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Abstract
Introduction: Continuity of care is vital for patient safety during healthcare transitions, where nursing care reports facilitate coordination and reduce risks.
Objectives: To reach a consensus on additional fields that should be included in the nursing care report for haemodialysis patients transitioning between care centres.
Material and Method: We conducted an exploratory study divided into 2 rounds. In Round #1, an expert committee designed a questionnaire based on literature review and Gordon's functional health patterns system, to determine the additional fields. In Round #2, a modified Delphi technique was applied in 2 rounds to reach consensus on the additional fields. 56 experts participated in the first round and 14 in the second. Consensus was considered when at least 80% approved an additional field.
Results: Consensus was reached on 54 of the 57 additional fields presented in Round #1 to be included in the report, such as the originating centre, need for medical transport, number of weekly dialysis sessions, duration of each session, and specific vascular access data. Elements related to the patient's health according to Gordon's patterns were also agreed upon, highlighting aspects such as blood glucose control, presence of muscle cramps, and use of aids for night-time rest.
Conclusions: The study successfully developed a standardised nursing care report for haemodialysis patients in transition, aiming to improve safety and continuity of care.
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Copyright (c) 2025 Cristina Labiano-Pérez-Seoane, Irene Larrañeta-Inda, José Luis Cobo-Sánchez
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References
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- Tizón Bouza E, Camiña Martínez MD, López Rodríguez MJ, González Veiga A, Tenreiro Prego I. Coordinación interniveles, importancia del informe de continuidad de cuidados de enfermería y satisfacción de los pacientes y familiares tras la hospitalización. ENE Rev Enfermería. 2021;15(2):1-14.
- Rivas Cilleros E, Velasco Montes J, López Alonso JC. Valoración del informe de enfermería al alta tras la hospitalización. Nuberos científica. 2012;2(8):52-60.
- Luna-Aleixos D, Francisco-Montesó L, López-Negre M, Blasco-Peris D, Llagostera-Reverter I, Valero-Chillerón MJ, et al. Optimized Continuity of Care Report on Nursing Compliance and Review: A Retrospective Study. Nurs reports (Pavia, Italy). 2024;14(3):2095-106. DOI: https://doi.org/10.3390/nursrep14030156
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- Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445-51. DOI: https://doi.org/10.1370/afm.91
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- de Villiers MR, de Villiers PJT, Kent AP. The Delphi technique in health sciences education research. Med Teach. 2005;27(7):639-43. DOI: https://doi.org/10.1080/13611260500069947
- Crespo Montero R, Casas-Cuesta R, Ochando García A. Procedimientos y Protocolos con competencias específicas para Enfermería Nefrológica. 2a Edición. Madrid: Sociedad Española de Enfermería Nefrológica (SEDEN); 2024.
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- García Palacios R. Práctica Enfermera a pacientes con ERC. Documento de Consenso. Ministerio de Sanidad. Gobierno de España, editor. Madrid: Sociedad Española de Enfermería Nefrológica (SEDEN); 2015.
- Gordon M. Manual de diagnósticos enfermeros. Madrid: Elsevier España, S.L.U.; 2003.
- Gobierno de España. Ley Orgánica 3/2018, de 5 de diciembre, de Protección de Datos Personales y garantía de los derechos digitales. Madrid; dic 6, 2018. p. 119788.
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- Organización Mundial de la Salud. Comunicación de riesgos en emergencias de salud pública: directrices de la OMS sobre políticas y prácticas para la comunicación de riesgos en emergencias (CRE). Ginebra: Organización Mundial de la Salud; 2018. 1-79 p.
- Bansal L, Goel A, Agarwal A, Sharma R, Kar R, Raizada A, et al. Frailty and chronic kidney disease: associations and implications. J Bras Nefrol. 2023;45(4):401-9. DOI: https://doi.org/10.1590/2175-8239-jbn-2022-0117en
- Rajkumar T, Wong J, Harvey M, Weidersehn L, Surmon L, Makris A. Comparison of Sampling Methods for International Normalized Ratio Monitoring in Haemodialysis Patients (INRHaemo Study). Am J Nephrol. 2021;52(1):17-25. DOI: https://doi.org/10.1159/000513094
- Ma X, Tang C, Tan H, Lei J, Li L. Comparative effectiveness of nonpharmacological interventions for the nutritional status of maintenance hemodialysis patients: a systematic review and network meta-analysis. PeerJ. 2025;13(2):e19053. DOI: https://doi.org/10.7717/peerj.19053
- Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1-107. DOI: https://doi.org/10.1053/j.ajkd.2020.05.006
- Daugirdas JT. Residual Kidney Function and Cause-Specific Mortality. Kidney Int reports. 2023;8(10):1914-6. DOI: https://doi.org/10.1016/j.ekir.2023.08.024
- Pardo-Vicastillo V, Marks-Álvarez M, de Castro-De la Cruz T, Sanz-De la Torre L, Andrino-Llorente MT, Trocolí-González F. Impacto del estreñimiento en la calidad de vida de las personas en hemodiálisis. Estudio multicéntrico. Enferm Nefrol. 2024;27(4):340-8. DOI: https://doi.org/10.37551/S2254-28842024034
- Artículo en Acceso Abierto, se distribuye bajo una Licencia Creative Commons Atribución-NoComercial 4.0 Internacional.
