The PD to Home HD Flip—Part III: When the Lull Ends

This blog post was made by Jennifer Ravert, RN on October 5, 2023.

A Quick Recap

The first time I wrote about this topic, “The Flip”—Helping Patients Switch From PD To HHD, I touched on the need for PD and HHD programs to work together constantly to identify and follow individuals who have a reasonable likelihood of eventually requiring a modality shift. When you know where everyone you're watching is in space, you have a decent chance of being able to schedule a change when it's necessary, rather than have your patient crash into one. This should be a big objective of any home program.

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Also in that first blog, I talked about the importance of never “modality bashing” to patients at any point in time, as those first impressions you leave can affect people's abilities to make effective decisions about their own care in the future. It can also make your job much more difficult if you find yourself “trying to sell” something you previously painted negatively. There are risks and benefits to everything. That's the truth, check your modality bias at the door and be objective.

The second time, PART 2 - “The Flip”—Helping Patients Switch From PD To HHD: Making The Most Of The Lull, I addressed the necessity of utilizing lulls in medical progression to optimize health and do effective education regarding “what comes next.” People who are afraid can't learn—so…communicate when things are going well. That is your best opportunity to lay down a lot of information and ultimately to address problems early—while they are still manageable and non-emergent.

The conversation about access planning should be ongoing long before PD is exhausted, especially in the people expected to need a transition or live a long life. There is no right option for everyone, but informed decision making is the goal. Part of your patients' ongoing plan has to be, “what comes next”—especially when the chosen therapy (PD) is inherently temporary.

Signs that Change is Coming

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I'd like to next talk about what to do when you have clear signs that a change will need to be made and how to accomplish that in a manner that doesn't cause unnecessary disruption. When you take the time to prepare and plan ahead for transitions, there is far less to de-mystify.

Assuming that “staying home and independent” is the goal, and an individual who needs to do a modality conversion is able and supported enough to make the switch—find out what their level of understanding is early. If you've been educating throughout, your patient should be coming into this change with some information already.

What is the extent of that knowledge? Where does it end? What do they remember of those little nuggets of information you've been subtly dropping? Ask them to teach it back to you, and really listen to what they say. It's awesome when this works and the patient knows enough to roll forward without needing much fill-in-the-blanks.

Practice Makes Perfect

If your patient is declining on PD but has not needed to be transitioned over yet, see if additional equipment pre-education can be accomplished by inviting the person to drop in and learn to string an HD machine. Show how it's done a few times. Hand over the directions, and let the alarms occur. You do not need a treatment room for this if it is a training system only. Mistakes are fine in this stage—and being able to get new equipment through prime before needing to actually use it is a HUGE step in the right direction!

If a person can understand the treatment conceptually, going through the steps is easier. Once the ability to do this has been demonstrated on one modality, it is almost seamlessly translatable to the other. It's a gift when there is an already proven record of being able to follow the directions and self-manage!

Prioritize Current Patients Over New Starts

Gradually doing education gives you an opportunity to do an “experience the difference” while formally converting over and teaching by demonstration. Your patients who are already in the home program census and having difficulties—but want to remain in the home program—should take priority over new starts.

You cannot build a census while dropping one patient at the same time you add another. Keeping patients at home often requires creative thinking and planning. See if you can incrementally decrease one modality as you incrementally increase onto the other. That will allow for a seamless swap of equipment and a completed seamless flip.

Learn WITH Your Patients

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Home programs are busy. I know! There are seldom any breaks to the grind to take the time to “teach old nurses new tricks,” but in my second post I suggested that home nurses cross-train (and trade skills in general) as much as possible. I f you are looking for an opportunity to get a PD nurse up to speed on HHD, have them do “the flip” with the patient, which is even better if it was their patient initially. This is almost like having a buddy system!

It's really okay to show a patient what it looks like when staff are building and practicing skills too. Healthy, even. If the person and family are willing to share space with staff who also need those skills, it strengthens the relationship. You end up with more respect when you admit you're learning something new than when you pretend to have all of the answers.

It also shows by example that staff can learn both modalities, and have the knowledge of multiple systems—and therefore, so can patients.

Get Input from Patients Who Need to Switch

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Ask your patients how they want to work the modality shift time, and see if they can solve the logistics for you. They know what's possible for them, and (admit it or not) they know your hours! Set a date to stop stressing out by. Plan to convert the modality around that date. Remind them what “clearing the decks” means when adjusting to a new treatment schedule.

If there is an abrupt end to PD requiring immediate HD back-up, see if it's possible to schedule the patient to treat in the home therapies department, not on the clinic floor. Consider it an opportunity to catch up the education and not have the patient feel abandoned or dropped by the department. Respite care is technically part of home therapies, this counts for the PD patients too.

Use the Commonalities Between Modalities

When you begin training, start with what is similar. Hold up a yellow effluent line and ask what that gets connected to—it's a great icebreaker. Show how ALL no-touch aseptic connections are the same. PD patients are already familiar with the function of different parts of equipment—so tell me, how is a slow drain similar to a low arterial pressure? How can we self-assess for volume overload versus dehydration?

Find the positives

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When a person has just come off a failing PD membrane, HHD takes up so much less time! Explain how neat it is to want to remove 0.8L and how handy HD makes that to program in. Compare the BFR of a peritoneum to the BFR of an HD treatment and ask the patients to figure out where they feel best.

Be encouraging.

Be as enthusiastic as you can be without scaring your patients. Needing to convert modalities after PD is exhausted is a challenging experience for patients and clinics. PD patients who will eventually have to go to HD can and should be educated about HD before there is an emergency. If the patient prioritizes being at home, every attempt should be made to make the modality change within the home program and without a crash-in.