Virtual Ward for Home Dialysis - A Novel Model to Address Transitions of Care
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 215
- 试验地点
- 14
- 主要终点
- The number of care gaps identified.
研究概览
简要总结
Home based renal replacement therapy (RRT), including peritoneal dialysis (PD) and home hemodialysis(HHD), offers enhanced quality of life and clinical advantages compared to conventional in-center hemodialysis. Patients with end stage renal disease, that is failure of the kidneys such that dialysis is required, are at high risk for adverse health events especially during a period of transition following a change in care settings. The investigators aim to implement a Home Dialysis Virtual Ward (HDVW) strategy of telephone follow-up, which is targeted to minimize gaps of care during transitions in care.
The investigators aim to have clinicians follow patients by telephone if they meet one of the following four criteria;
- Discharge from hospital.
- Having an interventional procedure.
- Prescription of an antibiotic.
- Completion of Home Dialysis training.
The major goal of this HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability.
详细描述
End stage renal disease (ESRD) is kidney disease that requires dialysis or kidney transplant to replace lost kidney function. The most common renal replacement therapy in North America is conventional, in-center hemodialysis (CHD). Home dialysis - including peritoneal dialysis (PD) and home hemodialysis(HHD)offers benefits to quality of life, patient satisfaction and clinical advantages, including better survival compared to CHD. (references 1-11 in the protocol).
Patients with (ESRD) have a high burden of co-morbidity. Periods of transition of care from acute care to other settings are thought to represent times of increased vulnerability. Since patients who require home dialysis have high co-morbidity and have complex medical care issues, the investigators seek to improve transitions of care for these patients with a novel strategy of follow-up.
When patients have been hospitalized, had treatment for an infection, had a procedure, or have just transitioned to home dialysis therapy,the investigators aim to decrease gaps in care by having a clinician follow-up by telephone with these patients in a scheduled way.
During the telephone call the clinician will assess the patients care and symptoms, and make adjustments to prescriptions of medications and dialysis, or referrals to additional care as required. Evaluation of care will include:
- Indication for admission to the Virtual Ward.
- Dialysis prescription.
- Demographic and comorbidity data.
- Medication reconciliation.
- Symptom Assessment.
- Dietary review.
研究设计
- 研究类型
- Interventional
- 分配方式
- Na
- 干预模型
- Single Group
- 主要目的
- Prevention
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patient in the home dialysis program (PD and HHD)and on of the following:
- •Discharge from hospital following an inpatient admissions
- •Medical procedure (e.g. vascular access procedure).
- •Treatment with antibiotics.
- •Completion of home dialysis training program.
排除标准
- •Decline consent.
- •Unable to participate - (e.g. no phone at home, language barrier)
结局指标
主要结局
The number of care gaps identified.
时间窗: Up to 24 weeks post discharge from the virtual ward.
次要结局
- Dialysis prescription and adherence.(Up to 24 weeks.)
- Burden associated with travel time for patients.(Up to 24 weeks post discharge from the virtual ward.)
- Medication reconciliation.(Up to 24 weeks post discharge from the virtual ward.)
- Symptom management.(Up to 24 weeks post discharge from the virtual ward.)
- Morbidity associated with dialysis therapy.(Up to 24 weeks post discharge from the virtual ward.)
- Adherence with dietary recommendations.(Up to 24 weeks post discharge from the virtual ward.)
- Coordination of care among participating providers.(During virtual ward follow-up.)
- Patient satisfaction.(24 weeks post discharge from the virtual ward.)
研究者
Christopher Chan
Deputy Director-Nephrology/UHN
University Health Network, Toronto