of 354.
LITERATURE
REVIEW
HEALTH INFORMATION
SYSTEMS
Health Information
Systems are designed to integrate data collection, processing, reporting, and
the use of information necessary for improving the effectiveness and efficiency
of the health service through better management at all levels of health care
(WHO, 2000).
Medical records institute defines five distinct stages [Figure 3.2] of
health care information system towards the development of true
Electronic Health Record (EHR) (Weagermann, 1999) in Gash (1999). [15]
Definitions:
The market has confused
the electronic medical record (EMR) and the electronic health record (EHR). The
NAHIT has produced the following definitions for EMR and EHR and PHR:
EMR: The electronic
record of health-related information on an individual that is created,
gathered, managed, and consulted by licensed clinicians and staff from a single
organization who are involved in the individual’s health and care.
EHR: The aggregate
electronic record of health-related information on an individual that is
created and gathered cumulatively across more than one health care organization
and is managed and consulted by licensed clinicians and staff involved in the
individual’s health and care.
PERSONAL HEALTH RECORD:
An electronic, cumulative record of health-related information on an
individual, drawn from multiple sources, that is created, gathered, and managed
by the individual. The integrity of the data in the ePHR and control of access
to that data is the responsibility of the individual.
DIMENSIONS
OF EMR:
EMR is more than just electronic storage of
records/ data. It is a system. There are 10 DIMENSIONS OR CORE CAPABILITIES
OF EMR as defined by Gartner
 |
| 10 Dimensions of EMR , Fig 3.3
CHALLENGES IN
IMPLEMENTATION OF EMR:
A. Transition
(Paper Chart to Electronic) – Hybrid
B. Total
Cost (Return on Investment)
C. Integration
with the Workflow
D. Usability
(Clinicians)
E. Usability
(Nurses)
F. Interface
with rest of the system
G. Interface
with Devices
H. Down
time management – Availability, Disaster Recovery
The above challenges
can be overcome by a planned and effective implementation
IMPLEMENTATION OF EMR
American Society Of
Cataract And Refractory Surgery and American Society Of Ophthalmic Administration
have stated Five Steps of Implementation:
1.
Advance preparation
2.
System selection
3.
Implementing right fit
4.
Training/ maintenance
5.
Go live (continuous improvement)
ADOPTION SCENARIO OF
ELECTRONIC MEDICAL RECORDS: India
Majority of the
hospitals in Asian countries such as India, China, Thailand, Malaysia and
Indonesia are still in the early stages of IT adoption. These hospitals are far
behind in terms of IT adoption when compared to USA." said SourabhKankhar
Research Analyst, Asia Pacific Healthcare Practice, Frost& Sullivan.
Reasons of faster
adoption in West than India are perhaps based on certain specific factors
dominating the Western healthcare scene, such as increased patient awareness,
new government initiatives encouraging EMR, high penetration of computers, new
product innovations, economic pressures on healthcare organizations and
increased legal compulsions for greater accountability and well-maintained
records.
The EMR market is a
fast developing market in India. Barriers of EMR Adoption in India are: most
importantly lack of awareness among medium and small scale providers about the benefits and advantages.
Resistance to adoption are lack of compatible technology with existing systems
and lack of user friendly interface, high cost of implementation, long
implementation process, the decrease in productivity during implementation,
vendors lack domicile knowledge in healthcare.
GLOBAL MARKET:
Accenture conducted a
study of leading health care software, hardware, and services companies to
gauge the attractiveness of eight international electronic medical record (EMR)
markets of considerable size and EMR maturity. Those markets include Australia,
Canada, France, Germany, Japan, The Nordics, Spain and the United Kingdom (UK).
Other large markets— namely, India and China— were not studied due to
conflicting opinions of overall EMR maturity.
The market is expected
to grow at a rate of 6.6 to 9.7% across North America, Europe, Latin America
and Asia Pacific. The global market is expected to be $19.7 billion in 2013.
Asia Pacific’s EMR
market is expected to grow at 7.6 percent Compound annual growth rate (CARG)
from $2.3 billion to $2.9 billion (which is highly dependent on the growth rate
of INDIA and CHINA) as compared to North America with highest growth rate of
9.7% CARG from $7.4 billion in 2010 to $9.8 Billion in 2013. The acceleration
in the market is due to ARRA incentives and penalties.
Europe, Africa, and
Latin America will grow at 7.6% through 2013 driven by government incentives.
The study states that
there are four primary forces which have the most impact on EMR growth:
1.Emerging Markets:
Many emerging markets (for example, Malaysia, Thailand, Brazil, Russia, India
and China) and can potentially utilize innovative approaches such as
cloud-based solutions. The future of these markets will be largely dependent on
regulatory standards, government support and future trends affecting domestic
health care systems.
2.Government funding:
Government incentives (e.g. The United States’ ARRA incentives and penalties
3.Regional National and
multicountry integration
4. Labor Shortage: with
rapid increase of information technology in health care, there is expected
increase in demand of the clinically trained IT personnel and because of more
shortage of nurses in near future the need to have Electronic Medical Records
is definitively going to arise.
OBSERVATIONS:
1.
The Major problems with manual medical
records were identified to be:
· Delay
in patient care because of dispersed records.
