Question: What are some of the critical factors in creating a successful daily home hemodialysis program?

Answer:  A successful daily home hemodialysis program has tangible benefits for everyone. For patients with end stage renal disease (ESRD), the program offers a way to achieve independence, freedom, and greater normalcy. For the clinical team, the program offers an opportunity to see patients do better and achieve rehabilitation.

To develop the program, you will need to work smart and hard. The ramp-up for the program is time-consuming and nurses in busy dialysis units typically have no extra time. The work has many different aspects: assessing patients to choose appropriate candidates, educating and training patients on the hemodialysis machine, overseeing the patient’s journey home, and facilitating paperwork, especially for those clinics that need to add home hemodialysis to their certification process.

Working Hard
As a nurse clinician working with many dialysis units around the country to adopt this program, I know first hand that it takes a major commitment, so some advice is offered. Before you begin, answer some questions and be honest with yourself:

• What do you expect from a short daily home program?
• What outcomes will you evaluate as success measures?
• Are you and the staff, including the social worker and dietitian, excited about the prospect of the new program?
• Knowing the ramp-up will take work, who will manage the day–to–day operation of the program and who will back up that manager?
• Can you adjust nursing resources to provide the additional help when needed? Another factor to think about before beginning the program is the ability to flex your hours during patient training to accommodate working patients.
• If your background is peritoneal dialysis and you are anxious about teaching hemodialysis, can you be open-minded about expanding your area of expertise? Even though there may be some anxiety, the added experience will certainly increase your skill set and enhance your overall nursing career.

Working Smart
As you review literature to learn more about daily home hemodialysis and patient selection, consider age, compliance, vascular access, technical issues, and patient characteristics.

Age: The age range of patients is limited only by what your dialysis unit supports clinically. Pediatric patients warrant a look at technical considerations relative to the patient size and dialyzer/blood tubing volume.
 
Compliance. Patients who miss treatments or end  treatments early should not be automatically excluded. In fact, they may the best-suited candidates for home therapy. The reason for this perceived noncompliant behavior was studied by Gordon, Leon, and Sehgal (2003). Doctor appointments, personal business, traveling out of town, complications and technical problems during treatment, not feeling well before treatment, and transportation problems were listed as reasons for such behavior. Owendyk, Leitch, and Freitis (2001) stated that patients who are noncompliant with medication, fluid gains, and diet can be successful on daily hemodialysis because these problems tend to go away after starting short daily home therapy. Patients who dialyze daily have been able to decrease or eliminate their blood pressure medications because fluid removal becomes better controlled. Patients have more freedom to eat what they want so that restraints imposed on their diet are reduced or eliminated. According to Gruman and VonKorff (1997), it is critical that people with ESRD engage as fully as possible in their care, given the consequences of noncompliance with the rigorous regimen of medical and nonmedical activities attendant to this condition. What better way to be fully engaged and independent than dialyzing at home where patients have the freedom to set their own dialysis times at their own convenience?
 
Vascular access. Fistulae, grafts, and catheters have been used successfully for daily hemodialysis. Pre-conceived notions that more frequent cannulation contributes to access failure can have a negative impact on your recruitment efforts. Twardowski (1999) reviewed the literature on vascular access and daily hemodialysis and could find no indications that frequent hemodialysis was detrimental to the primary fistula longevity and complication rate.

Kjellstrand, Blagg, Twardowski, and Bowers (2003) studied longevity and complications with fistulae, grafts and central venous catheters in 23 patients on daily home hemodialysis. Cumulative survival at 15 months was 100% for fistulae, 80% for grafts, and 20% for catheters. At 3 years, it was 80% for fistulae and grafts.
Nurses who have developed daily home hemodialysis programs suggest that you contact patient advocacy groups or staff at existing programs to see if there are patients willing to discuss their experiences with more frequent cannulation. Having your patient talk to another patient who has gone through the experience may be more convincing than hearing your own comments based on no personal experience. Also, take time to research the buttonhole technique used in daily programs. It has proven a most effective solution for more frequent cannulation.

Technical. Most homes can accommodate a dialysis machine, but it is highly recommended that you evaluate the patient’s home setting before acceptance into the program. You will need to evaluate the selected treatment area to see whether it is suitable for dialyzing and handling emergency situations during your visit. You or the manufacturer’s technical service department need to evaluate the water situation, plumbing, and electrical needs. If the patient lives in an apartment, they will most likely have to get permission from the landlord to install the equipment.

After you educate yourself about the program, you will need to educate your dialysis staff, since they care for the patient population from which you’ll be recruiting. Clinic staff members may have their own preconceived notions about home therapy that can potentially hurt your recruitment efforts. As quickly as you talk to the patient about the therapy, when you walk away, the staff person dialyzing the patient may be telling him or her that it’s a bad idea: “Mrs. Jones, you don’t want to stick your access six times a week, do you?” While educating the staff, be sure to seek out staff members who seems the most interested. They can become significant supporters of the therapy and a big help to you during recruitment.
 
