Promoting Independent Dialysis

Over the past number of weeks, I’ve had the opportunity to meet with the peritoneal dialysis teams and the FHA Nephrologists to brainstorm on ways to support and enhance home dialysis penetration within the FHA renal program.  I haven’t forgotten the home hemodialysis team and hope to spend some time with them as well.

We know that independent dialysis provides clinical benefits beyond that offered with in-centre hemodialysis.  In addition, the independence and lifestyle opportunities possible with home dialysis are a definite advantage for many of our patients.

So if home dialysis is so great, why aren’t all our patients receiving it?  Well, this is a complex question with no simple answers.  But, in no specific order, here are some ideas that could be implemented to enhance home dialysis within FHA.

Enhancing education on home dialysis

Almost all patients receiving dialysis in FHA flow through the Kidney Care Centres or make contact with the Renal Care Co-ordinator (RCC) through the hemodialysis units.  We need to ensure that the nurses and physicians working in these environments have adequate education about the advantages and opportunities for these forms of dialysis.  Dedicated training on site in the home hemodialysis and peritoneal dialysis programs may provide a unique opportunity for our team to become more comfortable teaching about these modalities.

FHA Nephrologists will create a lecture series on key topics in Nephrology.  These lectures will be no more than 15 minutes in duration and touch on key points about areas such as transplantation, vascular access and home dialysis.  With regards to home dialysis education, we will co-ordinate to ensure that all staff working in FHA have the opportunity to be exposed to the topic reviews, and commit to repeating the educational intervention on an annual basis.  With a more robust understanding of the benefits of home dialysis, we hope front line staff with be more equipped to encourage our patients to explore and pursue home dialysis.

To ensure all team members teaching about home dialysis have accurate information to share with prospective patients, we will need to provide up to date and readily accessible information on benefits and complications of each modality of renal replacement therapy, include those statistics which are specific to our program (eg. infection rates, modality success rates, etc).

Role of the Renal Care Co-ordinator

There has been much change and discussion around the role of the “Renal Care Co-ordinator”.  It is felt that this job has the most opportunity for significant impact by taking on the role of “transition nurse”. Patients new to dialysis should work with the RCC to achieve the following goals

a) encourage early living donor transplantation
b) encourage education and rapid transition to HHD or PD
c) for those patients that choose HHD or facility-based HD, facilitate rapid AVF creation
d) facilitate end of life discussion and decision making
The RCC role could be supported through rigorous and dedicated experiences in HHD and PD and through additional training with Diane Watson in order to adopt her published and highly successful strategy to quickly move new HD patients to home dialysis.  Of note, we’re excited to share that Diane has agreed to come to FHA to teach us her techniques.
We will also need to create formal communication tools to ensure the work of the RCC is communicated to the team in the hemodialysis units and the patient’s primary nephrologist.  This will likely be achieved through the use of existing information technology including the Meditech electronic patient record and our shared drive with patient lists.
Capacity

Increasing patient interest in home dialysis is only the start.  Will we be able to handle the load once patient volume increase?

For peritoneal dialysis, we will work to ensure we have the capacity to provide PD catheter insertion at RCH and ARH, and provide any needed IPD and PD training at both sites.  Surrey patients will continue to be supported through the RCH site.  We currently have 5 Nephrologists able to insert PD catheters at the bedside, with a 6th being trained.  We have excellent surgical support at RCH and while we have an interested surgeon at ARH, we are still petitioning to get OR time to facilitate this critical surgical activity.

Home hemodialysis presents a unique challenge given the long training period needed to get a patient comfortable doing hemodialysis independently.  We continue to recruit training nurses and will explore the option of training more than 1 patient per nurse (using staggered start dates).

Increasing Home Dialysis Candidacy

We will increase the number of patients who may be candidates for PD by continuing to promote such innovative programs as presternal PD catheter insertion, a unique technique to insert PD catheters that opens the door to PD for patients with ostomies and other conditions that previously were viewed as contraindications to PD.

Many patients need chronic placement and would be candidates for peritoneal dialysis.  We will work to increase the number of nursing home beds available to patients on PD, especially in the eastern region of FHA.

Patient Engagement

We know we will only be successful if we’re offering care that patients find attractive. We would like to physically move home dialysis patients and training so that other patients can directly observe their experience and hopefully seek to learn more.

We also believe that patients deserve to be exposed to educational materials in physician offices, the kidney care centres and the dialysis units so that they can learn about home dialysis, even when not formally working with a member of our clinical team.  These materials can include posters, pamphlets, educational videos and online materials.  We will make investments to ensure we have the appropriate DVD library and DVD players in the HD units.

Referral Process

In order to remove barriers to home dialysis, we will be encouraging all staff members to educate and refer, even if they are not the patient’s primary Nephrologist.  In the interests of continuity, there will be an expectation and systems in place to ensure the patient’s primary Nephrologist is aware and support the shift in dialysis modality.

We will be adding simple checkboxes on commonly used pre-printed order sheets, in order to both remind and expedite home dialysis referrals.

Cross-Promotion 

Patients who have experienced home dialysis generally don’t want to return to in-centre hemodialysis, even when medical conditions or social factors dictate that the modality is no longer possible.   We will work with the home hemodialysis and home peritoneal dialysis programs to ensure they cross-promote one another’s program.

Role of the Nephrologist

Many of our patients start dialysis in a suboptimal fashion with an inpatient dialysis start on a central venous catheter.  While the RCCs can certainly play a role in optimizing care, we will work to create a model whereby the patient’s primary nephrologist reviews all such patients within 4 weeks of starting dialysis – this will provide an opportunity to facilitate home dialysis transitions.

Just as we will use the PROMIS database to encourage physician review of patients’ vascular access, we propose to use the PROMIS database to review patients whose profile fits someone who may be a candidate for home dialysis.  This list will be provided to each primary nephrologist on a regular basis.

Just as we have proposed for our vascular access strategy, we will work to develop consistent messaging around home dialysis that Nephrologists will communicate in their private offices.

Offer More Acute PD

Traditionally, for patients who have needed to start dialysis in a hurry, we have offered HD starts with a central venous catheter (CVC).  We need to recognize, as a program, that starting a patient on HD with a CVC commits them to an extended exposure to what we know to be the worst type of dialysis – hemodialysis with a central line.  While we support the patient’s right to choose dialysis modality, we can only recommend PD or HD with an established vascular access.  For patients who won’t have a vascular access in place given the short time frame to get dialysis started, we will encourage and facilitate rapid initiation of dialysis via PD and provide IPD until such time the patient can be trained to do PD independently.

Avoid Losses from our Home Dialysis Program

Preventing losses from our home dialysis program is as important as recruiting patients into the program.  In my next post, I’ll share ideas how we can minimize the number of patients who discontinue home dialysis and return to in-centre hemodialysis.