Peritoneal Dialysis: A Case Home Visits

Peritoneal Dialysis: A Case Home Visits

Jeannine Farina

When training patients to perform home peritoneal dialysis (PD), emphasis and education are placed on the environment where the actual dialysis will be performed. However, the PD training usually takes place within a controlled environment in a dialysis unit and, in some instances, a specific home training room. Hence, an ideal way to assess and see the actual implementation of the training objectives is to perform a home visit.

Carboni (1990) describes home as being more than a physical environment — it is also an experience that emerges from many complex relationships between the individual and the environment. Home is seen as a locale where patients have typically lived before being trained for PD. The home training coordinator (HTC) is responsible for understanding the patient’s lifestyle and seeing beyond the home as a mere dwelling place. The home may be a place of pride, comfort, support, or seclusion. It may host a variety of visitors, such as friends, grandchildren, and animals, or the home may have none of these things. However, this may not mean that it is a place of loneliness and isolation (Twinn, Roberts, & Andrews, 1996). The attributes that make a living place a home are essential elements in the assessment, planning, implementation, and evaluation of PD treatments in the home setting.

Significant benefits can be obtained with home visits. First, they ensure information that was presented, demonstrated, and learned during the training process was translated to the home environment. Since the home, rather than the dialysis unit, is the setting for the PD treatment, it is imperative the home be evaluated for potential problems that max not have been discussed during training or were not shared with the staff.

Interestingly, this raises the issue of where the actual PD training should be executed. In the United Kingdom, Davies and colleagues (2000) found that at-home PD training was practical, cost effective, and provided benefits for patients as well as the dialysis unit. At-home training decreased mean training time from 7-10 days to 2.5 days, with overwhelmingly positive patient acceptance.

Since 1995 in the United States, Hoffman et al. (2000) began a protocol of training patients in their homes. Patient and nurse surveys were developed to assess a preference of the training location. Results demonstrated that 87% of the patients trained at home were in strong favor of this locale, and the nurses surveyed also strongly supported PD training in the home. Many benefits of at-home training were cited, such as higher patient satisfaction, improved home assessment, individualized education that is adaptive to the patient’s specific home, patient convenience, and decreased patient anxiety.

Another benefit of home visits is reinforcing to patients that they have an active function as health care team members rather than just passive recipients of care (Lowrey & Moore, 1989). As a result, concerns that patients and family members would normally not discuss in the dialysis unit setting may be more readily and effectively discussed in the home setting.

Many times patients experience anxiety and have frequent questions when moving from the dialysis unit to the home setting. A home visit allows patients to vent concerns and questions as they apply specifically to the home environment. It also can provide an opportunity for the HTC to interact with other family members, friends, or partners who may want to discuss particular psychosocial problems by providing support and encouragement.

Uttley (1999) points out that for the disabled patient, a home visit is indispensable in disclosing the potential need to adapt the home to the patient’s disability. In this situation, the home training staff and the social worker need to coordinate with other services to accommodate the patient’s disability.

One criterion for success in performing PD at home is to have a sense of personal motivation. The home visit provides an unparalleled opportunity to observe and conclude the patient’s motivation and adaptation level (Lowrey & Moore, 1989) while allowing the patient to establish control of the environment (McCausland, 1989). A patient’s home can be an indicator of adaptation skills related to living with a chronic illness.

Van’t Land (1994) suggested that living with a chronic illness is similar to seeing life through shattered glasses because nothing can be seen clearly. It affects patients in all areas: physically, psychologically, spiritually, and financially. The home’s overall condition can be an indicator of the patient’s ability to manage himself or herself, the PD, and the chronic illness (Lowrey & Moore, 1989; Twinn et al., 1996). For example, is there organization in the home or is it littered with debris and clutter?

Patients often show creativity in performing their treatments in some less-than-ideal conditions, such as storing supplies in unique ways when space is at a premium. By observing the environment where the dialysis takes place and seeing what adaptations patients have made in order for the dialysis treatment to occur in the home, the HTC can answer several questions with a modicum of precision: Does the home present a generally clean appearance or is it a hodgepodge? Is it a place to live or is there a sense of personal investment in the dwelling? Answering these questions will help the HTC identify a patient’s willingness, dedication, and motivation potential to the modality in ways not often seen in the dialysis unit (Lowrey & Moore, 1989).

