Telehealth helps increase home dialysis rates

Melbourne's Western Health is running a trial of remote monitoring and video conferencing technology to improve the rates of home dialysis for patients with chronic kidney disease.

The home therapy utilising telehealth guidance and monitoring or HUG trial is the brainchild of the head of the nephrology unit at Western Health, Craig Nelson, and is based on similar projects conducted in the UK under its Whole System Demonstrator project.

HUG project manager Catherine Blackmore told the Australian Centre for Health Innovation conference in Melbourne last week that the aim of the trial was to increase rates of home dialysis of Western Health patients from 15 per cent to the new benchmark set by the Victorian Department of Health of 30 to 35 per cent.

“The rate [of home dialysis] does vary significantly if you look at different states,” Ms Blackmore said.

“NSW has one of the highest instances of home dialysis at 38 per cent, Victoria has around 21 per cent but even in Victoria the rates from hospital to hospital vary significantly.

“At Western Health, prior to HUG, our take up rates for home dialysis were 15 per cent before HUG. The Department of Health has set a KPI of 30 to 35 per cent of patients dialysing at home, so we have a lot of work to do to reach that.”

The trial, which started officially in July with patient recruitment beginning in April, is using a customised version of Tunstall's ICP system to both collect weight and blood pressure data for each patient that is reviewed by a renal nurse every week day, along with video conferencing capability so nurses can assist patients with correct needling and review exit sites for infection or inflammation.

So popular has the project been that the nephrology unit's dietitian is also conducting video conferences with patients in their own homes, remotely looking through their pantries and fridges and discussing foods with the patient, Ms Blackmore said.

The aim of the trial is not only to increase the amount of people dialysing at home – which is a far cheaper modality than centre-based dialysis, and is also more convenient for many patients – but also to reduce the number of people coming off home dialysis and returning to centre-based care.

“In excess of 40 per cent stop dialysing at home because of social reasons,” Ms Blackmore said. “It's often not really related to dialysis itself, but the burden of dialysis causing stress in so many aspects of their life. Often it is just too hard.”

The majority of Western Health patients need peritoneal dialysis, which requires them to dialyse every day, and to record their weight and blood pressure every day.

Using the ICP system, the patients are taken through an easy to follow “interview” through the ICP device in their home. They are asked to take their blood pressure and then their weight, and are then asked a series of questions about exit site care, the look of their fluids and whether there were any problems overnight.

The data is blue-toothed to the device and then is sent to a secure portal, where the renal nurse is able to check on each patient's data each day.

“It is a secure data transfer; we spent a lot of time with the company to make sure that was the case,” Ms Blackmore said.

“They do their interview, and then I log into the computer and have a look at that data. We analyse it, we interpret it and we make any clinical recommendations that we need to, and it is all done remotely.”

The patient's file in the hospital system allows nurses to see by colour code if anything needs immediate attention or needs to be monitored. Patients can send messages to the system during the interview, and nurses can also write comments on the file.

Nurses can also do video conferences with the patient – which has been useful particularly when the patient is first starting out on home dialysis and might still be unsure of needling or catheter exit site care – and messages can also be sent through the device to remind them if they have a doctor's appointment or the like.

Ms Blackmore said the trial only started in July so evidence of improved outcomes were only anecdotal, but there have been some successes.

Using the video conferencing aspect, nurses were able to see inflamed exit sites on two patients, who were then brought back to hospital for treatment. Another patient showed persistent brachycardia. She was assessed and is now waiting for a pacemaker.

“Some had persistent hypertension – there was a persistent pattern – so we could make some changes to medications,” Ms Blackmore said.

One unexpected success was the discovery that one patient was functionally illiterate. He has since been assisted to continue with the program when his wife is not present by repeatedly going through the steps of setting up the machine and taking the measurements, and he is now able to manage it on his own.

For patients on haemodialysis with a fear of needling, video conferencing provides a way for nurses to support and reassure them and keep them at home. “It is bridging that gap,” Ms Blackmore said.

The early results of the trial are showing good outcomes, with the rate of home dialysis up to 33 per cent. “It is very early in the trial but we are heading in the right direction,” she said.

Posted in Allied Health

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