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Ways to Support Patients on Peritoneal Dialysis

When it comes to the ongoing management of peritoneal dialysis (PD) patients, finding ways to help improve outcomes and reducing patient loss rate should always be the number one focus. In my experience, monthly patient visits are a key touchpoint in the constant quest to achieve better PD results. Monthly visits can be personally and professionally fulfilling because the Interdisciplinary Team (IDT) gets to meet with the patient and the patient’s family, reestablishing personal connections that help ground interactions and strengthen relationships. For planning purposes, it may be helpful to think of the monthly visits in three parts: the pre-visit, the visit, and the post-visit.

Pre-Visit

For pre-visits, it is important to meet separately with the IDT and review their chief concerns. A litany of topics, including any complications the patient has had and any new consults needing review, are discussed. The IDT also reviews any hospitalizations and, if they occurred, a root cause analysis is performed to understand the reason for admission and what actions to take to prevent a recurrence.

Visit

For the actual visit itself, a thorough checklist of what to cover in tandem with electronic health records (EHRs) for documentation may be a good place to start. However, at this point, it is useful to focus first on what is most important to the patient; even though getting through the checklist may be most important to you, it may not be what is most important to the patient. In order to ensure alignment between the two, be sure to cover all key areas, including anemia management, dialysis adequacy (Kt/V), and bone and mineral metabolism. Also spend a lot of time looking at the patient’s prescriptions, reviewing their documents from home, and proactively determining if the membrane is failing. If it is failing, consider other modalities and talk about the possibility of transplantation. Many PD patients are great transplant candidates so be sure they are up to date in their evaluation of that option.

Post-Visit

Taking a holistic approach to care is vital to ensuring that the patient is safe and healthy, not just on the day of the patient visit, but on the other 29 days of the month as well. In the same vein, adopting the following three strategies can encourage patients to remain active in their own healthcare while supporting improved clinical outcomes.

  1. Have the patient train on and demonstrate the PD techniques. Properly adhering to preferred procedures and techniques can help prevent infections and avoid cross contamination.
  2. Observe the patients at home. The ability for the IDT to visit patients at home not only helps support the patient’s health, it goes a long way in building trusted relationships. After completing the initial home visit for each patient, the number, timing, and frequency of additional home visits will be based on individual patient needs as indicated in the patient’s plan of care.
  3. Consider how to collaborate with the rest of the health system, including the hospital and other consultants. When patients are hospitalized, smooth transitions of care, whether going into or coming out of the hospital, are desired. Furthermore, the IDT can discuss with the hospital team how to best care for PD patients.

In summary, the best way to achieve improved clinical outcomes for PD patients is being diligent in the pre-visit, visit, and post-visit stages while proactively anticipating problems that might occur. Problems discovered in the pre-visit can be addressed when the IDT voices concerns they have. Any potential problems during the visit can also be addressed by listening to what’s important to the patient, and making sure a transition plan is in place if they need to transition to a different modality. Finally, we proactively address problems by training and retraining patients when they are in the dialysis center and also in their homes. When considered as a whole, all of these approaches can help keep PD patients safer and healthier.

David A. Roer, MD, FACP, FASH, FASN

David A. Roer, MD, FACP, FASH, FASN

David A. Roer, MD, is vice president of medical affairs for integrated kidney care at VillageHealth and DaVita Kidney Care. He also serves as the chairman of the patient safety and quality committee of the Renal Physician Association and is involved in several clinical research projects locally and nationally. He currently serves on the board of directors at St. Mary’s Hospital and, previously, he served as chief of nephrology, chief of staff and chair of the medical executive committee, medical director of patient safety and clinical quality, chairman of the peer review oversight committee and chair of the ethics committee. Dr. Roer was a member of the National Kidney Foundation of Connecticut’s board of directors for 15 years and developed comprehensive prevention and service programs for more than 3,000 dialysis patients and facilitated legislative changes for kidney disease. In 2008, the foundation honored him with the Gift of Life Community Achievement Award. He and his wife, Mary Lizabeth Aquavia, MD, are founding members of the Ada DeBold Society, a group that ensures the philanthropic future of the National Kidney Foundation. Dr. Roer is an associate clinical professor at Yale School of Medicine, where he also completed his nephrology and hypertension training. He has been awarded Teacher of the Year on six occasions from the Yale Primary Care Residency Program. He holds a specialty certification in clinical hypertension from the American Society of Hypertension and has been the managing partner of Nephrology and Hypertension Associates in Waterbury, Connecticut, for 30 years.