· Multiplicity of form types used to document the patient
records.
2.
The awareness levels among the health
care workers was highest among health care workers with post graduates and lowest
among those with diploma holders.
3.
The Acceptance Levels of the EMR which
was seen among the health care providers (nurses and Post graduate doctors 75%
and 86% respectively) in the tertiary care hospital were seen to be 75% andmajority
of the health care providers are willing to take up the training.
 
1.
There was need to increase the
infrastructure to 25% of number of computers and 15 % of printers (keeping in
mind the security of patient information).
2.
Cost of Implementation:
Ø The
total health IT includes:
v The
initial fixed cost of the hardware, software, and technical assistance
necessary to install the system;
v Licensing
fees;
v The
expense of maintaining the system; and
v The
“opportunity cost” of the time that health care providers could have spent
seeing patients but instead must devote to learning how to use the new system
and how to adjust their work practices accordingly. Various studies have stated
that the productivity decreases by 10%
to 15%
v Social
costs: Risk of lost privacy because of such system and such situations can be
avoided by complying to the governmental standards in their respective
countries, also by providing the ability to track who accesses the patient’s
record.
Ø The
costs of implementing vary widely based on the:
v Size
and complexity of providers’s operations.
v The
extent to which the providers want to perform their work electronically.
v Differences
in the amounts and types of associated training and labor costs (for operating
the system).
The cost calculated was
Rs. 2,31,00,000 based on all the above factors.
There were few areas
where recurring cost due to increase in infrastructure increased (because of
cost of maintenance, increase in electricity expenses).
The areas of cost
saving were the decrease in the labor, the stationery, which was estimated to
be Rs.38,00,000
CONCLUSION:
If the patients’
records are made electronic the space used presently for paper records can be
used for other purposes. As MRD is in the OPD block various other services can
be provided.
The major problems faced by nurses and post
graduates with the present paper records are:
Ä Delay
in service delivery because of dispersion of records by 66.9% nurses whereas
86.1% of post graduates face this problem
Ä Multiplicity
of form types consumes their major time (65.9%) whereas (83%) post graduates
face this problem.
graduates
highly agree and agree that health care should devote time to the training
The
Capital cost of implementation of
EMR was calculated to be 2 Crore 31 lakhs .Once the EMR is fully functional the
expected cost saving can be somewhere more than 35 lakhs per year.
SUGGESTIONS:
v First
of all the users’ needs and problems should be identified and their acceptance
to change must be evaluated. Orientation is important at this stage.
v The
institution must ensure that the inefficiencies in the department must be
removed first then the implementation must commence.
v The
cost of implementation is very high so the implementation can be stepwise and
the costs can be divided into two financial years.
SUGGESTIONS:
v First
of all the users’ needs and problems should be identified and their acceptance
to change must be evaluated. Orientation is important at this stage.
v The
institution must ensure that the inefficiencies in the department must be
removed first then the implementation must commence.
v The
cost of implementation is very high so the implementation can be stepwise and
the costs can be divided into two financial years.
v The
dependency on vendor should be minimized thus vendor operated systems should be
avoided
v The
EMR should be easy to learn, understand, operate i.e. no requirement of opening
of multiple windows, which tends the user make mistakes.
|
Nov 22, 2012
Summer Project on Kidney/Dialysis Disease Centre
DIALYSIS CENTRE PATIENT CENTRIC ISSUES
(As Contributed voluantrily by a follower of my blog, )Thanks Buddy
ON
“Study on Problems faced by Dialysis Patients and Caretakers”
STUDY CONDUCTED AT:
ABC HOSPITAL
U.P.
ACKNOWLEDGEMENT
Undertaking a project is never a one-person job. It always involves help from other people, who are either reviewing your work or teaching you things. It would have never been completed without the co-operation and sincere efforts of all the staff members of hospital who guided me throughout this project.
My sincere “Thanks” goes to:
ABC.
DECLARATION
I student of M.B.A. (Hospital Administration), hereby declare that this project has been completed by me is a part of our major research project. This report has not been submitted anywhere else to the best of my knowledge.
Date-
Student
MBA (HA) 4th Sem
CONTENTS
1. HOSPITAL PROFILE
2. PREFACE
3. INTRODUCTION TO THE TOPIC
4. LITERATURE REVIEW
5. AIM
6. OBJECTIVES
7. METHODOLOGY
8. DATA ANALYSIS AND INTERPRETATION
9. FINIDINGS
10. RECOMMENDATIONS
11. CONCLUSION
12. REFERANCES
HOSPITAL PROFILE
Introduction
Hospital is the only multicrore, Super speciality Tertiary Care corporate hospital in Utter Pradesh, which has been established in 1993 with a view to fill the wide gap between demands of high class medical services and actually available services thereof. The hospital was established with technical consultancy with Indian Hospital Corporation Ltd it is a listed Public Ltd. Company at BSE and UP Stock Exchange Ltd.
The hospital has OPD, 24 hours emergency service and in-patient admission facilities for 175 patients. The hospital has General Wards, Paediatric Ward, Semi- Private and Deluxe Rooms, bedsides ICU, ICCU and Neonatal Intensive Care Unit, PICU. The hospital is centrally Air-Conditioned including all rooms and General Wards. Round the clock diet and meals are provided to all patients free of cost under the supervision of Dietician.
