Our Experience of Home Visits in City and Rural Areas

Our PD Care Center

Global Hospital, a tertiary-care center based in the city of Hyderabad, India, started its PD center, which caters to South India, especially the state of Andhra Pradesh, in July 2003. The PD center operates as part of well-established nephrology department. The PD center has been striving to improve the wellbeing and quality of life of patients on chronic PD treatment. A team of trained CCs, working in shifts with a team of nephrologists available on-call around the clock, run the PD center.

Extensive in-House PD Training Program

After PD catheter insertion by a surgeon, the ESRD patient undergoes a PD break-in period of two weeks, unless the need for PD is urgent. A one-week training period follows. The patient and at least two family members are trained by the CC and nephrologists on the basics of PD:

Patients receive both counseling in the theoretical aspects and practical, “hands-on” experience. Instruction is provided using PowerPoint slide presentations, videos of the procedure, posters, and practical sessions with the CC in which the patient wears a training apron. Patients and family are allowed to watch through a glass window as the exchange procedure is done on other patients. Patient and attendants are trained to complete the patient logbook, in which are recorded daily blood pressure (by sphygmomanometer and stethoscope), radial pulse (by palpation), body temperature (by thermometer), and volume of infused and drained fluid during each exchange. Patient and family members are also exposed to the software used in the PD center so that they better understand the need to maintain the logbook details. Furthermore, they are trained in the use of mobile phones, digital phones, and the Internet (e-mail) so that they can communicate with the PD center when the need arises. Before the end of the training period, the CC visits the patient's residence and makes all necessary arrangements.

Home Visits, a Vital Part of a PD Care Program

The key person visiting the patient's home is the CC, a paramedical staff member trained in the field of PD. Regular home visits by the CC are an important part of follow-up care, because the family and the patient need to realize that continuing support is available (6).

The objective during a home visit is to ensure that the exchange technique is being adhered to as recommended, and that compliance is maintained. In addition, the CC strives to promote and support the patient's physical and social rehabilitation, to prevent morbidity, and to improve quality of life.

Schedule of Home Visits for a Pd Patient

The first visit occurs before the first exchange at home. This important visit assesses the realities “on the ground,” allowing for corrections immediately if needed. The patient is advised to perform the first exchange at home in the presence of the CC, which helps in early recognition and prevention of problems (7).

The second visit occurs one week after the first, to ensure that previous advice has been implemented. The patient's clinical and mental health is checked, and appropriate remedial actions are taken.

The third visit is scheduled three weeks after the first visit. Subsequent follow-up visits are scheduled once every three to four weeks.

A weekly nursing summary, including daily vitals, PD flow sheet, medications, and progress notes obtained during the home visit, are transferred to the main center's computer records. The training imparted to additional family members is also used temporarily if patients show acute deterioration or if ill health prevents partners from doing PD, as occurs elsewhere (6).

Accessories for Home Visit by a CC

Visits are scheduled on the monthly duty roster for the CCs. Each CC carries a standard kit for home visit that include a thermometer, sphygmomanometer, stethoscope, dressing kit, and magnification lens with light (for a better view of the exit site). They also carry a mobile phone and digital camera for capturing images of the patient, the exit site, and the effluent bag. If the CC is concerned about changes in the exit site and effluent bag and wants to consult with the nephrologist, photographs are taken and sent by e-mail to the PD center. The CC also ensures that the patient and family members are capable of sending pictures in case of emergency.

Assessment of Vital Signs

Assessment of vital signs includes checking temperature (to exclude infection), edema of the feet or back (to exclude fluid overload), blood pressure (to help maintain good control), respiratory rate, conjunctival pallor (to exclude anemia), and color of sclera (to exclude icterus).

Special Instructions or Recommendations Given during Home Visits

An initial observation made at the home visit pertains to hygiene in the PD exchange room. The need to maintain personal hygiene is reinforced. Dimensions of the doors and windows and their locations are noted. It is ascertained that, during exchanges, no air drift from fans, air coolers, or open windows occurs. Adequate lighting of the room is important for proper performance of the exchange procedure. Pets are strictly forbidden to be in the PD room during the exchange procedure. The height of the cot should be equal to the length of the patient's lower leg (knee to foot) so that the patient's foot is firmly on the ground and the leg remains in a vertical position during the exchange procedure.

Questionnaires Used and their Advantages

The following questionnaires are used to assess the patient's clinical status and quality of life (8):

Measures to Avoid Repeated Episodes of Peritonitis

The CC checks to see who is actually performing the exchange, strongly discouraging hired help, because, in our experience, patients do better if PD exchanges are performed by themselves or by a family member. Special emphasis is placed on correcting previous mistakes. A complete reassessment of exchange performance and retraining are carried out if necessary. Patients undergoing PD are advised to avoid contact with family members who have infectious illnesses.

Assessment of PD Fluid and Accessories Inventory

The CC trains the patient and family members to check the transparency of the effluent by placing the effluent bag over a piece of paper on which are printed alphabets in a standard font. Normally, on inspection, the letters of the particular font are clearly visible. During an episode of peritonitis, the letters cannot be discerned. We found this method useful for detecting peritonitis in home patients: they capture an image of the suspect solution bag using a digital camera, and they transmit the image to the PD center as an e-mail attachment. The effluent bag is closely inspected for cloudiness, fibrin strands, signs of hemorrhage, and so on. The new PD bag is inspected for damage in the packing, moisture, and other defects. A surprise check on inventory is one of the most effective methods of assessing compliance.