- https://creativecommons.org/licenses/by-nc/4.0/
- Kot G, Wróbel A, Kuna K, Makówka A, Nowicki M. The Effect of Muscle Cramps During Hemodialysis on Quality of Life and Habitual Physical Activity. Medicina (Kaunas). 2024;60(12):2075. DOI: https://doi.org/10.3390/medicina60122075
- Zhang K, Hannan E, Scholes-Robertson N, Baumgart A, Guha C, Kerklaan J, et al. Patients’ perspectives of pain in dialysis: systematic review and thematic synthesis of qualitative studies. Pain. 2020;161(9):1983-94. DOI: https://doi.org/10.1097/j.pain.0000000000001931
- Pereira B dos S, Fernandes N da S, de Melo NP, Abrita R, Grincenkov FR dos S, Fernandes NM da S. Beyond quality of life: A cross sectional study on the mental health of patients with chronic kidney disease undergoing dialysis and their caregivers. Health Qual Life Outcomes. 2017;15(1):1-10. DOI: https://doi.org/10.1186/s12955-017-0646-4
- Zhou Q, Yu T, Liu Y, Shi R, Tian S, Yang C, et al. The prevalence and specific characteristics of hospitalised pressure ulcer patients: A multicentre cross-sectional study. J Clin Nurs. 2018;27(3-4):694-704. DOI: https://doi.org/10.1111/jocn.14019
- Hants L, Bail K, Paterson C. Clinical decision-making and the nursing process in digital health systems: An integrated systematic review. J Clin Nurs. 2023;32(19-20):7010-35. DOI: https://doi.org/10.1111/jocn.16823
References
Cronin J, Murphy A, Savage E. Can chronic disease be managed through integrated care cost-effectively? Evidence from a systematic review. Ir J Med Sci. 2017;186(4):827-34. DOI: https://doi.org/10.1007/s11845-017-1600-5
Teper MH, Vedel I, Yang XQ, Margo-Dermer E, Hudon C. Understanding barriers to and facilitators of case management in primary care: A systematic review and thematic synthesis. Ann Fam Med. 2020;18(4):355-63. DOI: https://doi.org/10.1370/afm.2555
Davis KM, Eckert MC, Hutchinson A, Harmon J, Sharplin G, Shakib S, et al. Effectiveness of nurse–led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review. Int J Nurs Stud. 2021;121:103986. DOI: https://doi.org/10.1016/j.ijnurstu.2021.103986
McClellan W. Processes of care and reduced mortality among hemodialysis patients in the United States. Clin J Am Soc Nephrol. 2010;5(11):1905-7. DOI: https://doi.org/10.2215/CJN.08520910
Tizón Bouza E, Camiña Martínez MD, López Rodríguez MJ, González Veiga A, Tenreiro Prego I. Coordinación interniveles, importancia del informe de continuidad de cuidados de enfermería y satisfacción de los pacientes y familiares tras la hospitalización. ENE Rev Enfermería. 2021;15(2):1-14.
Rivas Cilleros E, Velasco Montes J, López Alonso JC. Valoración del informe de enfermería al alta tras la hospitalización. Nuberos científica. 2012;2(8):52-60.
Luna-Aleixos D, Francisco-Montesó L, López-Negre M, Blasco-Peris D, Llagostera-Reverter I, Valero-Chillerón MJ, et al. Optimized Continuity of Care Report on Nursing Compliance and Review: A Retrospective Study. Nurs reports (Pavia, Italy). 2024;14(3):2095-106. DOI: https://doi.org/10.3390/nursrep14030156
Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51(4):556-7. DOI: https://doi.org/10.1046/j.1532-5415.2003.51186.x
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327(7425):1219-21. DOI: https://doi.org/10.1136/bmj.327.7425.1219
Gjevjon ER, Romøren TI, Kjøs BO, Hellesø R. Continuity of care in home health-care practice: two management paradoxes. J Nurs Manag. 2013;21(1):182-90. DOI: https://doi.org/10.1111/j.1365-2834.2012.01366.x
Van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract. 2010;16(5):947-56. DOI: https://doi.org/10.1111/j.1365-2753.2009.01235.x
Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445-51. DOI: https://doi.org/10.1370/afm.91
Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2):159-66. DOI: https://doi.org/10.1370/afm.285
Gobierno de España. Ley 41/2002, de 14 de noviembre, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. Madrid; 2002. p. 1-14.
Gobierno de España. Real Decreto 572/2023, de 4 de julio, por el que se modifica el Real Decreto 1093/2010, de 3 de septiembre, por el que se aprueba el conjunto mínimo de datos de los informes clínicos en el Sistema Nacional de Salud. Madrid; 2023. p. 93313-78.
