Time distribution factors of hospital and home care among chronic haemodialysis patients

Today, many studies are available that focus on haemodialysis; however studies on the time distribution factor involved are lacking. It is therefore important to study the distribution of time, taking into account outpatient care, inpatient care and home care. The aim of the study was to chart over a five-year period, the time distribution factors of hospital care and home care among chronic haemodialysis patients. The design of the study was descriptive, and the data material was drawn from a patient register (N = 61). The data analysis was performed by means of both descriptive and inferential statistics.

Nursing issues related to patient selection, vascular access, and education in quotidian hemodialysis

BACKGROUND

Increased interest in quotidian hemodialysis (HD) programs requires that nephrology nurses have a larger role in transitioning patients to more frequent HD. Nursing issues include the selection, training, and education of patients before they begin more frequent HD therapy.

METHODS

The London Daily/Nocturnal Hemodialysis Study directly compared data from patients undergoing either short daily HD (n = 11) or long nocturnal HD (n = 12) with those undergoing conventional thrice-weekly HD (n = 22). Patient training, education, safety, and vascular access data were collected.

RESULTS

The patient training period varied from 10 to 25 days, with an average length of 16.64 days. Patients used 1 of 3 types of vascular access: native arteriovenous (AV) fistulae, grafts, or central catheters. No statistically significant differences in access flow rates between the study and control groups were noted or when comparing different types of access. A significant decrease in catheter infection rate was seen when patients switched to daily HD therapy. Patient cannulation surveys showed that patients with AV fistulae or grafts showed improvements with ease and comfort as the study progressed, and patients widely preferred the buttonhole technique to the rotating-needle method for cannulation.

CONCLUSION

With growing interest in the development of quotidian HD programs, HD nursing personnel face the exciting challenge of improving on existing training programs and treatment modalities.

Staff-assisted home hemodialysis in debilitated or terminally ill patients

End stage renal disease (ESRD) patients who are diagnosed to have a terminal illness or severe debility have limited options for their continued care. This results in a frequent decision to withdraw dialysis support. Due to their tenuous condition, continued transportation to the dialysis facility further aggravates the emotional, financial and physical burden to the patient and family. We would like to present our data on 28 patients with severe debilitating and terminal illnesses. The mean age was 69 years with a (+/-) 11.8 SD and range of 44-87 years. Nine of them were males and 19 females. All of these were considered terminally ill as most of these patients had multi-organ failure. Ten had stroke, 16 had cardiac failure, 2 had severe vascular insufficiency, one resulting in bilateral leg amputation, 5 had debilitating pulmonary disease needing oxygen therapy and 8 had cancer. These patients were dialyzed at their home by a registered nurse (RN) according to a dialysis prescription provided by an attending nephrologist. Twenty-three patients died at home, one transferred to acute care facility and 3 to hospice care after a mean staff-assisted home hemodialysis (SAHD) duration of 14.1+/-2.9 weeks. ESRD patients with severe disability can continue dialysis in a more convenient and comfortable setting at home, and yet be relatively cost-effective.

Home hemodialysis. Revival of a superior dialysis treatment

BACKGROUND

Home hemodialysis is usually considered a superior therapy, whose decline is related to demographic, social, psychological and financial factors as well as to competition with renal transplantation and PD.

METHODS

A home hemodialysis program was started in November 1998 in the University of Torino, Italy (200-210 patients on dialysis). Its main features are the tailoring of dialysis schedules and the acceptance of patients with comorbidity. Nurses assist home sessions in case of short-term problems, while the training center ensures follow-up for long-term clinical and logistic problems.

RESULTS

The program started in November 1998 on a previous one (active from 1970 to 1998; 6 patients on treatment in November 1998). Since then, 25 more patients joined the program. Out of 31 patients followed since November 1998, 4 were grafted, 2 died, and 2 dropped out from training. In June 2001, 15 patients were on home hemodialysis, 8 on training. Dialysis schedules and controls are flexible and tailored; in June 2001, range of dialysis time was 1.20-5 h; sessions: 2-6; 8 patients were on thrice-weekly dialysis, 7 on daily dialysis; all patients reached target EKRc >10 ml/min (median 15, range 11-24 ml/min).

CONCLUSION

Tailored, flexible schedules allowed home hemodialysis in over 10% of our patients, confirming that there is still room for this treatment in our setting.

