A learning process to deliver virtual staff training involving patients in shared haemodialysis care.

Shared haemodialysis (HD) care (SHC) is a person-centred approach delivering a flexible choice of options for centre-based HD patients to become more involved in their treatment. To support this, a 4-day course was developed to provide healthcare professionals with the confidence and skills to engage, involve, support and train patients in their care and has been accessed by >700 UK staff over 9 years. The disruption caused by the coronavirus disease 2019 pandemic in 2020 prompted a revision of what was deliverable within the restrictions. In response to this, we designed, developed and tested a virtual training program that was shorter and more accessible while remaining effective in meeting its core objectives. This provides a greater geographical reach and enables a collaborative team approach with patients and staff learning from and with each other, thus supporting a partnership approach advocated in shared decision making. In this review we explore the learning that informed the virtual training program 2022 and provide qualitative evaluation to demonstrate evidence of understanding, behavioural change and organisational benefit. Using a validated evaluation, we present key themes that support the initiation, development and sustainability of SHC in the form of a roadmap to guide strategic planning.

Symptom burden according to dialysis day of the week in three times a week haemodialysis patients.

BACKGROUND: Haemodialysis patients experience significant symptom burden and effects on health-related quality of life. Studies have shown increases in fluid overload, hospitalization and mortality immediately after the long interdialytic interval in thrice weekly in-centre haemodialysis patients, however the relationship between the dialytic interval and patient reported outcome measures (PROMs) has not been quantified and the extent to which dialysis day of PROM completion needs to be standardised is unknown. METHODS: Three times a week haemodialysis patients participating in a stepped wedge trial to increase patient participation in haemodialysis tasks completed PROMs (POS-S Renal symptom score and EQ-5D-5L) at recruitment, six, 12 and 18 months. Time from the long interdialytic interval, HD day of the week, and HD days vs non-HD days were included in mixed effects Linear Regression, estimating severity (none to overwhelming treated as 0 to 4) of 17 symptoms and EQ-5D-5L, adjusting for age, sex, time on HD, control versus intervention and Charlson Comorbidity Score. RESULTS: 517 patients completed 1659 YHS questionnaires that could be assigned HD day (510 on Mon/Tue/Sun, 549 on Wed/Thu/Tue, 308 on Fri/Sat/Thu and 269 on non-HD days). With the exception of restless legs and skin changes, there was no statistically significant change in symptom severity or EQ-5D-5L with increasing time from the long interdialytic interval. Patients who responded on non-HD days had higher severity of poor appetite, constipation, difficulty sleeping, poor mobility and depression (approximately 0.2 severity level), and lower EQ-5D-5L (-0.06, CI -0.09 to -0.03) compared to HD days. CONCLUSIONS: Measuring symptom severity and EQ-5D-5L in haemodialysis populations does not need to account for dialysis schedule, but completion either on HD or non-HD days could introduce bias that may impact evaluation of interventions. Researchers should ensure completion of these instruments are standardized on either dialysis or non-dialysis days.

A breakthrough series collaborative to increase patient participation with hemodialysis tasks: A stepped wedge cluster randomised controlled trial.

BACKGROUND: Compared to in-centre, home hemodialysis is associated with superior outcomes. The impact on patient experience and clinical outcomes of consistently providing the choice and training to undertake hemodialysis-related treatment tasks in the in-centre setting is unknown. METHODS: A stepped-wedge cluster randomised trial in 12 UK renal centres recruited prevalent in-centre hemodialysis patients with sites randomised into early and late participation in a 12-month breakthrough series collaborative that included data collection, learning events, Plan-Study-Do-Act cycles, and teleconferences repeated every 6 weeks, underpinned by a faculty, co-production, materials and a nursing course. The primary outcome was the proportion of patients undertaking five or more hemodialysis-related tasks or home hemodialysis. Secondary outcomes included independent hemodialysis, quality of life, symptoms, patient activation and hospitalisation. ISRCTN Registration Number 93999549. RESULTS: 586 hemodialysis patients were recruited. The proportion performing 5 or more tasks or home hemodialysis increased from 45.6% to 52.3% (205 to 244/449, difference 6.2%, 95% CI 1.4 to 11%), however after analysis by step the adjusted odds ratio for the intervention was 1.63 (95% CI 0.94 to 2.81, P = 0.08). 28.3% of patients doing less than 5 tasks at baseline performed 5 or more at the end of the study (69/244, 95% CI 22.2-34.3%, adjusted odds ratio 3.71, 95% CI 1.66-8.31). Independent or home hemodialysis increased from 7.5% to 11.6% (32 to 49/423, difference 4.0%, 95% CI 1.0-7.0), but the remaining secondary endpoints were unaffected. CONCLUSIONS: Our intervention did not increase dialysis related tasks being performed by a prevalent population of centre based patients, but there was an increase in home hemodialysis as well as an increase in tasks among patients who were doing fewer than 5 at baseline. Further studies are required that examine interventions to engage people who dialyse at centres in their own care.

