The goal of every home hemodialysis (HHD) program should be to provide safe, quality care; this cannot be accomplished without routine monitoring. Monitoring involves the systematic observation of particular parameters in order to discover disease, adverse outcomes, or risk factors or to assess interventions aimed at treatment, prevention, or reduction of risk. In this chapter, we will begin by discussing three basic questions involved in monitoring. We will then focus on population monitoring in an HHD unit as exemplified through the quality assurance and improvement (QAI) process, and lastly, we will discuss examples of individual patient monitoring utilizing recommendations from national guidelines.
When thinking about monitoring, three basic questions arise:
What is being monitored?
Who is being monitored?
Why is monitoring being done?
Monitoring can be used to screen for disease, adverse outcomes, or risk factors. For example, dialysis units periodically screen patients for hepatitis, anemia, hyperphosphatemia, and malnutrition irrespective of whether patients currently have these conditions. However, many patients do develop these conditions and require the initiation of therapy. In these cases, monitoring is used to access the efficacy of ongoing treatment. Typically, goals of therapy involve maintaining particular parameters inside prespecified ranges.
Monitoring, however, goes beyond laboratory testing. Non-laboratory monitoring is common for disease screening, assessment of therapy, prevention efforts, and risk reduction efforts. Common examples of non-laboratory screening include blood pressure monitoring for non-hypertensive patients, depression screening, and access monitoring via physical exam and access flow measurement. Examples of monitoring of therapeutic interventions include periodic depression surveys to assess depression treatment and blood pressure measuring for hypertensive patients. It is also vital to monitor the success of the dialysis therapy itself. To do so, we use both laboratory parameters (i.e., urea reduction ratio [URR] and Kt/V) and non-laboratory parameters (i.e., intradialytic weight gains, flowsheet monitoring, etc.).
Generally, there are two perspectives one might take with regards to monitoring: a patient perspective and a population perspective.
The patient perspective involves monitoring individual patients in order to discover disease, adverse outcomes, or risk factors and in order to assess interventions aimed at treatment, prevention, or reduction of risk. This perspective is fundamental. The interdisciplinary team (IDT) consisting of physicians, nurses, dialysis technicians, dieticians, and social workers evaluate and balance the multiple and sometimes competing therapeutic goals that exist in a particular patient at a particular time with all the unique exigencies and values that individual patients bring to a clinic encounter. Careful balancing must be done to achieve the optimal outcome. For example, in a patient who is exhibiting signs of malnourishment, the IDT may liberalize dietary restrictions even if this leads to a mildly elevated ...