Daily hemodialysis: a nursing perspective

Daily hemodialysis can be performed in the center or at home for varying lengths of time. Short daily hemodialysis (SDHD) can be defined as one and one half- to three-hour treatments performed 6 days per week. Nocturnal hemodialysis (NHD) is performed for 6 to 10 hours, 5 to 7 nights per week. Patient selection criteria can range from basic requirements, such as the ability to communicate, to medical necessity related to comorbid conditions. Central venous catheters (CVCs), mature arteriovenous fistulas, and synthetic grafts have been used successfully for daily dialysis therapies, although documented experience with grafts is somewhat limited. Documented nursing issues surrounding these therapies are very limited. Few changes are required to adapt daily dialysis to the in-center environment. Patient training strategies and scheduling for the home application vary between institutions, but the core approaches remain the same. Daily hemodialysis therapies can be integrated easily into existing home hemodialysis programs with very little extra effort. This article discusses nursing issues and provides relevant information for those who are interested in incorporating daily hemodialysis (DHD) therapies into their program.

Peritoneal dialysis: a case for home visits

Peritoneal dialysis (PD) training usually takes place within the dialysis unit. Home visits, however, provide an ideal way for the dialysis team to assess and observe the implementation of the training objectives and to uphold the continuation of care between the dialysis unit and the home. This article describes the benefits and limitations of performing home visits as well as practical guidelines, including the use of an assessment record to document the home visit.

21st century home haemodialysis: a new approach to an old treatment

Home therapies are increasingly being demonstrated to be the best treatments for the early stages of the dialysis life-cycle. Although home haemodialysis has declined dramatically over the last 20 years from 41% in 1983 (1) to 3.2% in 1998 in the UK alone (2), many studies have suggested that it offers the optimum dialysis in terms of outcomes (3,4,5). Evidence from a 1998 survey of UK dialysis staff indicates that the major perceived drawbacks of home haemodialysis were lack of suitable patients, family stress, cost of machines and training time (6). The study also strongly indicated that a lack of familiarity with the treatment was a major cause of its decline in many units. We set out to redesign our approach to home haemodialysis to make it suitable for many more patients.

Improvement in care: a collaborative approach to rehabilitation

Examination of the patient experience within our unit, from pre dialysis through to establishment of dialysis in the community identified that the care was fragmented. To improve patient care, a change process was initiated. Four home care teams comprising three qualified nurses and one renal care assistant were established with each team responsible for a caseload of patients within a specified geographical location. To measure the impact on the patient, 100 questionnaires were circulated after twelve months. Results from 60 patients showed 76% of pre dialysis patients and 80% of dialysis patients were very satisfied with the change process. The main advantage of this change for the patient is that they are in a continuous supportive cycle for all their non-inpatient care throughout their replacement therapy. We conclude that patient focused care is essential and should be a transition catalyst in a change resistant environment.

Pre-training assessment tool (JPAT)--a pilot study

A tool for assessing the suitability of candidates for home dialysis (Jo-Pre-training Assessment Tool--JPAT) was developed. JPAT acts as a screening instrument to identify suitable candidates for the home dialysis programme, and therefore increases a patient's chance of learning to manage the programme. JPAT is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication, ability to maintain self-care, psychological suitability and social support. A pilot study was conducted (n = 20, 1996-1997) using a descriptive study design, with subjects randomly selected from an existing dialysis programme. Pearson correlation and 2-tailed tests were employed to explore the relationship between the assessment outcome (i.e. the initial JPAT scores) and the follow up data (i.e. data collected within the seven days following the initial JPAT assessment). Many of the variables attained statistical significance (p < 0.05). The inter-rater reliability was calculated at an average Kappa value of 0.909. Overall, results suggest that JPAT is sufficiently reliable to be used as a tool for assessing patients who suffer from ESRD.

Patient's needs in substitutive dialysis treatment. Some psycho-social and organizational considerations

BACKGROUND

The observations here presented come from an action-research project carried out at the Dialysis Centre of Ivrea. The work is focused on the articulation between subjective (the felt experience) and objective variables (the structure and intervention typology) with the aim of understanding patient's needs from an organizational point of view.

METHODS

A questionnaire to evaluate the needs of dialytic patients and the burden that these have on the health service and staff, was formulated by the nurses.

