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Development of a Peritoneal Dialysis Program in the Skilled Nursing Facility
Regularly scheduled interdisciplinary team rounds including geriatricians, nephrologists, nurses, dietitians, and social workers from both facilities now take place at the SNF. These rounds provide for better patient care and improved quality of life. Team members review weekly dialysis records and provide opportunities for addressing patient-specific concerns. As this case report shows, patients are able to make the best use of their time in the SNF without the inconvenience of having to travel off-site multiple times per week for their dialysis treatment, and patients currently on PD are able to transition to and from the SNF seamlessly, with little interruption to their daily routines.
Patients with end-stage renal disease (ESRD) in the skilled nursing facility (SNF) typically receive hemodialysis (HD) as a means for renal replacement therapy, which is a lengthy but life-sustaining treatment. Due to the paucity of nursing facilities that can provide HD on-site, patients with ESRD invariably must travel to an HD center several times per week to receive treatment. This requirement often significantly compromises the patient’s quality of life and results in time lost from the SNF, which can impede meaningful participation in skilled rehabilitation programs as well as in other beneficial therapeutic activities.
Peritoneal dialysis (PD) is an underrecognized, underutilized alternative for patients requiring renal replacement therapy. Although less popular than HD, PD offers many advantages for patients in the postacute and long-term care settings. Due to the nature of PD, patients are dialyzed at their bedside throughout the night. In the community, PD patients are able to maintain an active lifestyle and are trained to perform the PD procedure independently, in their own homes. For patients residing in long-term care or requiring post-acute care in the SNF, receiving PD at night means that daytime hours can be spent participating in a skilled rehabilitation program or engaging in recreational or therapeutic activities, rather than traveling to and from an off-site dialysis facility.
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Previously in the greater New York City metropolitan area, hospitalized patients with ESRD who had been receiving PD did not have access to post-acute rehabilitation facilities that provided this service on-site. However, the provision of around-the-clock nursing care and ongoing supervision and observation makes the nursing home environment very well-suited to the needs of the PD patient. As a result of discussions with senior level administrative and clinical leadership at our facility in the Bronx, NY, and collaboration with a network-affiliated specialized kidney hospital in New York City, the concept of developing a specialized SNF PD program to address this need soon emerged.
This innovative collaboration first required the cross-training of staff from various disciplines at each facility. Postacute and long-term care physicians, dietitians, and nursing staff underwent orientation and training exercises aimed at increasing their understanding of the physiologic and nutritional needs specific to ESRD patients on PD. In addition, nursing staff received hands-on procedural training on performing PD at the bedside as well as comprehensive education on monitoring for signs and symptoms related to PD-associated complications. Conversely, hospital-based nephrologists and dialysis nurses received orientation regarding the structure and day-to-day functioning of the SNF.
Regularly scheduled interdisciplinary team rounds including geriatricians, nephrologists, nurses, dietitians, and social workers from both facilities now take place at the SNF. These rounds provide for better patient care and improved quality of life. Team members review weekly dialysis records and provide opportunities for addressing patient-specific concerns. As this case report shows, patients are able to make the best use of their time in the SNF without the inconvenience of having to travel off-site multiple times per week for their dialysis treatment, and patients currently on PD are able to transition to and from the SNF seamlessly, with little interruption to their daily routines.
Case Report
Mrs. ES is a 67-year-old woman with a past medical history significant for coronary artery disease, recurrent transient ischemic attack, diabetes mellitus, and systemic lupus erythematosus. She was diagnosed with ESRD due to lupus nephritis and had undergone an unsuccessful renal transplant. She was placed on PD, which she performed for herself in her home.
One week prior to admission to our facility, the patient was admitted to the hospital, and a new ischemic cerebrovascular accident was diagnosed. She was transferred to our facility for post-acute rehabilitation and actively participated in a program of physical and occupational therapy during the day. During the night, nursing staff performed PD at the bedside while the patient slept. Following successful completion of postacute rehabilitation, Mrs. ES was discharged back to the community, where she was able to resume the responsibilities of performing her own PD daily.
