Quality Assurance Audit of Technique Failure and 90-Day Mortality after Program Discharge in a Canadian Home Hemodialysis Program

Patient Training and Patient Safety in Home Hemodialysis

The success of a home hemodialysis program depends largely on a patient safety framework and the risk tolerance of a home dialysis program. Dialysis treatments require operators to perform dozens of steps repeatedly and reliably in a complex procedure. For home hemodialysis, those operators are patients themselves or their care partners, so attention to safety and risk mitigation is front of mind. While newer, smaller, and more user-friendly dialysis machines designed explicitly for home use are slowly entering the marketplace, teaching patients to perform their own treatments in an unsupervised setting hundreds of times remains a foundational programmatic obligation regardless of machine. Just how safe is home hemodialysis? How does patient training affect this safety? There is a surprising lack of literature surrounding these questions. No consensus exists among home hemodialysis programs regarding optimized training schedules or methods, with each program adopting its own approach on the basis of local experience. Furthermore, there are little available data on the safety of home hemodialysis as compared with conventional in-center hemodialysis. This review will outline considerations for training patients on home hemodialysis, discuss the safety of home hemodialysis with an emphasis on the risk of serious and life-threatening adverse effects, and address the methods by which adverse events are monitored and prevented.

Home hemodialysis technique survival: insights and challenges

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Less Complexity in Hemodialysis Machines Reduces Time and Physical Load for Operator Actions

Purpose

Innovative hemodialysis systems are designed to ensure user safety and reduce operational time to allow health-care personnel to focus on patient care. The 6008 CareSystem has been developed to simplify the extracorporeal circuit of the system through a disposable cassette, automate operation steps, and facilitate handling in comparison to its predecessor - the 5008 CorDiax. The present investigations were performed with the aim of evaluating usability, safety, and ergonomic aspects of the new therapy system.

Methods

A time-motion study compared these two hemodialysis systems with video and time recording of handling steps required to prepare, operate, and dismantle a dialysis machine. The ergonomic burden on hands and finger joints was evaluated in a second study, again by video-recording the simulated operation of both dialysis systems.

Results

The number of handling steps required for the 6008 CareSystem and critical contact points were reduced by 26% in comparison to the 5008 CorDiax for patients with arteriovenous fistula used for vascular access and by 22% for those with a catheter used for vascular access. Total process time was reduced by 2.83 and 2.57 minutes using fistulae and catheters for vascular access, respectively. The number of hand grips and finger and thumb presses was reduced by approximately 50% and required less strength to execute.

Conclusion

The most recent hemodialysis system confirmed its ease of use and user safety through fewer handling steps and less physical burden on the user. Shorter operational time should enable more patient-focused care.

Mortality After Home Hemodialysis Treatment Failure and Return to In-Center Hemodialysis

RATIONALE OBJECTIVE

Patients on home hemodialysis (HHD) may eventually return to in-center hemodialysis (ICHD) for clinical, technical or psycho-social reasons. We studied the mortality of patients returning to ICHD after HHD comparing it to the mortality experience among patients receiving HHD and patients receiving ICHD without prior treatment with HHD.

STUDY DESIGN

Retrospective cohort study.

SETTING PARTICIPANTS

All patients represented in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry who commenced HD during 2005-2015 and were treated for >90 days.

EXPOSURES

ICHD and/or HHD, and clinical characteristics at study entry.

OUTCOMES

Mortality and cause of death.

ANALYTICAL APPROACH

A time-varying multivariate Cox proportional hazards analysis with shared frailty was implemented to explore the association between patient treatment states and mortality. Patients were censored at the time of transplantation and change in treatment modality to peritoneal dialysis.

RESULTS

A total of 19,306 patients initiated HD and were treated for >90 days. The mean age of patients was 60.8y (SD=15.4y), 62% were male and 49% had diabetes. After HHD treatment failure, adjusted mortality was increased compared to continued HHD at 0-30 days (HR 3.93, 95% CI 2.09-7.40 p<0.001), 30-90 days (HR 3.34, 95% CI 1.98-5.62, p<0.001) and >90 days (HR 2.29, CI 1.84-2.85, p<0.001).

LIMITATIONS

Covariates recorded at dialysis initiation. Residual confounding underlying successful initiation of HHD treatment.Observational data lacking detail on cause of HHD treatment failure.