Hospital is having fully equipped 4 OT’s with laminar flow, zero bacteria air conditioning facilities with C-Arm, Laproscope Microscope and OT Tables of BLANCO GMBH made etc.
A new state of Art OPD wing has been started in , wherein Covering of all specialties are available under one roof.
Locational Advantage
ABC Hospital Ltd. is strategically located in the city of UP, which is one of the 10 largest metropolitan cities in India, and being the industrial and commercial capital of the state of Uttar Pradesh is a major service centre for surrounding districts.
There existed a wide gap between the demand of high quality medical services and supply available thereof, with a result that most of the patients are forced to go to other cities like Delhi and Bombay to get Medicare in corporate hospitals.
The company thereof has an assured clientele from the inhabitations of UP and surroundings districts.
Vision
Reaching beyond excellence in high-end tertiary healthcare, while doing business with a soul.
Mission
To become a leading professional healthcare company in super - specialty and tertiary care in the Region, leading in cardiac care with a range of products, services and quality consistent with the highest customer expectations. To maintain the pioneering leadership in health care in this region.
HOSPITAL QUALITY POLICY
ABC Hospital Ltd. aims
Commitment to provide high standard of healthcare with the best of technology
Working environment and a team of highly qualified doctors, nurses and other skilled paramedics of the country.
To meet the need and expectation, by providing healthy environment, safety, security, for the patients, staff and visitors.
RENAL SCIENCES CENTRE
INTRODUCTION
ABC Hospital Ltd. is all set to bring yet another health care facility at UP, meeting all international standards. We are coming up with an exclusive dedicated 70 bedded renal hospital for dedicated Nephrology and Urology patients. It is an ultra modern hospital with facilities for all kinds of Dialysis and Kidney Transplant.
The new centre will be backed by a dedicated team of highly qualified and experienced doctors, nursing staff and technicians. Along with Renal disease management, the centre will focus on preventive health management through its various community interaction programmes and scientifically designed preventive renal health care checkup."
The Aim of the Hospital is to give the best quality of treatment for all types of Kidney diseases. The hospital is fully computerized and well equipped seventeen dialysis machines were patients can get the most comfortable dialysis. Even many outsider patients are regularly coming to our hospital for dialysis. They feel no difference rather, some claim, they felt better.
We have advanced operation theatre including high definition image intensifier (C-Arm) for various operation of kidney. The Operation theatre is ultra modern OT of its kind.
We have computerized uroflowmetry for diagnosis of various lower urinary treat diseases including prostate & urethral diseases. The Laboratory is also computerized where result is obtained within an hour. The intensives care unit care unit (ICU) of the hospital is well managed by experience doctors and nursing staff round the clock.
NEPHROLOGY
The Department of Nephrology at ABC Hospital is the oldest and first of its kind in Northern India. The Department is headed by a senior nephrologists consisting of a dedicated team of nephrologists and Para-medical staff. The Nephrology wing of renal sciences deals with all sorts of diagnostic and therapeutical modalities of Kidney diseases.
For the diagnosis of complex renal diseases the department provides a combination of conventional and most sophisticated investigations like - 3 D US with Doppler study for Renal vessels, CT scan, IVP, Renal Angiography and Kidney Biopsy - to name a few. Kidney Biopsy is done by modern US guided automated gun. Biopsy needle & tissue thus obtained is studied by light & IF Microscope.
All possible modes of therapeutic interventions like maintenance hemodialysis on ultramodern Japanese hemodialysis machines with superb volumetric control ( Acetate as well as Bicarbonate), Emergency hemodialysis round the clock, continuous Ambulatory Peritoneal dialysis, Acute Peritoneal dialysis, Automated Peritoneal dialysis (APD), Hemofiltration, continuous Renal replacement therapy (CRRT) and Kidney transplantation.
A strictly related Renal Transplant programme is being conducted in the hospital for the last 5 years. The Department has a separate kidney transplant ICU with ventilator, C-PAP, CVP monitoring & Cardiac monitoring equipments. Isolated nursing care is provided to the patients by well trained & experienced Nursing Staff with special attention to asepsis, nutritional support & minimal handling to these immuno-compromised patients these immuno-compromised patients.
A post transplant OPD is run for all follow up patients on every Thursday of the week, where all these patients are seen by a team of nephrologists and Transplant surgeons. Apart from the above mentioned facilities, the department has taken special interest to promote preventive nephrology i.e. the prevention of Kidney diseases in susceptible individuals. For this a preventive nephrology OPD is run once a week and the department runs Kidney disease detection camps, public education programmes and CME programmes for Family Physicians throughout the year.
UROLOGY
Urology is that discipline of medical science, which deals with both medical and surgical diseases of urinary and genital systems of men, women and children.
The common ailments/subdivisions are:
Stone Disease
Stone formed in urinary system is a common ailment of human race from time immemorial. They are made of calcium, oxalate, uric acid, phosphate etc. in various combinations. There has been a remarkable advancement in treatment of stone disease. The common concept that every stone needs operation is not true. Majority of stone patients (up to 80%) do not need any intervention or operation. With modern techniques of ESWL (Lithotripsy) PCNL &URS, the need of open operation has gone down to about 5%. For details of these, please contact our Urologist.
