[Training and follow-up of the dialysis patient at home]

Regardless of the home dialysis technique, training of the patient or caregivers is necessary. Formalized over several weeks, this is carried out by an expert nursing team. The patient must acquire the skills and knowledge to be able to dialyse effectively at home, in optimal conditions of safety.

[Dialysis at home, from my place to ours]

The patient being cared for at home should be considered with his entourage. In the case of dialysis, the relative is involved and his relationship with the patient becomes more complex, because the patient is in a situation of increased dependency. Hence, the relative is a fully-fledged partner in home haemodialysis, particularly in the decision-making process. Support from professionals helps to rebalance this relationship, if necessary.

Perceptions and Practices of Nephrology Nurses Working in Home Dialysis: An International Survey

Globally, home dialysis prevalence has been declining relative to the increase in end stage renal disease and renal replacement therapy. The goal of this study was to identify international perceptions and practices. A web-based questionnaire was disseminated to nephrology nurses in 30 home dialysis-prevalent nations. Global telehealth use was low (23%), contrasting with 83% respondents agreeing telehealth would improve care. Only 31% of all programs enabled patient training outside of normal working hours (e.g., nights and weekends), and 31% of all program patients had some cost reimbursement, with a significant difference between U.S. and non-U.S. programs (U.S. 11%, non-U.S. 59%, 2 = 93.6, p < 0.0001). Significant differences in the need for monthly clinic visits (U.S. 72%, non-US 44%, 2 = 83.7, p < 0.0001) were also found. Telehealth provision and patient training flexibility is limited, and patient cost reimbursement is low. Increased telehealth, patient cost reimbursement, and flexible training models may promote home dialysis growth.

Nurses' elicitation of patient error as a practice in training end-stage renal patients in automated home peritoneal dialysis

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease-specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video-recordings (90:25h) from a programme for self-management of end-stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses' instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error-based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self-management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.

[The relevance of a patient education programme for self-management of home peritoneal dialysis]

INTRODUCTION

Nursing care is an essential part of the management of patients undergoing home peritoneal dialysis. The institution of an educational pathway facilitates ease and safety of self-management of peritoneal dialysis (PD) procedures.

AIM OF THE STUDY

The aim of this study was to evaluate the relevance of a nurse-guided training programme for PD patients.

PATIENTS AND METHODS

A questionnaire regarding quality of life was administered to patients undergoing PD at the Cardinal Massaia Hospital in Asti, Italy. The EQ-5D questionnaire was used with the adjunct of some study- specific questions. Prior research of relevant Pubmed references had also been performed.

RESULTS AND DISCUSSION

Our data confirm other works in the literature emphasising the central role of nurses during educational processes involving PD patients. The quality of life of these patients improved notably when compared to controls who had not followed an education programme. In fact, a higher average quality of life was reported by patients enrolled in our study when compared to that found in other studies. Nurses involved in our PD educational programme follow international guideline sources.

CONCLUSION

Patient education is a fundamental and on-going part of the process of nursing care and contributes to the well-being, safety, independence and compliance of patients undergoing PD at home.

How to overcome barriers and establish a successful home HD program

Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.

A PRE-TRAINING ASSESSMENT TOOL FOR HOME DIALYSIS (JPAT)

A tool for assessing the suitability of candidates for home dialysis (Jo-Pre-training Assessment Tool version 2.1 - JPAT) was developed, pilot-tested at one hospital and field-tested at two major teaching hospitals in Sydney. JPAT acts as a screening instrument to distinguish suitable candidates for the home dialysis programme, identifying patients with the greatest chance of learning to manage the programme. This study included an interview/test of home dialysis patients based on the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36). JPAT version 2.1 is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication ability, ability to maintain self-care, psychological suitability and social support. Overall, results suggest that JPAT version 2.1 is sufficiently reliable to be used as a tool for assessing patients who suffer from end-stage renal disease (ESRD), and to identify patients most likely to succeed in a home dialysis programme.

The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a potentially catastrophic hyercoagulable state. The prevalence of HIT in individuals doing nocturnal home hemodialysis (NHD) is unknown and the appropriate treatment protocol has yet to be determined. The objective is to describe the clinical course and treatment plan ofa patient who developed HIT while undergoing NHD. A 49-year-old man with a past history of end stage renal disease (ESRD) of unknown etiology was initiated on NHD in February 2005. His clinical and biochemical parameters improved after conversion to NHD. However, excessive bleeding at the vascular access sites complicated his treatments. Clinical investigations revealed development of HIT Alternative therapeutic strategies were attempted to enable our patient to continue NHD: unfractionated heparin, citrated regional anticoagulation, Danaparoid, and Argatroban. In conclusion, NHD patients with HIT pose a specific clinical challenge. We speculate that the augmented exposure of heparin coupled with a primed autoimmune response may be responsible for the development of HIT in our patient. Further research is required to elucidate the appropriate clinical monitoring and treatment strategy for this patient.

