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Treating Patients with CKD Who Are Violent or Homeless:
A Need for Further Study
Melissa Foster, BSN, RN, CNN, is
a Right Start Case Manager, Fresenius Medical Care, Nashville, TN. She
is also Leader Designate of ANNA’s Hemodialysis Special Interest Group
and a member of the Music City Chapter.
The care given to patients with chronic kidney disease (CKD) by all
members of the multidisciplinary team requires coordination and
collaboration. Members of the renal care team have profession-specific
goals designed to maximize the quality of outcomes and quantity of life
for each patient. Despite evidence-based research and knowledge shared
among the various disciplines, discussion concerning the homeless and
violent populations of individuals with CKD continue to generate more
questions than answers. These populations challenge and stretch a
team’s ability to provide care with a consistent model resulting in
positive clinical outcomes.
Patients with CKD Who Are Violent
Following a presentation on patients with CKD who are abusive/violent,
participants from various dialysis settings, including hospitals,
free-standing dialysis units, and prison systems, discussed the issues
of concern. The greatest concern expressed was the responsibility of
providing a safe environment for both staff and patients. Second,
nurses expressed legal concerns on discharging patients who were
violent or on implementing steps to allow the removal of such patients
from units. Finally, there was consideration of the financial impact of
the patient who is abusive, including added security personnel,
increased hospital admissions, and overall staff retention. The
discussion on issues of concern to nurses was followed by a discussion
of possible solutions, including patient contracts, physical and
chemical restraint orders, and terminating services. The audience
progressed towards a collective agreement on the use of staff education
through various methods to reduce incidents of violence in the dialysis
setting.
Patients with CKD Who Are Homeless
The
second group of patients reviewed during the presentation was patients
with CKD who are homeless. The National Law Center on Homelessness and
Poverty (2007) estimates that 3.5 million people are homeless in the
U.S. in any given year. While the U.S. Renal Data System (USRDS)
compiles patient and facility data into distinct areas of co-morbid and
demographic statistics each calendar year and additionally reports
statistically significant sociologic factors, patients with CKD who are
homeless are not measured as a differential group with data analysis.
Whether there is limited ability of the End Stage Renal Disease Network
data collection tools or an inability to accurately measure the
magnitude of the sample size, the population of patients with CKD who
are homeless remains largely undetermined. Given the number of homeless
individuals in the U.S. and the incidence of CKD, however, the
prevalence of the homelessness among the population with CKD is worth
investigating. The need for further study is also evident from the
limited literature available, which indicates an under-investigated
problem with few consistent answers to assist renal care teams.
Summary
With
changes in the U. S. healthcare delivery system over time and an
expectation of quality improvement, renal care providers are held
accountable for outcomes. Patients with CKD who are violent or homeless
represent a challenge to the renal care team. The renal care team’s
attention requires individualized plans of care based on evidence
resulting from research on both populations. Networking sessions such
as this provide an excellent opportunity for nurses to engage in open
discussion that results in a determination of the need for more study
and analysis in patients with CKD who are homeless or violent.
References
The
National Law Center on Homelessness and Poverty. (2007). Homelessness
and poverty in America. Washington, DC: Author. Retrieved January 3,
2008, from http://www.nlchp.org/ hapia.cfm
| The Practice Issues in Nephrology Nursing department
focuses on issues identified by ANNA's Special Interest Groups. Address
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The opinions and assertions contained herein are the private views of
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