Prostate Enlargement
Prostate is a gland present around the upper part of the urinary passage of men. It enlarges in size in all men after the age of 45 years. It is the commonest cause of urinary problems in aged men. If a man is troubled by urinary symptoms, the prostate needs to be removed. The technique of TURP is the best in today's date. In this technique, the enlarged prostate is removed by a telescopic instrument passed through the urinary passage. But before the decision of treatment is taken, it is important to prove that the urinary symptoms are due to prostate enlargement and not some other problem. This is a vital question and it requires the tests or UROFLOMETRY & CYSTOMETROGRAM.
Urinary Infections (UTI)
These are very common particularly in women. Frequent discharge of urine, burning, pain and difficult urination are present symptoms. For proper treatment, an Urologist should be consulted who carry out the urine would culture, uroflowmetry and ultrasound examination to find out the cause and nature of infection. The proper and effective treatment is based on these test reports.
Blood in Urine
Passage of blood with urine is known as hematuria. The commonest cause is urinary infection. The presence of blood in urine should not be neglected. It should always be investigated by tests such as urine culture, ultrasound, IVP and CT scan. The cause may be a stone, tumour of bladder or Kidney, vascular malformation, prostate enlargement etc. The treatment is according to the cause.
Stricture
Stricture is a term applied to narrowing of a tubular structure. When it occurs in urinary passage, it causes decrease in the flow of urine. This later causes effects on urinary bladder and kidneys. In majority of patients, its treatment is by a telescopic instrument (nonoperative) but in some it requires reconstruction of the urinary passage (urethroplasty).
Kidney Disease
Surgical diseases of kidney such as STONE, TUMOURS, CYST, and VASCULAR MALFORMATIONS require appropriate and timely treatment. The treatment is operative or minimally invasive or conservative depending upon the type and nature of the disease.
Kidney Failure
When both kidneys have failed working due to any disease, they need replacement. The best mode of kidney replacement is KIDNEY TRANSPLANTATION and a very economical package for this is available at ABC hospital.
PREFACE
Dialysis patients represent the overwhelming majority of patients cared for by all nephrologists. This patient group represents complex medical problems, is increasing in number at an annual rate of 8%, and suffers from very high morbidity and mortality. This would seem to represent the ideal situation for an academic research faculty. i.e. a major and increasingly problematic health issue and a patient population of sufficient number and motivation about which to pose investigative issues. Curiously, a significant fraction of the nephrology world views dialysis purely as a technology necessary to insure survival but requiring little in the way of intellectual contribution.
The record shows a failure of much of the academic community to become interested in the problems of the end-stage renal failure patient. In many academic circles, the tasks attendant to this procedure are often delegated to the most junior faculty members and research questions rarely present themselves at any higher level. That this attitude permeates the entire nephrology research establishment is shown by the very low level of research support for dialysis-related research by either the National Institutes of Health or Veterans Administration. Bear in mind that more than $5.4 billion is spent annually in the direct care of end stage renal disease patients. There had been support for research relevant to morbidity and mortality of the dialysis population in the early 1970s.
Many of the technological treatment advances of today in hemodialysis and peritoneal dialysis, followed this period of activity. Unfortunately this program was discontinued and no replacement was developed to fill the void.
INTRODUCTION TO TOPIC
In recent years the principal areas of research have been in the development of products which improve the safety and efficiency of dialysis including synthetic dialysis membranes and new delivery systems. Computerization of such machines with accompanying ability to produce and manipulate data is in its early stages. Similarly, work to develop machines which will provide on-line Information useful in altering pressures flows, and dialysate concentration in response to patient needs is in its infancy. Essentially all of these advances have been supported by Industry.
Research relevant to the health of the dialysis patient has been largely neglected. The reasons for this are complex, but a small group of Investigators, believed that part of the problem was the complexity of the problems and the lack of data.
ABC Hospital Ltd. is all set to bring yet another health care facility at UP, meeting all international standards. ABC hospital coming up with an exclusive dedicated 70 bedded Renal hospital for dedicated Nephrology and Urology patients. It is an ultra modern hospital with facilities for all kinds of Dialysis and Kidney Transplant.
Dialysis is a treatment for people in the later stage of chronic kidney disease (kidney failure). This treatment cleans the blood and removes wastes and excess water from the body. Normally, this work is done by healthy kidneys.
THE EMOTIONAL EFFECT OF RENAL FAILURE
Stress
One of the main causes of stress is change. All human beings find change stressful - even change that we are looking forward to, like moving house, raises our stress levels.
As a person with renal failure you will have to deal with more change than most people do. Not just the initial change of lifestyle that comes with the diagnosis, but ongoing changes as you deal with alterations to your diet, medication and forms of treatment.
All these changes will mean you have to take in a great deal of new information, make decisions, and learn new practical skills. You also have to adjust to new ways of doing things, to doing less than you would like to, and to asking for help... This is all extremely stressful - and it comes in addition to coping with the physical effects of kidney failure.
Different people react differently to stress - some get anxious or feel overwhelmed, others may get irritable or hostile, others may deny there is a problem and keep pushing themselves to "cope."
