Community visiting nurses training plan: Home dialysis support.
Peritoneal dialysis (PD) has been an excellent renal replacement therapy (RRT) choice for many years. The medical benefits include: less exposure to hospital-acquired infections, maintenance of residual renal function, fewer symptoms related to fluid shifting (e.g., less intradialytic and postdialytic muscle cramps and hypotension), and lower mortality rates when compared to hemodialysis (HD) (Perl et al., 2011; Termorshuizen et al., 2003). Patients report benefits ranging from a more liberalized diet and less fluid restriction to more free time for family activities and ease of travel.
REQUIREMENTS FOR SUPPORT
Historically, the PD patient inclusion criteria have been very selective, and support for home care was restrictive. The previous weight limit (i.e., over 130 kg), ability and/or mobility limitations, and a history of previous abdominal surgery excluded many from being considered for PD. The Provincial Peritoneal Dialysis Coordinating Committee gives two absolute medical contraindications to PD: (1) "documented loss of peritoneal membrane function or extensive abdominal adhesions that limit dialysate flow"; and (2) "uncorrectable mechanical defects that prevent effective PD or increase the risk of infection" (e.g., surgically irreparable hernia). Morbid obesity became a relative medical contraindication (Peritoneal Dialysis Coordinating Committee, 2006a, p. 19). Some patients weighing over the weight limit have tried PD and dialyzed for some time before being transplanted or switching to hemodialysis.
Home care support was limited to short-term care with a "teach and leave" approach, i.e., providing one to two daily nursing visits for a short-stay client within a 60-day period (Provincial PD Coordinating Committee, 2006b and 2006c). These earlier restrictions, along with the lack of evidence-based selection criteria in PD units, excluded those requiring long-term care needs in their homes (Hutchinson & Courthold, 2011; Keating, Walsh, Ribic, & Brimble, 2014). As a result, in-centre hemodialysis (HD) became their only choice. Less mobile, chronically well patients travelled to their HD units in all weather conditions and followed a more restrictive dietary and fluid regimen. Some of the most adherent HD patients endured post-treatment symptoms, especially cardiac and hypotensive patients, and then braved travelling home feeling unwell. The advancement in selection criteria and expanded home care support created growth in PD numbers. By October 2014, more patients were choosing to live with the benefits of PD (Perl et al., 2011). Along with this growth came two practice changes at London Health Science Centre (LHSC) that caused increased demand on home visiting nurse support: (1) The implementation of twice-weekly, at-home pre-training flushes to maintain catheter patency; and (2) the LHSC urgent-start PD program that allows patients to start automated PD (with deferral of manual PD training) within three weeks of catheter insertion (Alkatheeri, Blake, Gray, & Jain, 2016). Due to the attraction of PD in the more remote areas of the LHSC catchment area, the PD unit (PDU) staff identified two geographical areas with severe shortage of trained nurses.
Historically, two full days of training were offered to community nurses at the LHSC PDU. One PD nurse would be assigned to train three to seven community visiting nurses. Upon completion, each nurse would receive a certificate of competency allowing the nurse to practise this new skill. There were frequent cancellations or no-shows for the classes; sometimes classes would only comprise two students. On two occasions, a whole class did not show. Delving into the reasons behind the frequent absences was enlightening. Community visiting nurses expressed their helplessness in finding a coworker to care for their assigned patients while they underwent the two-day training at LHSC. If coverage could not be found, these dedicated professionals would not leave their patients, hence, the empty PD classes. In response to this deficiency, some community visiting nurses would provide their colleagues with basic rudimentary knowledge of PD without formal training to combat the shortage at the "front line". The work was technically done, but safety was compromised (Provincial Peritoneal Dialysis Coordinating Committee, 2006d).
The LHSC PDU staff offered to come to the visiting nurses' communities. Seven case managers from the Community Care Access Centre (CCAC) provided the PDU with contacts for the nursing agencies they regularly used for the LHSC PD patients in their areas. The initial focus was placed on the areas with the least number of PD-trained community visiting nurses. Dates were offered, and the managers selected the nurses for training, concentrating on areas with the greatest deficiencies. The nursing agency manager arranged a suitable venue in their town for training; locations included agency offices, local hospital board rooms, and even a converted train station. Once PD trainee numbers were confirmed, the PDU staff made arrangements for delivery of Dianeal solutions and cyclers through Baxter. Ancillary PD supplies, training manuals, and the training video were brought by the PD staff. Evaluations were requested after each completed training session. During the trial period of October 2014 to January 2015, LHSC hosted four two-day training sessions. Each class averaged nine students with a total of 32 graduates. One month post training a fictional case study was sent electronically to the newly trained alumni for follow-up learning. The PD staff discovered that this opened up and maintained the flow of communication with the newly PD-trained community visiting nurses.
After this trial, the LHSC PD patients had trained community visiting nurses in every geographical area reaching the most remote areas. The urgent-start patients (i.e., patients who start PD within three weeks of catheter insertion) had trained staff to monitor their progress in the early stage. The PDU had a sufficient pool of excellent skilled staff to call upon. Community visiting nurses were better able to cover their workload. The community nurse trainees arranged to see their home patients before class, after class, or even during the lunch break on their training dates. These community visiting nurses recognize the benefit of learning PD from LHSC PDU staff and insist on learning from the experts.