Research on the frequency of home visits as well as general guidelines for home visits is limited. Gartland (1993) surveyed 15 renal pediatric facilities in the United Kingdom and Ireland. Of the 15 units, only 10 had a renal nurse from the dialysis unit performing home visits. Five of the units rarely or never visited the patient. However, it should be noted this is a variation from the norm for the adult PD population in the United Kingdom. Naylor (1992) described how using a multidisciplinary approach a community dialysis team was established to follow 120 hemodialysis and PD patients. The goal was to treat as many patients as possible at home rather than in the hospital due to severe budget constraints. The team was composed of a renal unit nurse and several community dialysis nurses. During the home visits, the community dialysis nurse had a role as counselor, teacher, and provider of encouragement and remained responsible to patients until they stopped home dialysis.

In order to determine the frequency and characteristics of home visits in the United States, a survey was distributed to dialysis centers performing PD. Nearly 80% of the responding centers included home visits in the care of their PD patients (Bernardini & Dacko, 1998). A total of 52% made an initial home visit with at least one follow-up visit, 11% made a single visit, and 16% made visits only as needed. Interestingly, those centers that did not make home visits were not different from those that did according to number of patients, number of registered nurses, rural or urban location, or affiliation with a university.

At the Kidney Center and Hyonam Kidney Laboratory in Seoul, Korea, Chung et al. (1995) had a PD nurse visit 27 patients’ homes and used observations/questionnaires to test the necessity of continuing the home visit program. The authors found that 40.7% of the patients had unacceptable personal hygiene, 25.9% had an unacceptable treatment facility, and 11.1% demonstrated unacceptable technique, thereby, validating the need to continue performing home visits.

As part of a formalized PD retraining program, Lewis and Picketing (1995) incorporated annual home visits to assess environmental factors. The peritonitis rate improved from a rate of one episode in 9.3 months in 1989 to one episode in 13.9 patient months in 1991.

Ponferrada et al. (1993) found an initial home visit was effective and could not be substituted by assessments performed in the hospital or dialysis unit. Although initially costly, recommendations and changes implemented during the home visit, could reduce preventable complications and in turn result in cost savings. However, the home visit policy was changed from an annual visit to a single visit for each new PD patient. Additional visits were performed only if significant problems were noted.

Lowrey and Moore (1989) felt that home visits could be both a facilitator as well as a predictor of rehabilitation. The home is seen as the primary location where the treatments take place, where patients and not the staff is in charge. The HTC then has the opportunity to foster more independent and self-care behaviors with the home visits by allowing patients to take control.

As part of a successful PD program, Lauder and Zappacosta (1988) performed home visits after the patient completed training and then every 6 months as needed. The goal of the visits included patient and family adaptation, learning needs, and review of the PD exchange procedure. Also, the dialysis team was informed of problems seen during the visit in order to determine a solution. The authors cited a peritonitis rate of 1 episode every 20 months at the time of publication.

In the home health care area, Vivian (1996) stated home visits benefit patients in promoting education. A continuous relationship between the provider (the dialysis unit) and the patient is an important factor influencing compliance with the treatment regimen. Naylor (1992) described that as a community dialysis nurse, she found home visits provided the opportunity for patients and families to discuss any problems they may have experienced on the modality. The nurse-as-counselor listened to problems/concerns of the patient and family, suggested solutions to particular difficulties, and provided support and encouragement.

Compliance with performing PD was readily assessed by Bernardini and Piraino (1998) via home visits. In the study, successive home visits were performed to measure inventory of dialysis solution on 49 PD patients. The study found 35% of the patients were noncompliant with the prescribed exchanges. These noncompliant patients performed only 74% of the prescribed exchanges. More importantly, the study identified that noncompliance occurs in the first 6 months of starting PD, concluding home visits could be a way of assessing compliance.

Ideally, a home visit should be performed by the primary nurse who has trained (or will be training) the patient and/or significant other. During the visit, the nurse may want to consider assessing the patient’s ability to adapt to performing the dialysis procedure at home and his or her competency in performing the procedure, and review the environment and storage location of the supplies. According to the Health Care Financing Administration (HCFA) regulations: “For a home dialysis patient whose care is under the supervision of the ESRD facility, the care plan provides for periodic monitoring of the patient’s home adaptation, including provisions for visits to the home” (HCFA, 1989). This article, however, is not meant to interpret the guidelines, but rather to strongly encourage home visits, making the visit an invaluable instrument in assessing the PD patient’s needs.

Advantages

There are many advantages to performing a home visit (see Table 1). First, the HTC is given the opportunity to see a more complete perspective when interacting with patients in the home environment as compared to observations in the dialysis unit only. This, in turn, results in the HTC correcting potential or real hazards not evident prior to the visit, thus preventing infections and keeping patients at home rather than in the hospital. To illustrate, a HTC notes during a visit that the family pet cat sleeps on the patient’s bed. Upon further assessment, it is uncovered that the cat sleeps with the patient during the nightly PD cycling treatment. There is the potential the cat could chew through the cycler tubing and cause peritonitis. Also, since PD is performed using aseptic technique, no animals should be present during the treatment. The HTC would review this with the patient during the home visit in order to correct a potentially preventable peritonitis.

