392 Setting Up a Paediatric Home HD Program Patient Selection Criteria The reasons for selecting a HHD treatment can be multiple, including medical, social, education or families exercising their righ[.]
D K Hothi and C P Schmitt 392 etting Up a Paediatric Home HD S Program Patient Selection Criteria The reasons for selecting a HHD treatment can be multiple, including medical, social, education or families exercising their rights to choose a unit where HHD is an option At the earlier stages of a HHD program, it is advisable to set conservative selection criteria until the team’s experiences and confidence grows A suggested patient selection criteria are listed in Table 23.2, but the specifics should be determined in the planning stage of a home HD program by a multidisciplinary team With growing confidence and experiences, the team at Great Ormond Street Hospital has gradually moved away from a lengthy list of inclusion criteria to a few exclusion criteria that mainly comprise (i) a lack of a home or home base to accommodate the dialysis treatment and (ii) lack of commitment to deliver the agreed dialysis schedule reliably and consistently Failed home PD does not necessarily preclude the possibility of HHD Table 23.2 Key selection criteria for paediatric home HD Patient and family commitment to delivering the dialysis schedule consistently at home Patient cut-off weight determined by home dialysis system Well-functioning vascular access Absence of or controlled psychosocial concerns Sufficient room within the family home to accommodate the dialysis equipment and 1-month supply of dialysis consumables If reverse osmosis dialysis system required, permission and ability to modify the home water source Adequate family household hygiene that does not increase the patient’s risk of infection Family home is not located in an area with frequent and prolonged electricity supply disruptions or an emergency source of power is not available at all times Patient is medically stable despite clinical manifestations of multi-disease or multi-organ involvement Infrastructure Developing a HHD program requires careful planning, resources, a commitment to safety and risk management and dedicated staff The service delivery model can vary considerably and is largely influenced by four factors: • Resources and existing expertise –– Is the ambition to be fully independent or will a partnership with a neighbouring paediatric or adult service become necessary? • Spectrum of dialysis prescriptions to be offered –– Will routine prescriptions include daytime and nocturnal treatments? –– How many sessions will be routinely prescribed per week? • Preferred dialysis system –– What home modifications will be required? –– How familiar is the in-centre dialysis team with the home dialysis system? –– Which dialysis consumables will be delivered to the home and how often? –– How will the dialysis machines and dialysate system be serviced and maintained? • Training patients and their carers –– Will training take place on the dialysis unit or within a dedicated facility? –– Is a training program available or will it need to be designed? Finances and Business Case A dialysis team wishing to develop a program will need to prepare a robust business case for the hospital board or executive team A key requirement of a business case is a risk-benefit analysis Geary et al have explored the cost of delivering HHD in children and reported a 27% saving after comparing the cost of delivering a HD treatment at home compared to a dialysis unit [12] Cost saving was largely from removing the cost of the hospital bed and dialysis staff The latter is particularly relevant in paediatrics owing to the recommended 1:1 or 1:2 nurse-to-patient ratio when delivering HD treatments in hospital To 23 Home Haemodialysis in Children establish the potential cost savings for a HHD program, each unit needs to predict the projected size of the program and multiply that by an accurate cost-saving calculation when patients transition home This financial ‘gain’ must then be offset against the cost pressures of delivering a home HD program These include: • Staffing the multidisciplinary team required to deliver the program • Lease, rental or purchase of dialysis machines alongside service and maintenance costs • Home conversions or modifications to accommodate the dialysis systems • Dialysis consumables and drugs cost which will be proportionally higher as the prescribed weekly treatment frequency often increases • Establishing and maintaining a training facility • The resultant and unintended bed vacancies as in-centre patients transition home In adult programs the potential savings from a home dialysis program can be significant as the HD patient pool may be in the hundreds and thousands In comparison the size of paediatric HD programs typically range from to 25 patients Thus, the potential cost benefit of a paediatric HHD program will depend on the number of children that transition home and in real terms will be small In comparison, the financial risk and investment to establish a HHD program is significant and probably higher than adult programs owing to the larger multidisciplinary team requirement Thus, in the first few years the financial risk to benefit analysis of a paediatric HHD program will feature risk dominance as the program attempts to establish itself and gain momentum Further difficulties of convincing policy makers and insurance companies may arise from the fact that for the majority of children HD is a short-term bridging therapy to transplantation It is estimated that HHD with a home conversion only becomes more cost-effective than in-centre HD when patients remain on treatment for more than 14 months [13] In Europe median waiting time for deceased donor kidney transplantation in Europe is still about 15 months [14] 393 If one was to broaden the financial case of paediatric HHD to the health economics related to the life of a patient, the narrative should be more favourable Children on HHD should typically have improved health outcomes and thus a lower medical burden Access to school and education has the potential to improve future career prospects and the subsequent financial contribution to society Truth to be told, similar to many paediatric case studies, building a population- based financial case for HHD is challenging and less convincing than the emotive case around the potential gain for an individual child Safety HHD in children remains a relatively new therapy that places a high-risk clinical procedure directly under the care of patients and their families within their homes Therefore, safety should be the central focus point of any program design with mitigations in place to minimise the potential to cause harm The greatest sources of risk fall under four broad categories Vascular Access Children can be dialysed at home through a central venous line or preferably an arteriovenous fistula (AVF) Whilst training for home dialysis, families need to develop an understanding of the common complications related to the vascular access and the appropriate response Central line malfunction and infection risk are attenuated with weekly alteplase locks [15] At minimum, weekly dressing changes are recommended with monthly surveillance for exit site infections Patients with fistulae are advised to check them at minimum daily For buttonhole needling, we encourage needling by the same person, to promote good health of the fistula At Great Ormond Street Hospital, where possible we actively promote older children or young adults to become the primary person who needles their fistulae Any major change in blood flow rates and system pressures should be reported to the centre We suggest functional ultrasound surveillance of the 394 fistulae every 3 months for early and timely detection of issues Anticoagulation Clotting in an HD circuit can affect the quality and quantity of dialysis provided Children at home can use unfractionated heparin (UFH), often as an initial bolus dose and then a continuous infusion [16] in line with in-centre prescribing practices Alternatively, a low-molecular-weight heparin (LMWH) can be prescribed Lutkin et al have reported their experience using dalteparin, a LMWH, for children on home HD. Each child was started on a single intravenous dose of 50 IU/kg through the arterial arm of the dialysis circuit within 15 minutes of the treatment starting The dose was increased if clots were repeatedly visible in the circuit and dialyser and reduced if there was any evidence of bleeding events or prolonged bleeding from an AVF in children dialysed in this way The dalteparin dose was routinely increased if a child was moving from daytime to nocturnal home HD. The median dalteparin dose at 12-month follow-up was 40 IU/kg (range 8–142 IU/kg) Factors associated with higher dalteparin dosing requirements included a younger age of the child (p