How Much PD Training Is Enough?
If you’re a PD training RN, have you ever asked yourself whether you have provided enough training to assure that your patients understand why you want them to follow the steps you taught them in preparing for and performing their exchanges? Do you and your team members ever ask yourselves whether you gave your patients enough information to manage their diet and fluids effectively, to avoid infection, and to live a full life with PD instead of focusing only on the mechanics of the treatments and defining themselves by their dialysis?
Recently I communicated with a new patient who had lots of questions. This patient wanted to be an active participant in care and care planning, wanted to stay as healthy as possible, and even hoped to mentor other patients. The nurse had warned the patient about the risk of infection and the patient was understandably nervous. The nurse had shut down the patient’s questions, saying they were “not things to worry about.” When the patient told me how short training was per day (just an hour!) and I saw the lack of understanding reflected in this person’s level of questions, it alerted me that staff providing home training may not be aware of CMS’ expectations.
The Medicare Conditions for Coverage at § 494.100(a)(3) describes what training should include:
(i) The nature and management of ESRD.
(ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician’s prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient’s plan of care.
(iii) How to detect, report, and manage potential dialysis complications, including water treatment problems.
(iv) Availability of support resources and how to access and use resources.
(v) How to self-monitor health status and record and report health status information.
(vi) How to handle medical and non-medical emergencies.
(vii) Infection control precautions.
(viii) Proper waste storage and disposal procedures.
The Medicare Benefit Policy Manual, Chapter 11 §30.2 describes Medicare coverage:
- The manual says an average PD training day lasts 8 hours, 5-6 days a week. It says it usually takes a patient 6-8 CAPD and/or 5 CCPD exchanges per day to learn the PD technique, although it doesn’t require a specific number of PD exchanges per day. A facility can bill for up to 15 PD training days.
- Incidentally, the manual says the average HD training time is 5 hours per training day 3 times a week. A dialysis facility can bill for up to 25 HD training days.
- A facility can bill for more HD or PD training days if justified for medical necessity.
Why would a facility cut training time short? If patients do not spend enough time in home training to learn basic information about their modality and how to perform it safety and do spend enough time observing the RN trainer to learn how to perform their dialysis themselves and troubleshoot problems without becoming rattled, the likelihood of success is limited and the time and money a facility spent training that patient will be wasted—not to mention the emotional toll it can take on a patient to fail a desired modality.
The next time you schedule a patient for training, please take enough time to get to know the patient well enough to take his or her learning needs and challenges into consideration. Assure that your patients know what they need to know and can competently perform dialysis independently whenever possible or with as little help from a care partner as possible. Set your patients up for success, not failure. They put their lives in your hands. Please don’t let them down.
I’m curious to know whether this patient’s experience is common or an outlier, so please comment with answers to these three questions:
- How long is your PD training and how do you know it’s enough?
- How do you determine that your patients are competent to do PD?
- How do you know your patients can handle common or not-so-common problems?
 Part 494 Conditions for Coverage for End-Stage Renal Disease Services Interpretive Guidance, Interim Final Version 1.1, October 3, 2008, http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/esrdpgmguidance.pdf (Accessed July 4, 2014)
 Medicare Benefit Policy Manual, Chapter 11 – End Stage Renal Disease (ESRD), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf (Accessed July 4, 2014)