Patient characteristics.  Motivation goes a long way in overcoming other obstacles, so try to start with the patient who wants to go home and have more independence. There may be some patients you are considering who would benefit from the therapy, but need some discussion and persuasion. Keep in mind that reluctant participants may be risky and may cause your new program to falter from the start. An eager patient who volunteers can help assure that the program starts off successfully. In turn, your patient then becomes another advocate for the program and can be a huge asset for recruitment efforts.

Next, you need to determine if the patient needs a helper at home. Some patients are capable of dialyzing themselves; they may or may not need a helper. Other patients may have co-morbidities that require total dependence on the helper for all dialysis-related tasks. If  helpers are needed, they also need to be motivated to handle the role. Ask them direct questions.

1. Will the helper be willing to become a caregiver or minimally be present at the patient’s home 5-6 times a week? In one instance, a patient’s relative agreed to be the helper. Near the end of patient training, she couldn’t commit to doing the dialysis treatment everyday and the patient had to drop out of the program.  Knowing that this is a possibility, the social worker might consider additional questions and further discussion with the patient and helper to better assess their support structure and dedication to self-therapy.

2. Is the helper willing to learn access care and cannulation? In one training situation, the patient’s access location and her body size prevented her from self-cannulation. The husband felt he could learn to cannulate his wife’s upper arm graft. But when training commenced, he was so anxious, it caused him to tremble continuously. After the treatment on the second day, he said he did not think he would be able to cannulate.  In this instance, what would help is to have the person cannulating practice on a training arm so that you have a sense of their capability. This will not replace the real scenario, but it may provide some insight into whether a back-up plan is needed.

3. Is the helper able to handle medical emergency situations at home? In one case, the wife of a patient reluctantly agreed to be her husband’s helper. The first day of training, it became clear that she was anxious about assisting him. After consulting with the social worker, we learned that the wife had a bad experience when her husband collapsed at home while on CAPD.  She had to call 911 and he required a lengthy hospitalization. As a result, the wife felt inadequate handling emergency situations.  Luckily, finances were not an issue for this family so a nurse’s aide was hired and trained to assist the patient during his treatment. It is important to make sure the psychosocial assessment includes a review of previous experiences that the patient/helper had with other home therapies.
   
4. Will the helper be willing to arrange his/her schedule to come in and train with the patient? 

5. Will the patient and/or helper be able to complete the required documentation such as flow sheets and lab-work submission forms? Will they be able to collect, pack and ship water and dialysate samples? Make sure to explain these procedures early in your discussions so that patients fully understand the scope of their responsibility.

Summary
AThe literature supports that patients on daily hemodialysis do much better overall. They tolerate dialysis better, have less complications and less fluid to remove, their appetites are better, they have more energy, and they have greater blood pressure control. Patients with cardiovascular disease who cannot tolerate the rigor of conventional, three times a week dialysis do better on daily hemodialysis. Here are quotes from just a few patients dialyzing at home:
“I no longer experience the large energy swings and the night cramps as I did with in-clinic dialysis.” (Delores: 74 years)
 
“I’ve been on dialysis for 26 years, and for 26 years I haven’t felt good. But now my friends and family are seeing a real change in me because I’m excited, I’m feeling better.” (Richard: 48 years)

“Instead of spending time with the nurse, I can spend time with my husband, and I have more energy. I think it is because I’m dialyzing 6 times a week.” (Sharon: 52 years)

Short, daily at-home dialysis helps patients reclaim a more normal life. You and your colleagues will be able to see dramatic improvements very soon after sending them home, leading to a greater chance of rehabilitation.

Most importantly, if you choose to develop a daily home hemodialysis  program, you should consider yourself and the team very special. You will be among the first clinics in the country to introduce and implement a unique and needed change in the renal arena. As this article outlines, it may not be easy at first, but you will find it to be one of the most rewarding nursing experiences you have had in your career.



References
Gordon, E.J., Leon, J.B., & Sehgal, A.R. (2003). Why are hemodialysis treatments shortened and skipped? Development of a taxonomy and relationship to patient subgroups. Nephrology Nursing Journal , 30, 209-217.

Gruman, J., & VonKorff, M. (1997). The patient as a co-manager in the health care system. Seminars in Dialysis, 6, 329-334.

Kjellstrand, C.M., Blagg, C.R., Twardowski, Z.T., & Bowers, J. (2003). Blood access and daily hemodialysis: Clinical experience and review of the literature. ASAIO Journal, 49, 645-649.

Leitch, R., Ouwendyk, M., Ferguson, E., Clement, L., Peters, K., Heidenheim, P.,  & Lindsay, R. (2003).  Nursing issues related to patient selection, vascular access and education in quotidian hemodialysis. American Journal of Kidney Diseases, 42(1), Suppl. 1 (July) pp. S56-S60

Owendyk, M., Leitch, R., & Freitas, T. (2001). Daily hemodialysis: A nursing perspective. Advances in Renal Replacement Therapy, 8, 256-267.

Twardowski, Z. (1999).  Blood access complications and longevity with frequent (daily) hemodialysis and with routine hemodialysis. Seminars in Dialysis, 12, 451-454.