In-Center Nocturnal Hemodialysis, Part III: Prescription and Operational Guidelines

In-center nocturnal hemodialysis (INHD) is a hybrid modality administered at a dialysis facility at night typically for six to eight hours, three times per week. Although INHD offers potential clinical and lifestyle benefits (as described in the first of this series of blog posts), it may not be appropriate for all patients. (Read this DMI blog post for more information on optimal patient characteristics.) The therapy is selected by the physician in discussions with the patient. The physician designs the INHD prescription that best meets the clinical and lifestyle needs of the individual patient. Prescription and operational guidelines for INHD are presented here.

Prescription guidelines

While the prescription parameters detailed in literature have minor variations, they are reasonably consistent. In addition, an acceptable range for nocturnal dialysis prescriptions is shown below.

Additional ancillary items that may be appropriate based on the patient’s individual situation include

• Oxygen (2–4 liters)
• Chilled dialysate (35–36 degrees C)
• Dialysate sodium concentration adjustment
• Ultrafiltration (UF) profiling

Patients with sleeping difficulties, which most often occur during the first few weeks after starting INHD, may benefit from sleep medications—such as temazepam, zolpidem or diphenhydramine—as per physician order for patients adjusting to therapy.

Many dialysis patients have sleep apnea and use continuous positive airway pressure (CPAP) devices at home. These devices can generally be used at night in dialysis facilities for patients who need it.

Treatment time

A small percentage of nocturnal prescriptions are written for less than six hours, which can potentially prevent patients from fully experiencing the clinical benefits of extended treatment times and can disrupt the sleep patterns for the remaining patients in the unit. Prescriptions written for six hours or more (generally, about eight hours) per night result in better outcomes compared with HD performed for between 3 and 5.5 hours. Accordingly, medical directors may wish to discuss this information with attending physicians. Physicians, registered nurses (RNs) and patient care technicians (PCTs) need to educate patients on the importance of treatment time adherence to have a better chance of achieving the full spectrum of INHD’s clinical and lifestyle benefits. Patients must arrive before a designated lights-out time to help avoid disruption for patients already on treatment and avoid interfering with the regular workflow for staff caring for INHD patients. Physicians should require that any patient who leaves treatment early sign an against medical advice (AMA) form to help limit treatment time non-adherence and track the numbers of patients who are not leveraging the benefits of an extended treatment time.

Operational considerations

Adding a nocturnal program to an existing in-center hemodialysis (ICHD) facility can be an attractive way to help improve clinical results, align the dialysis modality to the patient’s risk factors not responding to alternate treatment modalities, support patients’ lifestyle needs, increase facility capacity and differentiate the center’s offerings from those of alternative dialysis providers. Facility operation leaders and corporate executives need to balance the required investment and higher cost structure against the potential benefits of INHD (lower mortality rates, reduced hospitalization, improved lab parameters). Facility operations leaders should enlist the support of the medical directors and other physicians who can function as champions to support the therapy. To help ensure the success of a nocturnal program, consider the following operational aspects:

• For three-day-a-week INHD programs, shift coverage for nocturnal RNs and PCTs during absences must be addressed. If a nearby nocturnal program is open on alternate days, sharing resources is preferred. However, it is generally necessary to arrange for day-shift staff teammates to cover the nocturnal shift.
• Rounding schedules. Physicians or their designee (non-physician practitioner (NPP)) are required to round on patients at night while the patient is on INHD at least once each quarter but otherwise can evaluate the patients in the HD unit prior to their treatment times or in the physician’s office more frequently (weekly, monthly). Rounding in the unit at frequent intervals increases the interaction between the physician, health care team and patient, and helps drive improved clinical outcomes.
• Patient monitoring. No special cardiovascular monitoring is typically required during INHD treatments; INHD prescriptions with reduced blood flow rates (BFR) and UF rates can potentially reduce the risk for hemodynamic instability that can be experienced by select patients undergoing standard dialysis.
• Most facilities can support a nocturnal program with no capital investments in their water treatment infrastructure. However, it is necessary to verify water tank capacity, regeneration run cycle and water softener needs with a biomed technician.
• For most nocturnal programs (especially six-day programs), the facility cleaning schedule will probably need to be adjusted to before or after the nocturnal shift.
• Start-up expenses. Besides marketing expenses, many facilities can support a nocturnal program with minimal additional start-up expenses. However, facilities should evaluate the need for additional investments, such as chair pads, beds, dimmer switches or security cameras on a case-by-case basis.

INHD is a form of dialysis treatment that constitutes a significant opportunity both to improve clinical outcomes for patients and to increase capacity at existing dialysis facilities. INHD is a distinct modality with unique parameters, characteristics and outcomes and, as such, warrants further application and increased medical and operational consideration by the health care community.

Read In-Center Nocturnal Hemodialysis, Part I: Clinical Benefits

Read In-Center Nocturnal Hemodialysis, Part II: Optimal Patient Characteristics