The impact of a nurse-led clinic on self-care ability, disease-specific knowledge, and home dialysis modality

A nurse-led clinic focusing on education and self-care for patients with advanced renal failure was introduced in a renal outpatient clinic in Sweden. The purpose was to enhance patients' disease-related knowledge, involvement, and self-care ability. This article reports the results of a study comparing patient outcomes with the nurse-led clinic to the previous model of care. The hypothesis was that the nurse-led clinic would increase medical control and self-care outcomes. The participants in the nurse-led clinic chose and started dialysis in a self-care alternative and also had a functioning, permanent dialysis access to a greater extent than the patients in the comparison group. Those choosing home-hemodialysis rated their self-care ability higher. The participants rated self-care and effects of treatment options on family and everyday life as the most important disease-related areas of knowledge.

Influence of autonomy and type of home assistance on the prevention of peritonitis in assisted automated peritoneal dialysis patients. An analysis of data from the French Language Peritoneal Dialysis Registry

BACKGROUND

In France, 48% of home-based peritoneal dialysis (PD) patients require assistance to perform their exchange and manage their treatment. A total of 7% are aided by their family, and 41% by a private nurse. Of all the continuous ambulatory peritoneal dialysis (CAPD) patients, 61.7%, and among automated peritoneal dialysis (APD) patients 23%, are assisted at home for their bag exchanges and connections. Assisted APD patients (AAPD) are more comorbid and elderly so that a home helper is not always available: this explains why most helpers at home are private visiting nurses paid by the National Social Security. In addition to the home helper (nurse or family), 58% of centres make regular additional home visits to check the respect of procedures previously taught during the initial training of the nurse or the family helper. The aim of this study was to evaluate whether the type of home assistance received by dependent patients had an influence on peritonitis rates, and if home visits done by nurses of training centres may improve results.

METHODS

Peritonitis rates and the probability of being peritonitis free were analysed for 1624 new APD patients recorded in the French PD Registry (RDPLF) between 2000 and 2004, and followed-up until early 2005.

RESULTS

Nurse-assisted APD patients had a peritonitis rate of one episode every 36 months, and family-assisted patients one episode every 45 months; using Poisson analysis this trend was not significant (P=0.11). However, the probability of being peritonitis free was significantly higher for family-assisted (69.8% at 2 year) compared with home nurse-aided persons (54.4%) after adjustment for age, diabetes and the Charlson comorbidity index. This difference disappeared when nurses from the training centre regularly visited PD patients at their home in the presence of their helper, whichever type of assistance they received. In addition, when the nurses from the training centres visited private nurse-assisted patients, the probability of being peritonitis free was significantly improved in comparison with those persons who did not receive home visits, from 33.9% to 50.8% at 3 years (P=0.028).

CONCLUSIONS

APD patients assisted at home by a private nurse have a higher risk of developing peritonitis than family-assisted patients, unless additional regular home visits are organized by the original training centre. Therefore, we recommend that home visits be regularly made for dependent PD patients to optimize the quality of care provided by the helper.

Effective and safe IV iron and anemia management during home hemodialysis: a dialysis facility's experience

Studies have shown that IV iron therapy, in conjunction with EPO, is essential in managing anemia in patients on hemodialysis. In addition, data have shown that IV iron therapy can be safely administered during hemodialysis, whether performed at home or in the center. Nurses should be aware of how to administer this therapy and be knowledgable of possible allergic-type reactions that have been associated with its clinical use.

Development of a nocturnal home hemodialysis (NHHD) program for children

Whereas the success of nocturnal home hemodialysis (NHHD) as a treatment modality for adults has been clearly demonstrated, there is very little experience with NHHD in children. There are genuine concerns related to patient safety, as well as a potentially overwhelming burden on the parents of children, while supervising NHHD. Each of these issues has been considered in the development of the NHHD program for children in Toronto. The steps involved in the development of this program are outlined. The experience of Simonsen (4), that NHHD is feasible and provides excellent dialysis for children, is confirmed.

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.