CONCLUSIONS

HHD treatment failure is associated with a significant increase in mortality compared to continued HHD. This risk was present in both the early (first 30 days and 30-90 days) and late (>90 days) periods after HHD treatment failure. Further investigation into the specific causes of treatment failure and death may highlight specific high-risk patients.

Risk of hospitalization, technique failure, and death with increased training duration in 3-days-a-week home hemodialysis

INTRODUCTION

Quality training is a core component of successful home hemodialysis (HHD) and training duration varies significantly between dialysis centers as well as at the patient level. This study aimed to assess the adverse outcomes associated with HHD training duration.

METHODS

All HHD patients successfully trained in a single dialysis center between January 2005 and July 2017 were included. A multivariable multiple-events (Andersen-Gill) survival model was built to evaluate the association between training time and main adverse events, including hospitalizations, technique failure, and death on HHD. Potential confounding factors were defined a priori (age, diabetes, coronary artery disease, and year of training start). Adjusted risk of vascular interventions (arteriovenous fistula angioplasties and central venous catheter replacements) was assessed as the secondary outcome in a negative binomial regression.

FINDINGS

Forty-eight patients were included in the study. Median HHD training duration was 86 (67-108) days, using a thrice weekly training schedule. Over a follow-up median time of 2.0 (0.7-3.3) years, three patients died while on HHD, 10 had a definitive transfer to HD, and 18 experienced a least 1 hospitalization (38 hospitalizations in total). Training duration was associated with a higher risk of hospitalization, technique failure, and death in unadjusted (hazard ratio [HR] 1.16 per month, 95% confidence interval [CI] 1.08-1.24) and adjusted multiple events model (HR 1.21, 95% CI 1.04-1.43). Risk of vascular access intervention was also significantly higher with increased training time (adjusted incidence rate ratio 1.31, 95% CI 1.03-1.64, per training month).

DISCUSSION

In this single-center observational study, HHD training duration was associated with a higher risk of adverse events including, death, technique failure, hospitalizations, and vascular access intervention. Enhanced clinical follow-up and home support should be offered to these more vulnerable patients to mitigate this heightened risk.

Understanding Home Hemodialysis Patient Attrition: A Cohort Study

Background:

Home hemodialysis (HHD) offers a flexible, patient-centered modality for patients with kidney failure. Growth in HHD is achieved by increasing the number of patients starting HHD and reducing attrition with strategies to prevent the modifiable reasons for loss.

Objective:

Our primary objective was to describe a Canadian HHD population in terms of technique failure and time to exit from HHD in order to understand reasons for exit. Our secondary objectives include the following: (1) determining reasons for training failure, (2) reasons for early exit from HHD, and (3) timing of program exit.

Design:

A retrospective cohort study of incident adult HHD patients between January 1, 2013—June 30, 2020.

Setting:

Alberta Kidney Care South, AKC-S HHD program.

Participants:

Patients who started training for HHD in AKC-S.

Methods:

A retrospective, cohort study of incident adult HHD patients with primary outcome time on home hemodialysis, secondary outcomes include reason for train failure, time to and reasons for technique failure. Cox-proportional hazard model to determine associations between patient characteristics and technique failure. The cumulative probability of technique failure over time was reported using a competing risks model.

Results:

A total of 167 patients entered HHD. Training failure occurred in 20 (12%), at 3.1 [2.0, 5.5] weeks; these patients were older (P < .001) and had 2 or more comorbidities (P < .001). Reasons for HHD exit after training included transplant (35; 21%), death (8; 4.8%), and technique failure (24; 14.4%). Overall, the median time to HHD exit, was 23 months [11, 41] and the median time of technique failure was 17 months [8.9, 36]. Reasons for technique failure included: psychosocial reasons (37%) at a median time 8.9 months [7.7, 13], safety (12.5%) at 19 months [19, 36], and medical (37.5%) at 26 months [11, 50].

Limitations:

Small patient population with quality of data limited by the electronic-based medical record and non-standardized definitions of reasons for exit.

Conclusions:

Training failure is a particularly important source of patient loss. Reasons for exit differ according to duration on HHD. Early interventions aimed at reducing train failure and increasing psychosocial supports may help program growth.