Table 1

Advantages and Limitations of Home Visits

Advantages Limitations

* Assessment of home environment * Time consuming process

* Observations and correction of potential * Staffing issues

or real hazards

* Assessment of supplies, equipment, and * Costly

medicines

* Evaluation of procedures demonstrated * Some environments cannot

during PD training changed be

* Reinforcing the patient as an active * Potentially dangerous

partner as a health care team member environment for the

team member visitor

* Enables patient and family to discuss

concerns/issues specific to the home

setting

* Observation of family adaptation

skills/burnout

* Reinforce patient’s confidence in the

dialysis unit by providing support and

encouragement of self-care behaviors

* Assessment for the need to provide

services to accommodate the home for

a patient with a disability

* Assessment of motivation and adaptation

skills

* Assessment of compliance

* Initiation and reinforcement of patient

education

Observing family adaptation skills as well as any family support and involvement helps the HTC develop an appreciation of how the dialysis impacts all members of the household. Brunier and McKeever (1993) found home dialysis stressful for the patient’s spouse, noting that women are responsible for the home care whether they are the patient or provider of the care for a family member. Home visits can reinforce the patient’s and/or significant other’s confidence and faith in the dialysis unit and staff.

The home visit also lets the HTC check to ensure that the dialysis supplies are kept in a clean and dry environment, free from any potentially harmful sources, such as water damage, dampness, and bug infestation. For example, the HTC can ascertain if there is enough room for supplies and if the patient is ordering/receiving the correct amount of supplies. How the patient stores the supplies and whether the family made special preparations for the dialysis, such as building shelves to house the equipment/supplies, help the HTC assess the patient as well in terms of adaptation to the modality.

Additional questions to consider pertain to expired solutions or medicines. If a prescription change has occurred, is the correct solution being used and has the previous solution been removed from the home? Also, the HTC should observe where the actual dialysis takes place. Is there a dedicated area to perform the dialysis, and is this area free of potential hazards — an air conditioner, heating vent, pets/animals, or an open window? Are antibacterial soap, running water, clean towels, and good lighting present? What type of water is used — if it is from a well, how often is it treated?

The HTC may want to observe an actual dialysis treatment in order to ensure proper procedures. For instance, are procedures being followed as taught or are shortcuts being taken? Is the person who was taught to perform dialysis actually performing the treatment? Is the patient performing the correct technique in masking and washing hands? Have others been taught by someone other than the HTC, such as by the patient, to perform the PD? If so, the HTC may want to watch everyone’s technique for potential problems and correct as needed. Once the treatment has been performed, is the used dialysis solution being disposed of properly as instructed?

Surveying of equipment is another advantage of home visits; obviously, it is easier on the patient than bringing the equipment to the dialysis unit. A number of questions can be answered with a simple home visit, such as, is the dialysis equipment (cyclers and assist devices) and other support equipment (blood pressure cuff and glucose meter) clean and in working order? Is there any visible damage to the equipment that may cause potential problems? Are electrical equipment cords frayed or overloading a particular outlet? In regards to cyclers, is the correct prescription programmed in the machine? Is there a build-up of blood on the glucose meter, and has it been checked for accuracy via a control solution?

Finally, home visits can provide the opportunity for continued patient education both related to dialysis and beyond, including explanation of medicines, prevention of infections, fluid balance, nutrition, and exercise.

Limitations

For the many advantages realized in performing home visits, there are also several disadvantages (see Table 1). These include such variables as dangerous neighborhoods, where one staff member alone cannot safely perform the visit. Thus, two staff members must remain out of the dialysis unit for a home visit, which may not be feasible. In addition, some patients might be embarrassed or ashamed of their homes and may not cooperate with having a staff member visit.

If the home environment is unsanitary, sometimes there is little the HTC can do to improve the situation other than make recommendations and follow-up at a later date to see if improvements have occurred. In some environments, the HTC has even less control in improving the environment, such as in a prison, personal care home, nursing home, rehabilitation center, or the patient who is homeless. Reinforcing the benefits of a clean working area, good hand washing, and wearing of a face mask cannot be overemphasized, no matter what the home dialysis environment.