Schell JO, Germain MJ, Finkelstein FO, Tulsky JA, Cohen LM. An integrative approach to advanced kidney disease in the elderly. Adv Chronic Kidney Dis. 2010;17(4):368-77. DOI: https://doi.org/10.1053/j.ackd.2010.03.004
de Villiers MR, de Villiers PJT, Kent AP. The Delphi technique in health sciences education research. Med Teach. 2005;27(7):639-43. DOI: https://doi.org/10.1080/13611260500069947
Crespo Montero R, Casas-Cuesta R, Ochando García A. Procedimientos y Protocolos con competencias específicas para Enfermería Nefrológica. 2a Edición. Madrid: Sociedad Española de Enfermería Nefrológica (SEDEN); 2024.
Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-164. DOI: https://doi.org/10.1053/j.ajkd.2019.12.001
García Palacios R. Práctica Enfermera a pacientes con ERC. Documento de Consenso. Ministerio de Sanidad. Gobierno de España, editor. Madrid: Sociedad Española de Enfermería Nefrológica (SEDEN); 2015.
Gordon M. Manual de diagnósticos enfermeros. Madrid: Elsevier España, S.L.U.; 2003.
Gobierno de España. Ley Orgánica 3/2018, de 5 de diciembre, de Protección de Datos Personales y garantía de los derechos digitales. Madrid; dic 6, 2018. p. 119788.
Fletcher BR, Damery S, Aiyegbusi OL, Anderson N, Calvert M, Cockwell P, et al. Symptom burden and health-related quality of life in chronic kidney disease: A global systematic review and meta-analysis. PLoS Med. 2022;19(4):e1003954. DOI: https://doi.org/10.1371/journal.pmed.1003954
Organización Mundial de la Salud. Comunicación de riesgos en emergencias de salud pública: directrices de la OMS sobre políticas y prácticas para la comunicación de riesgos en emergencias (CRE). Ginebra: Organización Mundial de la Salud; 2018. 1-79 p.
Bansal L, Goel A, Agarwal A, Sharma R, Kar R, Raizada A, et al. Frailty and chronic kidney disease: associations and implications. J Bras Nefrol. 2023;45(4):401-9. DOI: https://doi.org/10.1590/2175-8239-jbn-2022-0117en
Rajkumar T, Wong J, Harvey M, Weidersehn L, Surmon L, Makris A. Comparison of Sampling Methods for International Normalized Ratio Monitoring in Haemodialysis Patients (INRHaemo Study). Am J Nephrol. 2021;52(1):17-25. DOI: https://doi.org/10.1159/000513094
Ma X, Tang C, Tan H, Lei J, Li L. Comparative effectiveness of nonpharmacological interventions for the nutritional status of maintenance hemodialysis patients: a systematic review and network meta-analysis. PeerJ. 2025;13(2):e19053. DOI: https://doi.org/10.7717/peerj.19053
Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1-107. DOI: https://doi.org/10.1053/j.ajkd.2020.05.006
Daugirdas JT. Residual Kidney Function and Cause-Specific Mortality. Kidney Int reports. 2023;8(10):1914-6. DOI: https://doi.org/10.1016/j.ekir.2023.08.024
Pardo-Vicastillo V, Marks-Álvarez M, de Castro-De la Cruz T, Sanz-De la Torre L, Andrino-Llorente MT, Trocolí-González F. Impacto del estreñimiento en la calidad de vida de las personas en hemodiálisis. Estudio multicéntrico. Enferm Nefrol. 2024;27(4):340-8. DOI: https://doi.org/10.37551/S2254-28842024034
Artículo en Acceso Abierto, se distribuye bajo una Licencia Creative Commons Atribución-NoComercial 4.0 Internacional.
https://creativecommons.org/licenses/by-nc/4.0/
Kot G, Wróbel A, Kuna K, Makówka A, Nowicki M. The Effect of Muscle Cramps During Hemodialysis on Quality of Life and Habitual Physical Activity. Medicina (Kaunas). 2024;60(12):2075. DOI: https://doi.org/10.3390/medicina60122075
Zhang K, Hannan E, Scholes-Robertson N, Baumgart A, Guha C, Kerklaan J, et al. Patients’ perspectives of pain in dialysis: systematic review and thematic synthesis of qualitative studies. Pain. 2020;161(9):1983-94. DOI: https://doi.org/10.1097/j.pain.0000000000001931
Pereira B dos S, Fernandes N da S, de Melo NP, Abrita R, Grincenkov FR dos S, Fernandes NM da S. Beyond quality of life: A cross sectional study on the mental health of patients with chronic kidney disease undergoing dialysis and their caregivers. Health Qual Life Outcomes. 2017;15(1):1-10. DOI: https://doi.org/10.1186/s12955-017-0646-4
Zhou Q, Yu T, Liu Y, Shi R, Tian S, Yang C, et al. The prevalence and specific characteristics of hospitalised pressure ulcer patients: A multicentre cross-sectional study. J Clin Nurs. 2018;27(3-4):694-704. DOI: https://doi.org/10.1111/jocn.14019
Hants L, Bail K, Paterson C. Clinical decision-making and the nursing process in digital health systems: An integrated systematic review. J Clin Nurs. 2023;32(19-20):7010-35. DOI: https://doi.org/10.1111/jocn.16823