Anemia management for home dialysis including the new US public policy initiative

Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.

Strategic Planning for Starting or Expanding a Home Hemodialysis Program

The American Advancing Kidney Health Initiative has renewed interest in home hemodialysis (HHD). Many perceived barriers exist for adoption of HHD despite well-reported clinical benefits. A well-designed program ensures patient success further engaging more patients. The initial planning regarding the surrounding patient population, stakeholders, economics, and physical location is essential. The services offered including modality education and different kinds of HHD modalities depend on local expertise and economics. The program should fulfill conditions for coverage requirements for personnel, physical infrastructure, and quality metrics to begin operations. The patient recruitment is facilitated by a patient-centric modality education program developed by the multidisciplinary team. If the patient is interested, a training schedule should be discussed with the patient and caregiver. A system to ensure remote patient monitoring, respite care, and 24 hours on-call availability should be established. These practical considerations ensure initial success and future growth of the program.

Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting

Patient safety is of the utmost importance in home hemodialysis (HHD). Recognizing that there are risks related to vascular access (both infectious and noninfectious events), dialysis water quality, and procedural-related adverse events (including arteriovenous fistula needle dislodgement or air embolism), there is a need for systematic identification and management. Although adverse events are relatively infrequent in HHD, the potential consequences of these events may include significant morbidity, HHD treatment failure, or death. Therefore, having a systematic framework to review each event, audit and retrain patient technique, disclose and discuss events with patients, home unit staff and device companies (if relevant) and determine preventative measures to avoid future adverse events, is crucial. In this review, we will describe the literature around the types and relative frequency of serious adverse events in the HHD setting and we will outline a quality assurance framework for capturing, managing, and avoiding serious adverse events. Finally, we will describe some of the novel existing approaches to preventing or addressing serious adverse events and critical knowledge gaps that should be evaluated in future study.

The Potential Burden of Home Dialysis on Patients and Caregivers: A Narrative Review

Purpose of review:

Home dialysis modalities offer several benefits for patients with end-stage kidney disease when compared with facility-based thrice-weekly hemodialysis. To increase uptake of home dialysis, many centers are encouraging a “home-first” approach. However, it is important to appreciate that “one size may not fit all” and that dialysis modality selection is a complex decision that needs to be individualized. The purpose of this review was to explore aspects associated with home dialysis that may be associated with burden for patients and their caregivers and to discuss strategies to alleviate these concerns.

Sources of information:

Original research articles were identified from PubMed using search terms “peritoneal dialysis,” “home hemodialysis,” “home dialysis,” “barriers,” “quality of life” and “burden.”

Methods:

We performed a focused narrative review examining potential sources of burden with home dialysis therapies after conducting a critical appraisal of the literature and identifying the major recurring themes.

Key findings:

Home dialysis is associated with burden for certain patients. Indeed, some patients may experience ongoing concerns regarding the risks of adverse events and of inadequately performing dialysis on their own. Psychosocial issues affecting quality of life may also arise and include fear of social isolation, sleep disturbances, perceived financial burden, anxiety, and fatigue. Patients who depend on a caregiver may worry about creating a stressful home environment for their close ones. Furthermore, the demands associated with being a caregiver may lead to psychosocial distress in the caregivers themselves. All these factors may lead to burnout and consequently, therapy discontinuation necessitating an unplanned transition to in-center hemodialysis leading to adverse outcomes. However, certain strategies may help alleviate burden especially if concerns are identified early on.

Limitations:

As we did not apply any formal tool to assess the quality of the studies included, selection bias may have occurred. Nonetheless, we have attempted to provide a comprehensive review on the topic using numerous diverse studies and extensive review of the literature.

Implications:

Future studies should focus on better identifying patient priorities and strategies to facilitate dialysis modality selection and improve quality of life.

Optimization of Dialysis Modality Transitions for Improved Patient Care

Purpose of review:

Initial and subsequent modality decisions are important, impacting both clinical outcomes and quality of life. Transition from chronic kidney disease to dialysis and between dialysis modalities are periods were patients may be especially vulnerable. Reviewing our current knowledge surrounding these critical periods and identifying areas for future research may allow us to develop dialysis strategies beneficial to patients.