Rationale and design for SHAREHD: a quality improvement collaborative to scale up Shared Haemodialysis Care for patients on centre based haemodialysis.

BACKGROUND: The study objective is to assess the effectiveness and economic impact of a structured programme to support patient involvement in centre-based haemodialysis and to understand what works for whom in what circumstances and why. It implements a program of Shared Haemodialysis Care (SHC) that aims to improve experience and outcomes for those who are treated with centre-based haemodialysis, and give more patients the confidence to dialyse independently both at centres and at home. METHODS/DESIGN: The 24 month mixed methods cohort evaluation of 600 prevalent centre based HD patients is nested within a 30 month quality improvement program that aims to scale up SHC at 12 dialysis centres across England. SHC describes an intervention where patients who receive centre-based haemodialysis are given the opportunity to learn, engage with and undertake tasks associated with their treatment. Following a 6-month set up period, a phased implementation programme is initiated across 12 dialysis units using a randomised stepped wedge design with 6 centres participating in each of 2 steps, each lasting 6 months. The intervention utilises quality improvement methodologies involving rapid tests of change to determine the most appropriate mechanisms for implementation in the context of a learning collaborative. Running parallel with the stepped wedge intervention is a mixed methods cohort evaluation that employs patient questionnaires and interviews, and will link with routinely collected data at the end of the study period. The primary outcome measure is the number of patients performing at least 5 dialysis-related tasks collected using 3 monthly questionnaires. Secondary outcomes measures include: the number of people choosing to perform home haemodialysis or dialyse independently in-centre by the end of the study period; end-user recommendation; home dialysis establishment delay; staff impact and confidence; hospitalisation; infection and health economics. DISCUSSION: The results from this study will provide evidence of impact of SHC, barriers to patient and centre level adoption and inform development of future interventions to support its implementation. TRIAL REGISTRATION: ISRCTN Number: 93999549 , (retrospectively registered 1st May 2017); NIHR Research Portfolio: 31566.

Training nurses to support greater patient engagement in haemodialysis.

BACKGROUND: Evidence supports the view that people with long term conditions who are encouraged to take a greater interest in their treatment can experience a range of health benefits. Traditionally centre-based haemodialysis patients have been passive recipients whilst nurses have been deliverers of care. The Shared Haemodialysis Care (SHC) programme changes this relationship. OBJECTIVE: Our aim was to initiate a programme of education in SHC across Yorkshire and Humber in North England, with its objective to support centre-based patients to take on aspects of their own treatment. DESIGN & PARTICIPANTS: A three tiered training model was designed to educate all grades of nursing staff. Central to this approach was the development of a four day competency based course aimed at training 25% of junior sisters/charge nurses, staff nurses and Level 3 health care assistants (unqualified nurses). MEASUREMENTS/APPROACH: We measured the number of staff trained and assessed staff knowledge using a pre and post course questionnaire. Individual course day evaluations and 'Light bulb moment 'sessions captured qualitative data and a census form relating to interest in and uptake of SHC captured patient engagement data. RESULTS: The pre and post delegate questionnaires from every cohort have demonstrated significant positive shifts in all the objectives of the training programme. The target of 25% of staff trained has been reached in all but one group of units. A third of all patients across Yorkshire and Humber are significantly engaged in their haemodialysis care. CONCLUSION: A nurse-led education programme can provide nurse participants with the tools to encourage and support patients to become more engaged in their haemodialysis treatment.