The best way of coping with stress is to recognize that it can be a problem in its own right and that if you are suffering from it, it is with good reason. Accept that you need to actively take time to "de-stress". There are many ways of doing so and they can all contribute to helping you cope with kidney failure.
Anxiety
This can be a specific "worry" related to something in particular, or a more general sense of "being on edge" or "not feeling safe."
Specific anxieties that renal patients may have include:
• Worries about how the illness will affect your relationships,
• Your ability to work,
• Your finances
• Your quality of life
• You may also be anxious about understanding your condition or managing your treatment.
Ways of reducing anxiety are:
To see if there is something practical you could do to help you feel better. Make that appointment to see the doctor/dietitian/social worker/counselor about what is worrying you. Ask a nurse about that part of the procedure you don't understand.
There will of course be things that worry you that you can do nothing practical about. Most patients will say, however, that they find it helpful simply to talk about their worries to people who understand. Whether it's another patient, a nurse, a family member or a counselor, don't keep yourself alone with your anxiety.
Generalized anxiety is just as difficult to live with as anxiety that has an obvious cause.
Feeling generally "unsafe" may have something to do with a sense of "having no control" over your own body and life.
Many patients find that they can regain a sense of control by learning as much as they can about kidney failure and its treatment. Becoming an "expert" enables them to participate more actively in making decisions and to feel that they are working with the medical staff to control the condition rather than being passive.
Other people find that setting reasonable goals for themselves, such as going out, exercising, or keeping up certain activities - and achieving them - gives them a feeling of control.
Depression
Like anyone else, you will have times when you feel a bit down and less able to cope with life in general. You may also feel sad and "need a good cry" sometimes. If, however, the sadness turns into a real sense of despair that goes on for some time, this is depression.
You may feel depressed because you are having difficulty coming to terms with some of the changes their condition is imposing on you.
These might include:
• The loss of your previous lifestyle
• The loss of independence and self-confidence
• The changes to your body and appearance
• Difficulties with sex or with having children
• Awareness of your own mortality
If you are feeling depressed it may help you feel less isolated if you talk to others who understand. This may be one of the renal unit nurses, the renal social worker, a counselor or even a good friend. Sometimes a short course of anti-depressant medication may be useful to get over these acute problems.
Anger
It seems quite appropriate for people who are going through these experiences to feel angry at times. It can even be energizing, sometimes, to feel angry.
Where problems arise, however, is if you get "locked into" your anger in a way which makes you unhappy and you can't seem to move through it into some degree of acceptance.
Anger is also a problem when it is expressed in destructive or self-destructive ways - when the feelings of anger and frustration lead to rebellion against diet and fluid restrictions, for example, or to aggressive behaviour towards friends, relatives and staff. When people are angry, they may tend to "push away" the people who want to support them.
Anger expressed in these ways is self-destructive because it puts your health at risk, and - on an emotional level - leaves you feeling even more isolated.
It can feel like the hardest thing in the world to reach out for support when you are feeling angry. Paradoxically, it may be the one thing you can do to regain a real sense of power and control in your life.
Sexual problems
Some kidney patients never have sexual problems, but many do.
The reasons for these problems may include:
Hormonal problems: The hormones that control sexual urges may be either higher or lower in people who have kidney failure.
Medication: Some of the medication prescribed to renal patients may have the effect of inhibiting sexual desire.
Tiredness: This can be caused by anaemia or by not having dialyzed sufficiently.
Emotional factors: When people feel stressed, depressed or anxious, they often do not feel like having sex.
Relationship difficulties: The stress that kidney failure can bring to a relationship may affect the couple's sex life.
Sexual problems in men
Impotence (the inability to get or maintain an erection) may be a problem in male kidney patients.
There are various approaches to treating impotence. Initially, doctors will look at possible causes such as anaemia, under-dialysis and medication, and consider the treatments for them. There are physical treatments for impotence that can be considered including physical techniques and drugs. Two recent studies have shown that Viagra is effective in haemodialysis patients like it is in patients with normal kidney function. Remember though, it is not a guaranteed success and some patients do not show any response. UK patients can receive Viagra on the NHS scheme as kidney disease is on the list of conditions allowing prescription
When women patients experience a lack of sexual desire or inability to have orgasms, causes related to anaemia, under-dialysis and medication can be investigated.
There may be changes in the menstrual cycle and there is no doubt that the chances of getting pregnant if the kidneys have failed are much reduced. If kidney function is only mildly impaired and the blood pressure is under control before and during pregnancy, it is likely that pregnancy will progress as normal, but there will be a close liaison between the kidney doctor and the obstetrician. Some drugs particularly ACE inhibitors will need to stop before pregnancy and the blood pressure will be checked very carefully.
REVIEW OF LITERATURE
The department of Nephrology and urology are important part of any hospital. It functions with a full complement of infrastructure needed both for diagnosis and treatment of renal disorders such as Acute & chronic nephritis Connective tissue disorders and other renal problems like Acute & chronic renal failure Nephritic syndrome Secondary hypertension Diabetic nephropathy etc.
WHAT IS KIDNEY?
In humans, the kidneys are two small organs located near the vertebral column at the small of the back. The left kidney lies a little higher than the right kidney. They are bean shaped, about 4 in. (10 cm) long and about 21/2 in. (6.4 cm) wide.
