The physical infrastructure includes the clinic space and layout as well as dialysis equipment. In keeping with the theme of “it’s all about the patient,” we strongly believe that space needs to beautiful, comfortable, warm, and appealing (photos 1 and 2). Patients should feel that we are committed to our program so the space should be front and center and not relegated to a remote corner of the dialysis facility.
It is often difficult to retrofit existing space for home HD in most dialysis facilities because a storage closet converted to a multiuse training and examination room is rarely attractive and does not allow for growth. A new program should focus primarily on training patients, but eventually the nursing staff will spend a significant portion of their time with monthly, routine, and urgent clinic visits. A space that focuses only training rooms and not the workflow of the staff during clinic visits will fall short of needs and will lead to tremendous inefficiencies and frustrations for the nurses.
At our new facility, University City Dialysis, we elected to have a central nursing station with work spaces and rooms surrounding the nursing station. The nurses also have laptops with a wireless connection so they can document and enter orders easily in every room.
We also like having two training rooms connected by sliding pocket doors so they can be used to take care of two patients at once during training yet also provide privacy when needed.
We have designated clinic rooms that are not used for training, but the training rooms can be used for clinic visits during very busy days. The training rooms should obviously have appropriate drains for used dialysate and, if you plan to use the Fresenius [email protected] machine make sure there is appropriate water and electric connections. The Nxstage machine does not require special plumbing and it runs on standard electric outlets. Its size, simplicity, and portability make it the machine of choice for almost all of our patients.
The multidisciplinary model
Developing policies and procedures is beyond the scope of this limited article. Suffice to say some policies are universal and apply to both in-center and home HD. But there needs to be home HD-specific policies, procedures, and protocols.
We believe in the multidisciplinary model of home dialysis care and schedule monthly patient visits at the home dialysis center with the nurse, physician, social worker, and dietitian all present. Some programs have a separate nursing visit at the facility and a physician visit at the physician’s office or at the facility on another day.
We mandate that physicians participate in the multidisciplinary visit because we find that we are much more effective and thorough when we see the patient at the same time. We also train our nephrology fellows from the University of Pennsylvania, so we find that their educational experience is enhanced by the opportunity to learn ddirectly from the nurses, dietitians, and social workers.
Finally, QA and CQI projects are especially important in the early, developmental phase of the program. Identify quality indicators other than the usual Kt/V, anemia, and albumin, for example, which you feel are important and specific to your program such as drop out, blood pressure control and adherence with treatments. If you outcomes fall short of your goals develop projects and teams to fix them.
The quality of your program helps increase the size of your program because dropout rates will be lower. Having a larger program will not guarantee better outcomes if you don’t have the right staff, facility, and procedures. QA and CQI projects are a win-win situation: They improve patient care as well as the professional satisfaction of your team.
From experience, I know that whatever you invest in your home HD program you will get back 10-fold. Investing in staff education will make your job easier in the long run. Lastly, giving patients the opportunity to live better and longer will give you tremendous, everlasting professional fulfillment.
Joel D. Glickman, MD, is Associate Professor of Clinical Medicine and Director of Home Dialysis Programs at the University of Pennsylvania in Philadelphia and Medical Director for the Davita University City Dialysis Center in Philadelphia.