PART 2 - “The Flip”—Helping Patients Switch from PD to HHD: Making the Most of the Lull

When working as a PD nurse, it’s really great when each month has a predictable cadence. My favorite way to accomplish this was by scheduling all of the monthly nurse visits and bloodwork for the first week. Kt/V is done every 3 months, or more often if it’s warranted. I used to like to sync up my quarterlies for all of my patients so it never got missed. In the second week, my pattern was to go through the results as they rolled in, checking 6-month trends, and comparing treatment sheets to previous months, all the while scanning for anything that stood out enough to cause curiosity.

Regardless of what the numbers were, I called people to talk about them. Is that time consuming? You bet it is. But it's not enough to flippantly say, “labs look good” or, “labs look bad” when you’re dealing with people who are learning to self-manage. A happy face or a sad face really falls flat on the home crowd.

Keep the Lines of Communication Open

I really liked it when there were no interesting changes to report, but when there were, I found it very helpful to be speaking the same language in a conversation with my patients. Maintaining open communication is seriously important to keeping people at home. If you are a PD nurse, it is safe to assume that most of the people you care for want to be at home and independent, right? Keep that as your goal, too.

You know, this might just have been my experience, but when I called to check in, and asked folks (genuinely) how they were doing—I usually asked about their kids, dogs, and jobs first—the things that matter most. I found that people very seldom seemed to mind hearing from me, and going through labs and meds at the same time. I was often thanked and told it was nice to hear from me. It’s the little things that help build trust—like being friendly.

My mentor back then used to say, “PD patients who are stable should have stable labs and stable fluid status all of the time. That’s how PD works!” She’d also say things like, “When they’re doing well, they should look and feel well, and you should be able to pull them in at random off the street for bloodwork and be able to guess the results! That’s what a stable patient is!”

Recognize and Make Good Use of the Lull

Anecdotally, my personal favorite measure of stability has always been when my patients’ primary complaints were more regularly about the weather, their daughter’s no-good boyfriend, or their nosy neighbor, rather than anything involving me. That’s the sweet spot. Go team, go! When you start to hear your patients talking normal like that, point it out, as congratulations are in order.

When you’re in that sweet spot, it’s easy to put a patient on the back burner. I understand how time consuming it can be to disengage the autopilot, but once a patient is home and independent and back to their lives, the job doesn’t end. That lull is fantastic, but it can be short-lived. Your new focus is to help figure out how to maintain that for as long as possible.

Get the most out of the lull before the next round of chaos. How? Focus your education on good nutrition, general health, blood pressure control, blood sugar management, rehabilitation—any “thing” that will preserve their residual renal function and delay decline as long as possible. Talk a lot about membrane preservation, infection control, lower-glucose dialysate. Make sure your patients understand their labs and what their medications do. Connect dots that may have been missed in training.

It never mattered to me if new patients took a year (or more!) of repetition to grasp their reasons for caring about each” little” thing—that’s time we had to take. Helping it to be less confusing is part of the job. So, please, have talks with patients even when they’re “fine.” That way, when you think you’re starting to notice signs that PD isn’t going so great, they are more likely to tell you if they are actually doing the treatments as prescribed, or if they were really busy last week and skipped some. People need to know why you’re asking.

Coping with PD Changes

When the relationship between the treatments and the labs is understood by all, knowing when the time has come to get more creative to keep the modality sustainable is much more straightforward. The changes can be insidious. It takes some time to identify in labs the need to change a once-stable prescription and re-tweak it to perfection.

There are usually lots of mutual questions circulating when working through an issue of worsening labs. Did the residual take a hit? Is there some treatable inflammatory or infectious process gumming everything up? Or, is the membrane declining? In all of these scenarios, the attempt is typically made to preserve the modality for as long as possible with the usual tricks of increasing volume of exchanges, maximizing cycle times, adding exchanges, challenging the membrane, repeating the PET, etc. Sometimes, it’s a correctable issue. That’s the first hope.

If is indeed a progressively declining membrane, a good team can limp on with it for a long time sometimes, until all of the options are exhausted, which is really great! It can also be exhausting and a deep source of stress for a patient, especially toward the end of the modality. It is best to avoid having a scary conversation with a suddenly confused person in crisis. It is so much easier for all involved to have an honest conversation with an informed person when they can still think straight enough to make plans to transition over to the HD side.

Teach Before the Fear Hits

Humans can’t learn when we’re scared; at MEI we talk about that a lot. A stable patient is not a fearful one. If you’ve helped them achieve an acceptable holding pattern, you’ve probably established a whole lot of mutual respect and rapport. Adults will only learn things they care about, and feel are relevant.

We shouldn’t wait for “failure” to teach more, and we shouldn’t call it “failure” either. No one did anything wrong. There was no test to fail. It’s not school. The peritoneum is not meant to be used for dialysis in the first place. Due to this fact, it will naturally and progressively decline with use. The fact that it works at all is astounding!

The lull in PD is a great time to build-up someone who can self-manage their health independently, with their own process and critical thinking skills. It's a time to draw parallels between PD and HD for no reason other than future reference. It’s a great time to show how some clinical skills are universal, and should be recognized as such. An example of cross-over technique is aseptically assembling a needle and syringe. Show what is similar first. Patients who are familiar with PD have been trained in aseptic technique that is often more stringent than HHD. Ask them to re-teach you what perfect connections look like with new tools.

Explain that the blood flow rate of the peritoneum is about 100 mL/min. So, what’s the difference with HD? Oh, it’s faster? Is that why the treatments are shorter? Start with questions like that to shore up the fundamentals.

Find Positive Things to Focus On

To a person who has been working through the steps of PD modality salvage, HD is way less time consuming on an hour-for-hour basis. Pay enough attention and you will see genuine relief when you bring up that no one is doing HHD around the clock, and the treatment burden will lessen.

Look at your home programs during the lulls. Do you have HHD nurses and PD nurses? Are they swapping information and cross-training each other? Have you considered, even in smaller programs, swapping responsibilities every now and then to give your staff more exposure and experience? The more you’re able to see in macro-view, the more you are able to find solutions that keep patients where they want to be.

To be continued…