Discussion
At the end of 2008, there were more than half a million Americans living with ESRD.1 The number of elderly patients with ESRD continues to increase at a rate disproportionate to other age groups receiving dialysis.2 It is not expected that the number of donor kidneys will keep pace with the anticipated increase in ESRD prevalence over the next several years, which will translate into greater demand for dialysis as a modality for renal replacement. Observational studies reflect very similar rates of survival between both HD and PD methods of dialysis.1,3
PD offers a significant cost savings compared with HD. The costs associated with both forms of dialysis are covered through the Medicare program. However, annualized costs for PD patients are approximately $20,000 lower than for patients receiving HD.4 This is, in large part, due to the fact that PD does not require the overhead costs associated with the operation and staffing of a hemodialysis facility. The cost difference amounts to a very substantial savings to the nation’s healthcare expenditures.
PD is not without risks. PD-related infection and peritonitis continue to be serious complications and are the primary reasons for hospitalization among persons with ESRD on dialysis. However, the past decade saw greater implementation of newer, evidence-based infection control protocols that have resulted in a significant reduction in hospital admissions for peritonitis and sepsis. By 2010, the rate of hospitalization for PD-associated infections had
approximated that of vascular access-related infections in the HD population.3
n the last 20 years, few peer-reviewed studies have reported on the experience of performing PD in an SNF.2,5,6 Crucial to the long-term success of a PD program in this setting is the establishment of a strong partnership with a dialysis unit.7 The dialysis unit provides all necessary dialysis supplies and related medications to the SNF as well as comprehensive training of nursing staff and 24/7 availability for clinical support. The operation of the PD program should not require additional nursing staff in the facility. At our facility, the registered nurses expressed appreciation for the acquisition of new training and skills in performing PD. Ongoing educational rounds for nursing staff and frequent interdisciplinary communication help greatly towards achieving optimal PD technique and low incidence of PD peritonitis.
Despite improvements in automated PD delivery and comparable survival rates for both HD and PD, the percentage of ESRD patients receiving PD was just 7% in 2008, a significant decline from the 15% utilization seen during the mid-1980s.8 The greater numbers of HD centers, the perceived superiority of HD, greater physician familiarity with HD, and a greater number of reimbursement incentives for this modality may constitute some of the factors responsible for the underutilization of PD.9
Conclusion
It is important for clinicians to recognize the value of what can be accomplished through the shared expertise of an interinstitutional and interdisciplinary clinical collaboration. Patients benefit when all of their medical and rehabilitation needs can be met within one facility, as opposed to travel off-site for therapeutic treatment being required. Families appreciate the role that an SNF can assume in caring for the acute as well as chronic medical concerns of their relatives and loved ones. PD is an underutilized, increasingly safe, and cost-efficient form of renal replacement therapy that has substantial benefits for the postacute and long-term care population and outcomes similar to those of traditional HD. The development of innovative new programs to deliver PD in the nursing home setting is beneficial to the patient and the facility alike, as well as to the healthcare system.
References
1. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med. 2011;171(2):110-118.
2. Tong EM, Nissenson AR. Dialyzing the elderly: issues and concerns: dialysis in nursing homes. Seminars in Dialysis. 2002;15(2):103-106.
3. The United States Renal Data System (USRDS). 2012 atlas of end-stage renal disease—United States Renal Data Survey. USRDS website. www.usrds.org/2012/pdf/v2_ch3_12.pdf. Accessed March 15, 2015.
4. Chui BK, Manns B, Pannu N, et al. Healthcare costs of peritoneal dialysis technique failure and dialysis modality switching. Am J Kidney Dis. 2013;61(1):104-111.
5. Wadhwa NK, Suh H, Cabralda T, et al. Peritoneal dialysis with trained home nurses in elderly and disabled end-stage renal disease patients. Adv Perit Dial. 1993;9:130-133.
6. Dimkovic N, Oreopoulos DG. Assisted peritoneal dialysis as a method of choice for elderly with end-stage renal disease. Int Urol Nephrol. 2008;40(4):1143-1150.
7. Taskapan H, Tam P, LeBlanc D, et al. Peritoneal dialysis in the nursing home. Int Urol Nephrol. 2010;42(2):545-551.
8. Saxena R, West C. Peritoneal dialysis: a primary care perspective. J Am Board Fam Med. 2006;19(4):380-389.
9. Chaudhary K, Sangha H, Khanna R. Peritoneal dialysis first: rationale. Clin J Am Soc Nephrol. 2011;6(2):447-456.
