1. Home haemodialysis at QEHB.

2. Overview of the programme Introduction of button hole needling The future

3. There has been a home haemodialysis programme at UHB since mid 1980’s. To date we have 46 patients dialysing at home. Mixture of Gambro and fresenius machines.

4. Current UHB home haemodialysis programme. 46 patients at home to date (15 so far in this financial year) 46 patients at home to date (15 so far in this financial year)  86% AVF’s, 14% lines  20 transplant listed and 4 suspended  4 patients on HDF Youngest 23yrs Youngest 23yrs Eldest 83yrs Eldest 83yrs Average training time 6 weeks (minimum 4 sessions) Average training time 6 weeks (minimum 4 sessions)

5. DATA 68% male. 32% female. 68% male. 32% female. Dialysis carers: 4 mothers, 3 fathers, 2 son, 1 carer and 35 partners Dialysis carers: 4 mothers, 3 fathers, 2 son, 1 carer and 35 partners

6. Current home haemodialysis dialysis schedules

7. Blood results. Average Hb 11.1 Average Hb 11.1 Average Calcium 2.19 Average Calcium 2.19 Average Phosphate 1.59 Average Phosphate 1.59

8. Introduction of Buttonhole needling

9. Who can use it? Fistulas at present Fistulas at present Limited needling opportunity i.e brachial fistula Limited needling opportunity i.e brachial fistula Difficult fistula Difficult fistula Needle phobics Needle phobics Home haemo pts Home haemo pts

10. Benefits Ease of cannulation, plus no need to assess for needle placement each time Ease of cannulation, plus no need to assess for needle placement each time Reduced pain Reduced pain Reduced bleeding Reduced bleeding Less chance of aneurism formation Less chance of aneurism formation

11. Disadvantages Higher infection risk Higher infection risk Skin irritation from more frequent cleaning Skin irritation from more frequent cleaning Need for staff commitment in tract formation Need for staff commitment in tract formation De skills needlers De skills needlers Higher cost, currently blunt needles 3 times more expensive Higher cost, currently blunt needles 3 times more expensive

12. Implementation within HHDX One off teaching session One off teaching session Ongoing support from HH team Ongoing support from HH team Written step by step instructions Written step by step instructions Ordering of consumables Ordering of consumables

13. Problem solving Develop pathway in case of skin irritation Develop pathway in case of skin irritation Develop pathway in case of suspected infection Develop pathway in case of suspected infection Ensure support in case of problems Ensure support in case of problems Ensure supply of sharp needles in case of problems Ensure supply of sharp needles in case of problems

14. Current usage within home haemo team Over last 4 months Over last 4 months 40% of AVF patients converted to technique 40% of AVF patients converted to technique 2 patients withdrew 2 patients withdrew 92% use blunt needles 92% use blunt needles 0 infections 0 infections

15. Audit Invited 12 patients to participate in audit Invited 12 patients to participate in audit 11 responded 11 responded 64% reported less pain on cannulation 64% reported less pain on cannulation 100% reported easier cannulation 100% reported easier cannulation 73% reported less bleeding after removal of needles. 73% reported less bleeding after removal of needles. 100% preferred the technique compared to what they were doing previously 100% preferred the technique compared to what they were doing previously 1 person reported that they thought their fistula had changed in appearance. 1 person reported that they thought their fistula had changed in appearance.

16. Future All home patients to be educated on BH All home patients to be educated on BH Use of semi blunt needles Use of semi blunt needles Ongoing auditing Ongoing auditing Act as a resource to main unit and satellites Act as a resource to main unit and satellites

17. The Future and it’s challenges for HHDX at UHB

18. Data 24 pts on waiting list 24 pts on waiting list 21% waiting to be seen 21% waiting to be seen 34% have a training date 34% have a training date 13% housing issues 13% housing issues 26% waiting for a date 26% waiting for a date 4% pre dialysis 4% pre dialysis

19. Strategy for increasing numbers Engage with satellite and in centre dialysis units to develop self care Engage with satellite and in centre dialysis units to develop self care Consider training from pre dx/failing tx/capd directly Consider training from pre dx/failing tx/capd directly Solo dialysis Solo dialysis Employed dialysis carers Employed dialysis carers

20. Overcoming barriers Needling, offer button hole technique Needling, offer button hole technique Carer concerns, offer information sessions, peer support Carer concerns, offer information sessions, peer support Work commitments, offer flexible training, self care programme Work commitments, offer flexible training, self care programme

21. Maintenance of the HHDX programme Carers: ongoing support, training Carers: ongoing support, training Efficient service, use of centrifuges etc, paperless Efficient service, use of centrifuges etc, paperless Flexiblity of visits, clinics Flexiblity of visits, clinics Quality service, continuity of care Quality service, continuity of care Psychological support Psychological support Dietetics Dietetics

22. Research and Development Quality of life Quality of life Button hole technique Button hole technique Raise the profile of UHB Raise the profile of UHB