Finally, possibly the two biggest drawbacks to performing home visits are (a) they are time consuming and (b) costly to perform. Patients who live an extended distance from the unit incur greater expense for those units that do home visits. Units that have only one staff member for PD training and follow-up care are at a disadvantage when their solitary PD nurse is out doing visits. In addition, the cost rises if a dietician and/or social worker also participate in the home visit process.

At this time there is no study on hospital admissions being reduced when performing home visits. The need for future studies to track the outcome of home visits (such as a decrease in hospital admissions) would be of benefit to provide evidence to offset any increased costs and staffing problems encountered with home visits.

General Guidelines

The home visit ideally should be performed by the primary nurse prior to training. But this is not always feasible given staffing and time constraints. By visiting prior to training, the HTC could more effectively tailor the training to the specific environment where the dialysis will take place and correct potential problems before training begins. If the home visit is performed once PD training is completed, the home realistically should be assessed within the first 1 to 2 months. The goal of performing a home visit prior to training is to assess the home environment and social and family dynamics. Assessment of adapting the PD procedures from the dialysis unit to the home setting is the goal of the home visit after PD training (see Table 2).

Table 2 Components of a Successful Home Visit

Before the visit:

* Establish a home visit policy including the goals of the visit, frequency, who will be performing the visit, and reason(s) for the visit along with developing a written home visit assessment form.

* Explain the reason(s) for the home visit to the patient.

* Secure exact directions to the home and verify the visit with a confirmation phone call the day of the scheduled visit.

* Review violence prevention with a signed agreement to inactivate these risk factors.

* Notify supervisor of planned destination(s), provide phone number(s), directions, and an estimation of time away from the unit.

During the visit:

* Review with the patient the reason for the home visit.

* Via the written home visit assessment form, document the following:

A. An assessment of the home.

1. Is there a clean work area for performing exchanges?

2. Adequate lighting.

3. Running water (if well water, how often is it treated?), antibacterial soap, clean paper towels.

4. Draft free room away from open windows, fans, window air conditioner, ceiling and wall vents.

5. Free of pets/animals.

6. Storage of supplies: adequate room; free of bug infestation, dampness, and water damage; check for expired solution and correct solution.

B. Survey equipment: clean and in working condition; assess for any damage.

C. Compliance issues: receiving/ordering correct amount of supplies; if using a cycler, is the correct prescription programmed?

D. Family dynamics/adaptation skills: assessment for burnout of patient/family; provide emotional support and encouragement in allowing the patient to vent fears, concerns, or frustrations; if patient is disabled, do other services need to be arranged?

E. Assessment of procedures/technique: have the patient perform an exchange to assess procedures are being followed as taught; correct any shortcuts, mistakes in technique, etc.

F. Medicines: review all medications the patient is taking including over-the-counter medicines; check for proper storage, expiration, and discrepancies.

G. Provision of patient education as needed regarding specific topic(s).

H. Review of findings/recommendations/follow up issues via the written home visit assessment record with the patient/family and both parties sign and date.

After the visit:

* Review the results of the home visit with all members of the health care team.

* Brainstorm as a team to resolve difficult problems/issues.

* Follow up on any issues that need to be resolved and document.

* Place the written home visit assessment form in the patient’s permanent medical record.

* Track results of home visits over a period of time.

* Identify trends and opportunities for improvement.

For large home training programs, staff may want to dedicate 1 to 4 days per month for home visits in order to complete them in a timely manner. It is helpful to call 2 to 3 days in advance to verify the visit, secure complete and accurate directions to the home, and assess if any additional materials are needed for the visit. A map of the location should be obtained (the Internet can be a source, such as www.mapquest.com) or ask the patient and/or family member to meet the staff member(s) at a designated area near the home. This is especially helpful when traveling to remote areas because it saves time and prevents frustration on the staff member’s part.

The dialysis supplier that the patient uses also can assist in giving accurate directions to the patient’s home. For example, patients using Baxter Healthcare Corporation PD products can take advantage of the “Ticket to Ride” program. Baxter encourages the HTC to ride along with the Baxter driver who delivers the PD supplies to the patients. The HTC has a unique opportunity to observe the driver-patient interaction as well as visiting many patients in 1 day.

Another item to keep in mind on the day of the visit is to place a confirmation call before leaving the unit. Also, verify any specific information, such as what door or entrance should (or should not) be used. Finally, care planning and education goals should be clearly in mind before leaving for the visit, but the staff should be prepared to be flexible to the patient/family needs (Hunter, 1997).