WHAT DOES KIDNEY DO ?
Your kidneys are bean-shaped organs, each about the size of your fist. They are located near the middle of your back, just below the rib cage. The kidneys are sophisticated reprocessing machines. Every day, your kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The waste and extra water become urine, which flows to your bladder through tubes called ureters. Your bladder stores urine until you go to the bathroom.
The wastes in your blood come from the normal breakdown of active tissues and from the food you eat. Your body uses the food for energy and self-repair. After your body has taken what it needs from the food, waste is sent to the blood. If your kidneys did not remove these wastes, the wastes would build up in the blood and damage your body.
The actual filtering occurs in tiny units inside your kidneys called nephrons. Every kidney has about a million nephrons. In the nephron, a glomerulus-which is a tiny blood vessel, or capillary-intertwines with a tiny urine-collecting tube called a tubule. A complicated chemical exchange takes place, as waste materials and water leave your blood and enter your urinary system.
At first, the tubules receive a combination of waste materials and chemicals that your body can still use. Your kidneys measure out chemicals like sodium, phosphorus, and potassium and release them back to the blood to return to the body. In this way, your kidneys regulate the body's level of these substances. The right balance is necessary for life, but excess levels can be harmful.
In addition to removing wastes, your kidneys release three important hormones:
• erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells
• renin, which regulates blood pressure
• calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body
The Kidneys filter the blood and remove waste products and fluid which is called urine. The kidneys balance the potassium and sodium levels and also produce several hormones. When patients are diagnosed to have renal failure, it means these kidneys are not filtering properly and harmful waste products are accumulating in the blood. Some of the most common causes are diabetes, high blood pressure (hypertension), infections, drugs and polycystic kidney disease.
The treatment option available is dialysis and transplantation.
What is dialysis?
It is a technique of removing fluid and waste products from body with a In medicine, dialysis is primarily used to provide an artificial replacement for lost kidney function in people with renal failure. Dialysis may be used for those with an acute disturbance in kidney function (acute kidney injury, previously acute renal failure) or for those with progressive but chronically worsening kidney function–a state known as chronic kidney disease stage 5 (previously chronic renal failure or end-stage kidney disease).
Dialysis works on the principles of the diffusion of solutes and ultra filtration of fluid across a semi-permeable membrane. Diffusion describes a property of substances in water. Substances in water tend to move from an area where they are in a high concentration to an area of low concentration. Blood flows by one side of a semi-permeable membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. A semi permeable membrane is a thin layer of material that contains various sized holes, or pores. Smaller solutes and fluid pass through the membrane, but the membrane blocks the passage of larger substances.
Sometimes dialysis is a temporary treatment. However, when the loss of kidney function is permanent (as in end-stage kidney failure), you must continue to have dialysis on a regular basis. The only other treatment for kidney failure is a kidney transplant.
TYPES OF DIALYSIS
Hemodialysis
In hemodialysis, the patient's blood is then pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane. The dialyzer is composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the outside the fibers, and water and wastes move between these two solutions. The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several liters of excess fluid during a typical 3 to 5 hour treatment.
Peritoneal dialysis
In peritoneal dialysis, a sterile solution containing glucose is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a semipermeable membrane. The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs. The dialysate is left there for a period of time to absorb waste products, and then it is drained out through the tube and discarded. This cycle or "exchange" is normally repeated 4-5 times during the day, sometimes more often overnight with an automated system. Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis.
Hemofiltration
Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal circuit during the treatment.
Intestinal dialysis
In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste.
Does hemodialysis hurt?
Insertion of the needles causes pain, but only for a brief time. This can be difficult for some people. Occasionally nausea, muscle cramps or dizziness can occur due to the fast removal of extra water from your body, which may cause your blood pressure to drop.
How long does hemodialysis take?
Each hemodialysis treatment normally takes four to five hours, and usually three treatments a week are needed. More frequent, shorter treatments or longer treatments may be indicated for certain patients. Only a small amount of your blood is out of the body at one time. Therefore your blood must circulate through the machine many times before it is cleaned.
What is home hemodialysis?
Many dialysis centres in India offer the option of training patients or their partners to carry out hemodialysis at home. The dialysis machine and necessary modifications to your home are provided by the hospital. While some home hemodialysis patients follow a standard schedule of four to five hours three days a week, some Canadian centres are also offering nocturnal home hemodialysis in which patients go on dialysis four to six nights a week for six to eight hours while they sleep. Nocturnal home hemodialysis greatly improves the removal of waste products from the body and has been found to improve well-being, allow for a more liberal diet and reduce the need for medications.
What other changes are needed with hemodialysis?
You will need to plan your week around your hemodialysis schedule. You may have to take time off work or school before you start hemodialysis and when the treatments begin. However, once your health is more stable, you should be able to return to your normal activities. Depending on your energy level, you may have to make some adjustments in your work situation or limit your activities.
Is travel possible on hemodialysis?
There are dialysis units across India and in many parts of the world. They have suitable facilities for visitors who need hemodialysis treatment. However, it is necessary to plan several months in advance due to limited space and staff. Your dialysis unit and local Kidney Foundation office can provide more information and advise you about travel costs and arrangements.
