This session provided basic information
of the components necessary to
a successful home hemodialysis
(HHD) program. Connie Anderson, RN,
MBA, Northwest Kidney Center, Seattle,
Washington, stressed, first and foremost,
the importance of incorporating a philosophy
that includes commitment from the
administration, not only in terms of financial
support, but also incorporating
mechanisms for the education of staff
nephrologists and the multidisciplinary
team involved in the management of HHD
patients. She also stressed the importance
of an integrated system for training and
support of patients. Patient goals, mutually
accepted by both staff and patients, must
be identified and should include, but not
be limited to, rehabilitation, improved survival
rates, maximum independence, and
fewer hospitalization days. There must also
be a means of identifying suitable patients,
such as appropriate referral systems, and
the development of criteria for patient
selection. Written procedures and docu-mentation
are necessities. Communication
is of utmost importance among the interdisciplinary
team.
Tony Goovaerts, RN, nurse manager
for a home dialysis program at University
Hospital, Brussels, Belgium, addressed the
topic of education and training of patients
in preparation for HHD. He stressed the
importance of having a comprehensive yet
flexible education program that takes into
account patient differences in gender, age,
and socioeconomic and cultural backgrounds.
Ideally, a dedicated nursing staff
should be designated to do patient education
and training, because it takes time to
develop the knowledge, skills, and tools
requisite for a quality training program. An
environment conducive to the teaching-learning
process must be provided. A list of
theoretical aspects to be covered in the
education process includes principles of
dialysis, complications of dialysis, diet,
medications, and interpretation of blood
results. The skills and practical aspects of
dialysis that must be taught include
obtaining weight and blood pressure measurements,
setting up and dismantling the
dialysis machine, cannulation, management
of complications, and management
of emergencies. The use of a training manual
and a variety of teaching aids such as
posters, videotapes, etc., is helpful and
simplifies the teaching-learning process.
The traditional training for HHD takes 8 –
10 weeks, with the training done mainly
during the time when the patients receive
three-times weekly dialysis treatments. The
major drawback of HHD training compared
to peritoneal dialysis training is the
much longer training period for the patient
and partner. Mr. Goovaerts described an
accelerated training program that shortened
the training period to 3 – 5 weeks. In
this program, the patient’s objectives and
repertoire of skills remain the same; but
the focus is more on short-term objectives,
and techniques are broken down into
smaller components. Patients are expected
to train for 4 full days each week. The
shorter training period has enabled some
patients to utilize paid partners and community
nurses as backup.
Nocturnal home hemodialysis
(NHHD) can be easily integrated into an
existing home hemodialysis program.
Michaelene Ouwendyk, RN, University of
Toronto, Toronto, Ontario, Canada,
reviewed training techniques and shared
methods used by centers training patients
for NHHD. The time required for education
and training may vary from 2 days to 8
weeks, depending on the patient’s hemo-dialysis
experience. Patients are initially
trained to do conventional dialysis during
the day, and eventually are trained to perform
nocturnal dialysis on consecutive
nights. As in conventional HHD, training
strategies for NHHD include a partnership
between nurse and patient, the use of a
training manual, and the use of teaching
aids such as posters, pictures, and video
tapes. Evaluation of patient learning is
emphasized. The training staff make sure
that the patient can correctly and independently
perform all procedures a minimum
of three times prior to being discharged
home. Patients are also asked to evaluate
the training experience, and this is felt to
be the key to improving the training program.
For NHHD, safety is a major focus:
locking boxes are used to secure bloodlines
and patients must be well versed in securing
extracorporeal connections. Patients
are taught to recognize and immediately
report signs and symptoms of a potential
problem. Patients are also made aware of
the potential for increased blood loss since
they are dialyzing every day.
Follow-up when the patient is performing
HHD at home is just as important
as the initial education and training of
patients. According to Leonor Ponferrada,
RN, BSN, Dialysis Clinic, Inc., Columbia,
Missouri, the most important components
of follow-up care include: patient access to
the multidisciplinary team, safety of procedures
and equipment, and communication
with the health care team. Monitoring
medical and psychosocial aspects such as
adequacy of dialysis, anemia management,
blood pressure control, and adjustment to
dialysis must be done. Results of a survey
of HHD programs were reviewed, and conditions
from the Health Care Financing
Administration (HCFA) ESRD regulations
were cited in relation to each of the components
of follow-up care.