Following the trial, the LHSC PDU had a roster of trained community visiting nurses to call upon for their increased numbers and urgent-start patients. A closer connection was felt between the LHSC PDU and community visiting nurses. In addition, poor attendance was reversed, community visiting nurses were anxious to join classes, and PD nurse hours were used more effectively during the four months. When compared to four months of training in London from October 2013 to January 2014, the PD nurse was able to train more nurses in their day during the trial period from October 2014 to January 2015.
During LHSC training one year prior, nine PD nurse work days were needed to train 17 community visiting nurses, whereas, in the nurses' home towns, seven PD nurse work days were needed to train 32 community visiting nurses (Figure 1). Approximately 1.89 community visiting nurses were trained for each day spent in the LHSC training program; in contrast, each day spent outside of the London training program and in the community yielded 4.64 PD-trained community visiting nurses. Some comments from evaluations after the community held classes included: "Thank you for coming to us" and "I am anxious to put my new knowledge to work".
Taking PD training to nurses in the community has benefitted all parties. The patients receive consistent, safe instructions, as community visiting nurses use the same education tools and information as the LHSC PDU staff. This has led to patients feeling confident that they made a safe choice by opting for PD as their definitive RRT The community visiting nurses found that having classes closer to home gave them the freedom to organize their work schedules. Agency staff witnessed the portability of PD in their workplace. The LHSC PDU was able to arrange for home support more easily when needed. The PDU staff made efficient use of their work hours by having full classes. This experience highlights how successful home dialysis decreases the financial burden on our strapped healthcare system. Above all, it underscores the importance of maintaining the quality of life for patients undergoing PD at home, as well as for their families.
The author would like to acknowledge the guidance and encouragement of Lori Harwood, PhD, RN, CNeph(C), in motivating the author to create this article.
Alkatheeri, A.M.A., Blake, P.G., Gray, D., & Jain, A.K. (2016). Success of urgent-start peritoneal dialysis in a large Canadian renal program. Peritoneal Dialysis International, 36(2), 171-176.
Hutchinson, A.J., & Courthold, J.J. (2011). Enabling self-management: Selecting patients for home dialysis? Nephrology Dialysis Transplantation (NDT) Plus, 4 (Suppl. 3), iii7-iii10.
Keating, P., Walsh, M., Ribic, C.M., & Brimble, K.S. (2014). The impact of patient preference on dialysis modality and hemodialysis vascular access. BMC Nephrology, 15, 38. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3943442/pdf/1471-2369-15-38.pdf
Perl, J., Wald, R., McFarlane, P., Bargman, J., Vonesh, E., Na, Y., ... Moist, L. (2011). Hemodialysis vascular access modifies the association between dialysis modality and survival. Journal of the American Society of Nephrology, 22, 1113-1121.
Provincial Peritoneal Dialysis Coordinating Committee (2006a). Provincial Peritoneal Dialysis Joint Initiative resource manual: Detailed strategy on increasing peritoneal dialysis (PD) use in Ontario - Section 2b Initial Assessment & Triage (pp. 14-37) Retrieved from http://www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=100547
Provincial Peritoneal Dialysis Coordinating Committee (2006b). Provincial Peritoneal Dialysis Joint Initiative resource manual: Detailed strategy on increasing peritoneal dialysis (PD) use in Ontario - Section 3a Community Care Access Centers (CCACs), (pp. 73-78). Retrieved from http://www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=100547
Provincial Peritoneal Dialysis Coordinating Committee (2006c). Provincial Peritoneal Dialysis Joint Initiative resource manual: Detailed strategy on increasing peritoneal dialysis (PD) use in Ontario - Section 3b Long-Term Care Homes (pp. 79-93). Retrieved from http://www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=100547
Provincial Peritoneal Dialysis Coordinating Committee (2006d). Provincial Peritoneal Dialysis Joint Initiative resource manual: Detailed strategy on increasing peritoneal dialysis (PD) use in Ontario - Section D PD Training and Education (pp. 53-63). Retrieved from http://www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=100547
Termorshuizen, F., Korevaar, J.C., Dekker, F.W., van Manen, J.G., Boeschoten, E.W., & Krediet, R.T., for the NECOSAD Study Group. (2003). The relative importance of residual renal function compared with peritoneal clearance for patient survival and quality of life: An analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NEC0SAD)-2. American Journal of Kidney Diseases, 41(6), 1293-1302.
By Michele Ivanouski, RN, CNeph(C)
ABOUT THE AUTHOR
Michele Ivanouski, RN, CNeph(C), Multi-Care Kidney Clinic, London Health Science Centre, London, Ontario
Address for correspondence: Michele Ivanouski, Multi-Care Kidney Clinic, London Health Science Centre, Westmount Shopping Centre, 785 Wonderland Road South, London, ON N6K 1M6
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