AIM
To study the Problems faced by Dialysis Patients and Caretakers
OBJECTIVES
1. To get in-depth knowledge about the Dialysis unit of hospital.
2. To find out importance of artificial kidney unit for hospital.
3. To find out problems of the dialysis patient & their caretakers and provide recommendations.
4. To reduce the problems in the new set up of hospital with the help of research results.
METHODOLOGY
STUDY DESIGN: -
Survey questionnaire.
STUDY SETTING : –
ABC hospital, Madhuraj hospital, Rajaram hospital, KMC UP.
SAMPLE SIZE: -
100 Patients of Dialysis and care takers.
SAMPLING METHOD: -
Simple random sampling
INCLUSION CRITERIA: -
Acute and chronic dialysis patients.
METHODS OF DATA COLLECTION: -
Primary data is collected through questionnaire filled by dialysis patient and care takers.
STUDY PERIOD: -
15 May- 05 Jun: - Data collection
06 Jun- 11 Jun: - Data analysis and report preparation.
STATISTICAL ANALYSIS: -
Mean and percentage was calculated.
Pie and bar diagram is used for representation.
PATIENT SURVEY
To understand the patient expectations and their preference of hospitals and to know the factors which affect their choice of the hospital for dialysis a questionnaire is prepared. This questionnaire is filled by the 100 dialysis patients of various hospitals which are chosen for the study. The questionnaire contains following questions:-
SURVEY QUESTIONNAIRE
SAMPLE QUESTIONNAIRE
1. On an average, how often do you undergo dialysis treatment?
a. Once a week
b. Twice a week
c. Three times a week
d. Four times a week
2. On an average, after how many treatments do you replace your dialyzer?
a. After 8 treatments or less
b. Between 9 and 10 treatments
c. Between 11 and 12 treatments
d. Between 13 and 14 treatments
e. After 15 or more treatments
3. Approximately how much does it cost per week to buy Erythroprotein and other medicines?
a. 200 or less
b. Above 200 and up to, and including 250
c. Above 250 and up to, and including 300
d. Above 300 and up to, and including 350
e. Above 350 and up to, and including 400
f. Above 400
4. What brand of Erythroprotein do you currently purchase?
________________________________________________
5. Approximately how often do you have your tests done?
a. Once a month
b. Twice a month
c. Three times a month
d. Four times a month
e. Five times a month
f. More than five times a month
g. Every 12 months or less often
6. Approximately how much do you spend on diagnostics and tests a month?
a. 1200 or less
b. 1201-1300
c. 1301-1400
d. Above 1400and up to, and including 1500
e. Above 1500and up to, and including 1600
f. Above 1600
7. Approximately how often do you visit your Nephrologists?
a. Twice a month or more often
b. Once a month
c. Once every two months
d. Once every three to five months
e. Every six months or less often
8. When you for dialysis, how do you usually get to the hospital?
a. Walking
b. Shared Tempo
c. Rickshaw
d. Auto
e. Own Scooter
f. Own Car
g. Other, If so, how? ___________________________________
9. Approximately, how much do you spend on transportation per visit?
a. 5 or less
b. Above 5 and up to, and including 10
c. Above 10 and up to, and including 20
d. Above 20 and up to, and including 30
e. Above 30 and up to, and including 40
f. Above 40 and up to, and including 50
g. Above 50
10. Please rank the following services that you would like a dialysis center to offer from 1 to 7 according to your personal preferences; 1 being the most important and 7 the least important.
Pick-Up and Drop-Off Services
Personalized TV Screen
Wi-Fi
Package Pricing (One combined price for medicines, dialyzer and dialysis)
Counseling (How to better take care of yourself; dialysis friendly recipes, etc.
Flexible scheduling
Nice facilities for attendants
11. Which of the following best describes your dialysis treatment routine?
a. I go to my attendants by myself
b. I go to my treatments by myself and someone visits me while I receive dialysis
c. Someone takes me to and/or picks me up from the hospital, but he/she doesn’t stay
d. Someone takes me to the hospital and stays with me while I receive dialysis
12. Please mark the three schedules that are most convenient for you:
M Tu W Th F S
Morning(7:00-11:30)
Afternoon(11:30-17:00)
Evening (17:00-21:30)
Night (00:00-6:00)
13. If your current hospital began offering a Pick-Up & Drop-Off service for an additional charge, how much would you be willing to pay?
_______Rs per visit
14. If your current hospital began offering comfortable chairs with a personal TV screen for an additional charge, how much would you be willing to pay?
_______Rs per visit
To better understand how opinions vary among people with different characteristics, we need some additional information. Again, this information is confidential, and will be analyzed anonymously.
15. Age………..
16. Sex
a. Male
b. Female
17. What is your home address?
18. What is your work address?
19. How many people currently reside within your household?
20. What is the total income in your household?
a. Under and up to, 10,000
b. Above 10,000and up to, and including 25,000
c. Above 25,000and up to, and including 50,000
d. Above 50,000and up to, and including 75,000
e. Above 75,000and up to, and including 100,000
f. Above 100,000and up to, and including 125,000
g. Above 125,000
End of Questionnaire
Thank you for taking the time to complete this survey. If you have any questions related to this research, please contact:
***********
DATA ANALYSIS
AND
INTERPRETATION
Survey Results
The survey was conduct in various hospitals of UP, with a total number of 100 Patients as the sampling population. The Sample includes Acute and chronic dialysis patients.