RESULTS

The results showed how the patient's clinical history indicate, significantly, not only personal and subjective aspects (e.g. interpersonal relationships), but also how they construct their relationships with the hospital and its services (including the hospital staff).

CONCLUSIONS

Data open up certain reflections on what role communication and information play within the hospital structure. Efficient communication contributes both to reduce the anxiety level and to improve the organizational climate therefore influencing service quality.

Family issues in home-based care

In Australia, home-based care for the chronically ill is increasing. Technological advances and increased economic constraints are often cited as the reasons for the increase in home-based treatments. Exploring the development of home-based care, in particular home-based dialysis, using a case-study approach provided an opportunity to identify the issues of families involved in home care. Issues that emerged included: (i) the development of the home-based clinic; (ii) the role of women; (iii) social isolation; (iv) and the lack of effective support from general practitioners and health services.

A pre-training assessment tool for home dialysis

Learning only occurs when one is ready to learn and involves a wide range of intellectual skills. A pre-training assessment is the foundation for all client care activities, especially for the success of a home training programme. This paper discusses the process of the development of a pre-training assessment tool for home dialysis, which acts as a screening instrument to identify suitable candidates for the home dialysis programme, and therefore serves to reinforce the chance of success with the learning.

Quality of life and coping in home haemodialysis patients

Approximately 4,034 Australians are currently receiving dialysis therapy due to End Stage Renal Disease (ESRD) and of these 627 are performing haemodialysis within the home environment. Initial emphasis on the medical model, which considers bodily pathology and the technological potential to prolong life, is now expanding to incorporate a more humanistic picture of the individuals response to treatment and their quality of life (QoL). This uncertain partnership of technology and human experience has led to an increasing awareness of the need for health professionals to attain an understanding of the illness experience as it impacts on the patient's life. The importance of considering not only absolute survival time but the quality of that survival has triggered rapid growth in the areas of coping and QoL research. This paper provides a review of the literature which focuses on QoL and coping in haemodialysis patients and demonstrates the paucity of research which investigates the special concerns of home dialysis patients.

A division in theory and practice: the best basis for self-care?

The Home Haemodialysis Foundation (Stichting Thuisdialyse) was started in 1968 in conjunction with the University Hospital in Utrecht. Initially this centre was designed to stimulate home haemodialysis, but during the years the emphasis has changed and we now offer not only home haemodialysis, but also centre haemodialysis as well as forms of chronic peritoneal dialysis.

Patient education: partnership in action

This paper describes the work of the combined Patient Education Co-ordinator/Home Dialysis Nurse at The Richard Bright Renal Unit, Bristol, England. The renal unit is part of a large district general hospital of 1000 beds in the South West of England. We cover a 60 mile radius of Bristol over several counties, some of which are rural farming communities.

Slow nocturnal home hemodialysis (SNHHD)--one year later

High costs and overcrowding of dialysis centres are leading to a global crisis in health care provision. We are developing slow nocturnal home hemodialysis (SNHHD) in which patients dialyze for eight to 10 hours during sleep five to seven nights per week. Vascular access is by means of the Cook silastic jugular catheter. Special precautions are taken to prevent accidental disconnection and air embolism. Dialysis functions are remotely monitored on computer via a modem by trained staff. Five patients have completed five to seven weeks of training and have been successfully performing SNHHD single-handedly (three out of five patients live alone) for 14, 14, 11, 10 and four months respectively. All have discontinued their phosphate binders and increased dietary phosphate intake. Compared with conventional hemodialysis (CHD) results, average pre-dialysis urea and creatinine levels are remarkably reduced to 9.6 mmol/l and 486 umol/l respectively. The average cumulative weekly Kt/V for CHD is 5.0 as compared to 7.7 while on SNHHD. Four out of five patients report sleeping soundly and experience greatly increased energy and stamina. Their days are entirely free. Repeated in-situ re-use of the dialyzer and blood lines will reduce the patient's work and make SNHHD a very inexpensive modality. SNHHD appears to be a widely applicable treatment with many advantages to both the patient and the health care system.

Positive impact of home hemodialysis

The intended patient outcomes have been achieved. Home hemodialysis has improved the quality of life for this entire family. Continuous support is necessary to help this family maintain an acceptable lifestyle. This remains a primary goal of care. The nephrology nurse proved to be the key to this successful home hemodialysis experience. Appropriate training coupled with frequent communication and encouragement resulted in a positive patient and family outcome.