Although unusual, violence prevention needs to be considered before entering the home, especially since the HTC is entering an unknown environment. This includes asking the patient to list and identify any lethal items in the home, including weapons and lethal materials. The patient should then agree to lock away these items during any home visit by any staff member from the unit. Also, ask the patient to explain any volatile relationships and how these will be managed during the visit. Document these potentially violent items and have the patient/family sign an agreement to inactivate these risk factors before each home visit (Hunter, 1997).

Some other items to consider prior to the visit are identifying any pets or animals in the home. Personal safety during the visit should be discussed, such as whether the pet is accustomed to visitors, and if not, suggest the pet be placed outside or in another room. This will result in the freedom for the nurse and patient to interact without distractions during the visit.

Finally, when leaving for the visit, be sure to inform a supervisor of the planned destinations, leaving the phone number(s) and directions to every scheduled home visit during the day and how long of an absence this will require. Calling the HTC’s supervisor upon arrival and/or departure also will keep the dialysis unit aware of the HTC’s location during the day and avoid potential problems.

Additionally, since most staff will be using an automobile for the visit, the potential of an accident is always present. Discuss with a supervisor the unit’s liability insurance or any sort of insurance coverage offered to cover injury or damages incurred on the road. Also, any staff member traveling to see patients should verify what sort of coverage is available for any potential bodily harm.

Written Assessment Record

The home training staff should determine the goals and the objectives of the home visit and establish the areas that will be covered (see Table 2). Creation of a written assessment record of the home visit is necessary to verify that it has occurred. Items to consider for the assessment record are: identification of where the dialysis is performed, observation of the environment, and assessment of the storage of the dialysis supplies.

The assessment record should have space for the staff member’s recommendations and the record should be reviewed with the patient and/or family. Both the staff member and the patient should sign and date that the home visit was performed.

The above can be the basis for the home visit; however, there may be additional topics that the unit may want to cover during the visit. For patients who have experienced frequent infections, the HTC might consider having the patient perform a treatment with the HTC present.

Note if the patient is demonstrating the proper technique as instructed or if shortcuts are seen. Correct any technical areas observed with the rationale included. Check equipment to see if it has been cleaned recently, such as cyclers and assist devices. If the equipment is dirty, demonstrate how it should be cleaned for the patient and explain how often to clean.

A review of medications can occur during the visit. The HTC can ask the patient to show all current medications including any possible over-the-counter medicines, and where and how they are stored. Bring a copy of these home medications to compare with the list within the unit and record any discrepancies.

Follow-up as needed for any discrepancies with the primary physician and review with the patient. Check for any medicines that are expired or discontinued, encouraging disposal where needed. Also, check for correct dosages, strength, and storage. For example, if a medicine needs to be refrigerated, is it at the correct temperature (as per the package insert) and in the refrigerator? If it needs to be protected from light, is it in a light protected container? For any dialysis prescription changes that have occurred, verify that the correct product is in the home and the previous product has been removed. Make arrangements with the dialysis supply company to remove any incorrect product/supplies.

Observation of the patient’s support system via family adaptation to the dialysis can be documented. Support and involvement on the family’s part, such as assisting with the dialysis or other activities of daily living, can be examined and encouraged.

The home visit is an invaluable tool since the patient and/or significant other performs the treatment in the home rather than in the controlled environment of the dialysis unit. Clinic visits can provide the opportunity to assess the patient’s general condition and home records, but the home visit provides the PD staff with the opportunity to monitor the actual environment where the dialysis takes place. To assess the effectiveness of home visits, track the unit’s results over time (such as decreased in peritonitis, fewer hospital admissions, etc.) and identify trends and opportunities for improvement to the process. In this way, the PD unit is in a unique position to reinforce proper technique, make recommendations to reduce infections and hospitalizations, provide support and education to the patient and family members, promote rehabilitation, and, in general, to uphold the continuation of care between the dialysis unit and the home.

References

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Ponferrada, L., Prowant, B.F., Schmidt, L.M., Burrows, L.M., Satalowich, R.J., & Bartelt, C. (1993). Home visit effectiveness for peritoneal dialysis patients. ANNA Journal, 20, 333-336.

Twinn, S., Roberts, B., & Andrews, S. (Eds.). (1996). Community health care nursing: Principles for practice. Oxford, England: Butterworth Heinemann.

Uttley, L. (1999). The disabled continuous ambulatory peritoneal dialysis patient — The nurse’s role. Peritoneal Dialysis International, 19 (Suppl. 2), S505-S507.

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Jeannine Farina, MSN, RN, is a Clinical Specialist with Baxter Healthcare Corporation, McGaw Park, IL. Prior to this, she was a peritoneal dialysis home training coordinator for 12 years in an outpatient dialysis unit in Pittsburgh, PA.

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