Q. 01. On an average, how often do you undergo dialysis treatment?
Q.02. On an average, after how many treatments do you replace your dialyzer?
Q. 03. Approximately how much does it cost per week to buy Erythroprotein and other medicines?
Q.04. What brand of Erythroprotein do you currently purchase?
Q.05. Approximately how often do you have your tests done?
Q. 06. Approximately how much do you spend on diagnostics and tests a month?
Q.07. Approximately how often do you visit your Nephrologists?
Q.08 When you for dialysis, how do you usually get to the hospital?
Q.09. Approximately, how much do you spend on transportation per visit?
Q.10. Please rank the following services that you would like a dialysis center to offer from 1 to 7 according to your personal preferences; 1 being the most important and 7 the least important.
Pick-Up and Drop-Off Services
Personalized TV Screen
Wi-Fi
Package Pricing (One combined price for medicines, dialyzer and dialysis)
Counseling (How to better take care of yourself; dialysis friendly recipes, etc.
Flexible scheduling
Nice facilities for attendants
Q.11. which of the following best describes your dialysis treatment routine?
Q.12. Please mark the three schedules that are most convenient for you:
M Tu W Th F S
Morning(7:00-11:30) 74 2 60 24
Afternoon(11:30-17:00) 10 2 2 2
Evening (17:00-21:30) 2 2 4
Night (00:00-6:00) 4 6
Q.13. If your current hospital began offering a Pick-Up & Drop-Off service for an additional charge, how much would you be willing to pay?
_______Rs per visit
Q. 14. If your current hospital began offering comfortable chairs with a personal TV screen for an additional charge, how much would you be willing to pay?
_______Rs per visit
FINDINGS
1. The principal areas of research have been in the development of products which improve the safety and efficiency of dialysis, Including synthetic dialysis membranes and new delivery systems.
2. Research relevant to the health of the dialysis patient has been largely neglected. The reasons for this are complex, but, it is believed that part of the problem was the complexity of the problems and the lack of data.
3. Dialysis patient group represents complex medical problems, is increasing in number at an annual rate of 8%, and suffers from very high morbidity and mortality.
FINDING IN RESPECT OF ABC HOSPITAL
1. Charges for the dialysis are varies from hospital to hospital according to policy of hospital. In some hospitals charges for dialysis varies according to the fee of the doctor or nephrologists.
2. 90% of the patient undergo dialysis treatment twice a week.
3. In 94% cases the dialyzer is replaced after 8 treatments or less.
4. About 95% patient spent more than Rs. 400 to buy erythropoietin and other medicines.
5. About 96% of the patient have their test done once a month and 4% twice a month.
6. 86% of the patient spend approximately Rs. 1200 or less for the diagnostics and tests in a month.
7. The visit to the nephrologists are in 72% cases once a month, 14% twice a month, 6% cases once every two months and in 8% cases once every three to five months.
8. Patient get to the hospital for dialysis in 26% cases by own scooter, 22% cases by auto, in 20% cases by rickshaw, 14% cases by shared tempo, 10% cases by own car, 4% cases walking and other transport.
9. 78% of the patient spent more than Rs. 50 on transportation per visit.
10. Pickup & drop-off services and nice facilities for attendants is the top priorities of patient and Wi-Fi is the least priority.
11. In 92% cases patient come with the attendant who stay in the hospital during dialysis.
12. The most convenient time for the patent to receive dialysis are Monday and Friday morning.
RECOMENDATIONS
1. Pickup and Drop-off services can be started by the hospital for the dialysis patient according to survey results.
2. There should be nice facilities for attendants in waiting area.
3. The scheduling for the dialysis should be flexible and comfortable to the patient and relatives.
4. Counseling should be done by an expert or nursing staff about various issues of dialysis like how to better take care of yourself; dialysis friendly recipes, etc.
5. The hospital can increase number of patient coming for dialysis by reducing the charges for the dialysis to that level which patient find easy to pay.
6. As dialysis is a costly treatment so it is not possible for dialysis patients to afford the treatment for a longer time especially those who belong to the middle class or lower class families. such type of patient need some help in monetary terms so that hospital should increase their contacts with the trusts such as Sai baba dialysis help centre, Bharat vikas parishad etc. Such type of organizations not only provides help to the patient but helps hospital in attracting new patients and retaining them for a longer time.
7. The hospital should conduct aggressive promotional campaigns in remote areas or in villages so that a large number of populations come to know about the hospital and the facilities it providing for the dialysis.
CONCLUSION
Over the coming years, more and more people will have a renal condition in India. However, both the amount and choice of dialysis services in India is limited. For instance, at present, no Service providers appear to offer home haemodialysis, despite national guidance that says it should be offered.
We are pleased that many of these problems are being addressed and that renal services are now a priority in India. It is clear that the effect of dialysis on a person’s whole life and that of their family is not widely understood. We hope this review will bring about changes in provision and support which will help them.
This document makes recommendations to the ABC Hospital about renal services for people. It is based on local research conducted and led by me in cooperation with the ABC hospital and Institute of Management Studies.
REFERANCES
• “Research methodology” C.R. Kothari
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