Sources of information:

We searched the electronic database PubMed and queried Google Scholar for English peer-reviewed articles using appropriate keywords (non-exhaustive list): dialysis transitions, peritoneal dialysis, home hemodialysis, integrated care pathway, and health-related quality of life. Primary sources were accessed whenever possible.

Methods:

In this narrative review, we aim to expose the controversies surrounding home-dialysis first strategies and examine the evidence underpinning home-dialysis first strategies as well as home-to-home and home-to-in-center transitions.

Key findings:

Diverse factors must be taken into consideration when choosing initial and subsequent dialysis modalities. Given the limitations of available data (and lack of convincing benefit or detriment of one modality over the other), patient-centered considerations may prime over suspected mortality benefits of one modality or another.

Limitations:

Available data stem almost exclusively from retrospective and observational studies, often using large national and international databases, susceptible to bias. Furthermore, this is a narrative review which takes into account the views and opinions of the authors, especially as it pertains to optimal dialysis pathways.

Implications:

Emphasis must be placed on individual patient goals and preferences during modality selection while planning ahead to achieve timely and appropriate transitions limiting discomfort and anxiety for patients. Further research is required to ascertain specific interventions which may be beneficial to patients.

Prospective monitoring of after-hours nursing and technologist support calls to a regional Canadian home hemodialysis program

INTRODUCTION

Increasing renal care providers offer home hemodialysis (HD) as a modality choice. There is considerable variation in the provision of after-hours on-call support for self-dialyzing patients and no literature describing the utility of this service. In this prospective, observational study we sought to monitor and classify the number and nature of interactions between home patients and our on-call nurses and technologists, and enumerate the number of adverse events averted by the availability of on-call staff.

METHODS

Our home HD unit provided 24-hour on-call patient support and during a 4-month period in 2012, we prospectively monitored all patient calls to this service. The nature of the calls was logged as nursing-related vs. technical. Call outcomes were classified according to whether patients were able to initiate/resume their treatments or whether additional interventions were required.

FINDINGS

During this period, our program cared for 58 home HD patients. Nurses fielded 172 calls and dealt with 239 issues. One hundred nine (46%) were clinical issues including 5 (2%) of a serious nature involving potential harm; 67 (28%) related to machine setup or alarms, 36 (15%) required a technologist to resolve, and 27 (11%) were deemed non-urgent. One hundred six issues were directed to technologists in 99 calls. Issues pertained to machine malfunction (45 calls-43%), machine set-up and alarms (25 calls-24%), or the water system (24 calls-23%). Only 12 calls (11.3%) were not of a technical nature. Nursing and technologist support allowed patients to initiate or continue their treatment 75% and 71% of the time, respectively.

DISCUSSION

Home HD on-call services provide patients support to successfully continue their dialysis treatments by troubleshooting clinical and technical aspects of dialysis and by averting potential adverse events.

Home haemodialysis in Ireland

BACKGROUND

Home haemodialysis (HHD) has the potential to impact positively on patient outcomes and health resource management. There has been rejuvenated international interest in HHD in recent years.

AIM

We aimed to review the activity and outcomes of the Irish HHD Programme since inception (2009-16).

DESIGN

Retrospective review.

METHODS

Patient data were collected using the national electronic Renal Patient database (eMEDRenal version 3.2.1) and individual centre records. All data were recorded in a coded fashion on a Microsoft Excel Spread-sheet and analysed with Stata SE software.

RESULTS

One hundred and one patients completed training and commenced HHD; a further fourty-five patients were assessed for HHD suitability but did not ultimately dialyse at home. Twenty patients switched to nocturnal HHD when this resource became available. The switch from conventional in-centre dialysis to HHD led to an increase in the mean weekly hours on haemodialysis (HD) and a reduction in medication burden for the majority of patients. The overall rate of arteriovenous fistula (AVF) as primary vascular access was 62%. Most HHD complications were related to access function or access-related infection. Over the 7-years, 29 HHD patients were transplanted and 9 patients died. No deaths resulted directly from a HHD complication or technical issue.

CONCLUSIONS

Patient and technique survival rates compared favourably to published international reports. However, we identified several aspects that require attention. A small number of patients were receiving inadequate dialysis and require targeted education. Ongoing efforts to increase AVF and self-needling rates in HD units must continue. Psychosocial support is critical during the transition between dialysis modalities.