Exit-Site Care

Proper surgical technique for catheter insertion is crucial to avoid persistent exit-site problems. The ideal exit site points downward, so that gravity helps to drain the natural secretions. The primary goal of chronic exit-site care is to prevent exit-site infection.

Broadly, exit-site care includes assessment of the exit, cleansing the exit, and anchoring and immobilizing the catheter to avoid tugging, thus protecting the exit site and tunnel from trauma (9,10). The exit-site care protocol also includes education in good personal hygiene.

The typical skin color of Indian patients makes diagnosing infections difficult. Indian patients also have a tendency to keloid formation. Exit-site care also requires extra caution because of excessive sweating in India's tropical climate.

The patient learns how to assess the exit site, how to recognize signs and symptoms of exit-site infection, and when to notify the PD unit of exit-site problems. Exit-site complications to be looked for include swelling, crust, redness, pain, and drainage characteristics (9). After inspection of the exit site, the patient cleans the site with povidone iodine solution, dries it with sterile gauze, applies mupirocin ointment with sterile pad, and immobilizes and anchors the catheter. Repeated demonstrations are given of daily cleaning and good hand-washing technique, daily change of dressing immediately after a bath, inspection of the site, and photographing and e-mailing an image of the exit site if the PD center needs to review an abnormality for further corrective action.

Warning Symptoms Needing Attention by a Physician

Any warning symptoms noticed by the CC during the home visit are communicated to the nephrologist for corrective action. Examples include edema, dyspnea, fever, loss of appetite, itching, hiccups, vomiting, loss or gain of body weight in a short period, hypotension and hypertension hernia, problems with the Tenckhoff catheter (including cuff extrusion, extension line, and Luer-lock status), abnormal appearance of the solution bag (turbidity, fibrin strands, signs of hemorrhage, and so on), poor inflow or outflow, abnormal exit site, and tenderness or redness over the tunnel. If warning symptoms appear, the patient might need to make a visit to the PD center.

The patient's logbook (Table 1) provides the CC with an easy method of recognizing early changes in peritoneal membrane characteristics (11). If simple corrective measures such as relief of constipation by laxative or enema administration are insufficient, the patient will need to visit the PD center for further investigation of ultrafiltration failure.

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Table 1

Simple Method to Classify the Peritoneal Equilibration Test (PET) Status of Patients at Home ^a

Transport classification	Drain volume b	Net UF (per exchange)
High	1580–2084 mL	+420 mL to –84 mL
High average	2085–2367 mL	–85 mL to –367 mL
Low average	2368–2650 mL	–368 mL to –650 mL
Low	2651–3326 mL	–651 mL to –1326 mL

UF = ultrafiltration.

a

An easy substitute for the standard PET for practical purposes during home visits.

b

Volume of an effluent bag after a 4-hour dwell using 2 L of 2.3% dextrose solution.

Communications from Patients

Our patients can communicate with us by landline telephone, mobile telephone using the short message service and images (multimedia message services), Internet e-mail (images of exit site and solution bags sent as an attachment), and facsimile.

Table 2 shows that the communication facilities for rural patients are not very different from those in the city. India has made rapid strides in its communications connectivity; mobile telephone technology and Internet facilities have now spread to even distant corners of the country. It is not uncommon for our center to receive images of exit sites and solution bags for treatment advice from distances as far as 1500 km away.

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Table 2

Comparison of Communication Facilities Available to Rural and Urban Patients Affiliated with Our Center

Mode of communication	Rural (n=46)	Urban (n=83)
Mobile phone	46 (100%)	83 (100%)
Land line telephone	46 (100%)	83 (100%)
Internet access	14 (30.43%)	35 (42.16%)

However, patients in rural areas particularly suffer from lack of proper microbiology services, well-stocked pharmacies, and medical care for comorbid conditions. We always train our patients in the technique of intraperitoneal instillation of antibiotics, and we advise them to maintain a stock of essential drugs such as heparin, cefazolin, and amikacin. The CC visits the available laboratories and familiarizes the staff there with PD fluid cell counts (using a Neubauer chamber under a light microscope), Gram stain procedures, and culture methods. We are exploring the possibility of having patients keep a stock of Bactec blood culture vials (which have a long shelf life) in their homes. The patients could inject the vials with PD effluent during episodes of peritonitis and transport them to the PD center for further processing.

Peritonitis Incidence

Home visits have helped us to anticipate and prevent peritonitis episodes in our patients. For example, following the tsunami of 2004, one of our PD patients noticed minute damage to the outer packing of a solution bag, which on further evaluation was determined to be rodent bite marks. We were able to caution our other patients and thus probably prevented cases of peritonitis in them. Persistent efforts by the PD staff during initial training, home visits, and in-center visits has allowed us to achieve peritonitis rates of 1 episode per 63.2 patient–months (Nayak KS. Overcoming CAPD cost barrier in Asian developing countries. Presented at the First Asian Chapter Meeting of the International Society for Peritoneal Dialysis, 13–15 December 2002, Hong Kong; 2,12).

Conclusion

In India, PD has come to be an acceptable home therapy for ESRD patients. Home visits have helped our patients to significantly improve their quality of life and technique survival and to achieve remarkably low peritonitis rates. Mobile telephony and Internet services have helped with patient communication. The CC is the key link between the patient's home and the PD center.