Success for home haemodialysis project

The NICE Shared Learning Awards were developed to recognise inventive solutions to clinical problems and reward examples of how NICE guidance has been put into practice in the NHS, local authorities, voluntary and other organisations. The 2011 winner of the Award was the Central Manchester Foundation Trust (CMFT) for a project implemented by the haemodialysis team at the Manchester Royal Infirmary, empowering patients to perform haemodialysis independently at home, instead of having to regularly visit the hospital. The project succeeds in implementing NICE guidance TA 48: Renal failure – home versus hospital haemodialysis.1 Commenting on the winning programme, Val Moore, implementation programme director at NICE said: “Despite home haemodialysis improving outcomes for patients, uptake across the country is still very low. The Manchester programme is a real example of innovative thinking driving up patient care and delivering excellent results.” Despite technical improvements, patient outcomes on hospital haemodialysis remain poor with respect to quality of life, morbidity and mortality. Adjusted mortality on conventional dialysis is worse than most cancers. Current treatment is also expensive with a poor quality of life for the patient. The benefits of frequent haemodialysis, ideally performed at home, have been clearly demonstrated in clinical studies.2 Despite NICE Guidance in 20021 the prevalence of home haemodialysis (HHD) has not changed and the UK Renal Registry report 20083 showed no change in overall prevalence in this modality in renal units since 2002. Most home-based dialysis programmes in the UK failed to be sustained through the 1990s. The CMFT HHD programme was first introduced in 2004 at a time of rising incidence of chronic kidney disease, coupled with an unmet need for dialysis provision in the Manchester region. The initiative aimed at redesigning dialysis provision in the Manchester region. The Greater Manchester Renal Network (East Sector) serves a population density of 1.8 million with a multicultural, multi-ethnic population base. These provided a series of challenges to introducing self-care HHD as cultural, social and educational background are potentially significant barriers to self learning. The HHD prevalence in the North West region of England has, traditionally, varied between 0% and 5% of all dialysis patients.4 It was a combination of the emerging data on the inadequacies of standard hospital dialysis, the NICE recommendations and Renal NSF I advocating greater patient choice, which provided the impetus for the clinical team at Manchester Royal Infirmary to embark on a more innovative approach to dialysis provision, in line with NICE guidance. Dr Sandip Mitra, consultant renal physician, was instrumental in setting up the programme, which is open to all patients in the Manchester area undergoing treatment for kidney failure, and it is believed to be the largest project of its kind in Europe. Discussing the success of the programme to date, Dr Mitra said: “The programme is about creating a philosophy of patient empowerment in the unit and enabling self learning, allowing the patient to be in control of their haemodialysis treatment. Over the past five years, nearly 200 patients have been trained, with around 80 patients in the programme at a time who are able to undertake haemodialysis at home.” The aim was to design a HHD programme that was fit for purpose and accessible to all patients who might benefit, in line with NICE guidance. A model of service development was based on the principles of innovation as a continuous process that was applied through regular evaluation of all the components. A high impact implementation model was defined that required an environment of learning of a complex technology and a set of well defined programme policies, innovative tools and pathway redesign strategies implemented in three steps of training, choice and support The initiative, led by Dr Mitra, was fully supported and enabled by the CMFT clinical director and management team and involved a number of steps of change. The approach was that any patient who is motivated, willing to learn, wishes to be independent and has suitable living accommodation, would be assessed for home haemodialysis.

The first step

The first step is to provide an environment that would be conducive to teaching the patients about the complex haemodialysis technology. Firstly, a modular accelerated HHD learning programme was designed in-house and implemented over six months to improve communication, track progress and accelerate training time. Existing haemodialysis stations were reconfigured into a training centre to allow patients to learn how to self-care while on conventional dialysis. A fast-track training pathway was made available for appropriate learners. New cannulation strategies were implemented and tools to measure learning were developed to help reduce patient training time. A novel two-station ‘Step-down’ shift was also introduced at the haemodialysis unit to allow fully trained patients to undergo a short period of independent dialysis incentre, without staff intervention, to boost their confidence. A technique of self-cannulation was employed which is less painful for the patient, easier to learn and preserves vascular access. This allowed fast-track training for many patients and alleviated any needle-phobia concerns. Additional strategies of needle securement were also put in place to allow patients to use their home dialysis machines while asleep. A cost-per-therapy approach, with machine lease and renewal every five years, avoided large capital expenditure costs and the machines are serviced once a year by the kidney department’s own technical team. “The patients are issued with a machine that is more simple to use than the equipment in the centre. When we started the programme, we had problems finding the ideal machine. However, we have found that, in the intervening years, there has been huge interest among our industry to develop simple, one-touch machines that are more user-friendly. The equipment is becoming lighter, easier to install in the home environment and with improved aesthetics. We still do not have the ideal home use machine yet, but we are getting closer,”said Dr Mitra. The service delivery model was achieved through investment in a team of existing committed staff that believed in the therapy and inspired patient confidence. Since the start of the project, five years ago, a sustainable model of HHD provision has resulted in the baseline provision in Manchester (3% in 2004) having risen to 15.7% of all dialysis patients, a figure that is seven-fold greater than the national average of 2%, who have chosen independent haemodialysis to be established at home. So far, the programme has resulted in nearly 200 patients being trained at the centre, with ages ranging from between 21 to 78, with a 4% failure rate.