Speaker addresses ‘revolving door’ in maintaining patients on home dialysis
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Government initiatives aimed at increasing the number of patients who choose home dialysis need to be complemented with strong retention practices, a speaker at the virtual American Nephrology Nurses Association National Symposium said.
“If you have 20 or 25 patients in your home dialysis program, how many do you lose each month?” Nupur Gupta, MD, the medical director for home dialysis at Indiana University, asked attendees. “The first question is: Did you even think about it before or is it a revolving door? ‘We have admissions and we have discharges.’”
Gupta said data from the United States Renal Data System indicate monthly patient losses in home dialysis programs average more than 4%. “Your goal should be zero dropouts or closer to 1%,” Gupta said.
The most common causes for patient dropout, from the first 30 days of training to more than a year on home dialysis, have been patient selection, access malfunction, missed treatments, dialysis prescription and infections, Gupta said.
“All of these issues seem to be interrelated to patient retention. They do have an impact on each other,” Gupta said.
Corrective steps can include improving communication between nurses and patients during the training period.
“We believe patient selection as a reason for dropout is really about patient education,” Gupta said. “There will be times when this can get overwhelming, but we are there to support them.”
Patient retention during the home training sessions also becomes an issue because of the quantity of information being shared with patients.
“Videos are helpful, and we have end-of-the week quizzes to test what they have learned,” Gupta said. “We want to make sure they don’t feel isolated” during the training.
She also indicated that use of patient mentors – those who have already experienced or are currently on home dialysis – can help allay fears of the first-time home patient. The National Kidney Foundation and the End-Stage Renal Disease Networks offer peer support groups and patient mentors.
An important aspect of retaining patients on home dialysis is creating the right dialysis prescription, Gupta told attendees.
“The initial prescription, if done carefully, can help prevent hospitalizations,” Gupta said, noting patients on dialysis are at a high risk for hospitalizations in the first 90 days on dialysis.
That initial prescription also includes an accurate determination of residual renal function. “There has been an increasing emphasis on using urine output as part of the prescription, so we ask patients how much urine they generate in a week,” Gupta said.
A key to helping patients stay on home dialysis is providing adequate support and keeping patients involved in their therapy. Monthly meetings with patients can be used to set goals along with checking on home infrastructure and discussing family-related issues and any problems with the home dialysis machine.
“If a patient is missing their treatments, is there something going on in their job or at home? Is there a problem with the supplies?” Gupta said.
If a patient does want to change home modalities or go in center, it is a good idea to start those conversations early with the patient.
“All of these things are part of the care of the patient,” Gupta said. “In the end, we as a team need to work together and discuss in each step how we can do better. It is our moral duty to provide the best care for our patients and help them in the best possible way.”
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Gupta N. Session #211. Presented at: American Nephrology Nurses Association National Symposium; Aug. 29-31, 2020 (virtual meeting).
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