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A Mobile Hemodialysis Network in Northern Michigan
Vol. 113, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
A MOBILE HEMODIAL YSIS NETWORK IN NORTHERN MICHIGAN JOHN W. HALL
AND
H. ALLAN RANKIN
From the Burns Clinic Medical Center, Petoskey, Michigan
Recent advances in hemodialysis technology have helped solve many social and psychological factors involved in hemodialysis. The time required for each dialysis is becoming shorter and maintenance hemodialysis is a tolerable existence. For many patients the time in dialysis represents only a short interval before transplantation. Home training has also provided many patients the advantage of low cost dialysis with minimal disruption of normal living habits. There is a group of patients who do not fit into the aforementioned categories. The potential cadaveric transplant recipient faces a waiting period of weeks, months or years. Some programs start immediate home training of these patients but this seems like a wasted effort and expense if transplantation can be achieved within a reasonable interval. Every hemodialysis center also has a group of patients for whom home training is inappropriate. Elderly patients without a family have provided many problems. Other sociologic, psychologic and intellectual problems have made some younger patients unsuitable for home training at our Center. This applies even to the group of patients considered most ideal for renal transplantation. Hence, there are some patients who require low cost maintenance hemodialysis with some level of technical assistance. Such a group has developed in the sparsely populated areas of Michigan's northern Lower Peninsula and eastern Upper Peninsula (fig. 1). This area, with a population of 400,000, stretches over 250 miles. The dialysis load in this area is quite variable. Furthermore, as patients undergo transplantation or die the patient load becomes quite unpredictable. One potential solution to the problem of supplying hemodialysis to this population base would have been the development of small local dialysis units. However, these units would have been inefficient and trained personnel would have been idle as the load varied. Also, such a plan would have required extensive local physician retraining. The economy of bulk purchasing would have been lost and valuable hospital space would have been inefficiently used. Initially, a centralized unit, the ideal solution in areas of high population density, was developed. It worked well but the patients had to drive long distances, up to 250 miles round trip 3 times weekly. The centralized unit proved to be a tre-
mendous hardship on our patients and their families. The inclement weather in our area added further to the problems of these chronically ill patients. Hence, the need developed for a mobile hemodialysis system that could be taken to various satellite hospitals on a regularly scheduled basis. This schedule would be predicated on the patient load at any time and in any given area. It would require the establishment of a single unit to be
Accepted for publication August 2, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974.
668
Fm. 1
shared by all satellites. It would allow the healthy to bring care to the ill. In March 1973 initial steps were taken to activate this idea. With the cooperation of the Kidney Foundation of Michigan and Michigan Department of Public Health, a mobile hemodialysis unit was established in a 26-foot recreation vehicle purchased by Little Traverse Hospital in Petoskey, Michigan (fig. 2). A 1973 General Motors Corporation motor home was selected because of its quality, craftsmanship, ease of renovating and
MOBILE HEMODIALYSIS NETWORK IN NORTHERN MICHIGAN
FIG. 3
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670
HALL AND RANKIN
FIG. 4
non-confining interior. Remodeling was accomplished by the Hospital Maintenance Shop. The Kidney Foundation of Michigan furnished 2 Drake-Willock artificial kidney units and a complete water purification system (fig. 3). The Michigan Department of Public Health provided a grant for training personnel, staffing the unit for a year and for vehicle maintenance. The total cost of this effort was approximately $45,000. A network of satellite hospitals was then established. Contact was made with the cooperating hospital administrators and medical staff to solicit support and cooperation. Each hospital had to install an adequate water supply, a drainage line for used dialysate and a power source. The unit was preferentially located near the hospitals' emergency rooms and thus local physician coverage through the emergency room was insured. A mobile hemodialysis unit is staffed by a registered nurse trained in hemodialysis procedures (fig. 4) and by a male dialysis technician who also serves as the driver and maintenance expert. Dependable, stable and innovative personnel are required to fill these positions. They work 10-hour days and are able to provide 4 patients with dialysis on each trip. All patients have hospital charts with a complete set of orders. Each patient is dialyzed twice weekly on the mobile unit and once weekly in the Center, at which time medical re-evaluation is made and orders are revised as indicated, including dialysis time, ultrafiltration requirements and so forth. Therefore, close supervision of each patient is maintained. Laboratory tests can be obtained at the Center, eliminating the need for any blood testing on the mobile unit except for microhematocrits. To allow for the optimal number of dialysis per day in a limited work day, shorter dialysis times were necessary. We had had considerable experience using in-series dialyzers. With the square meter hour hypothesis for adequacy of hemodial-
ysis as well as clinical parameters, 3 to 3 ½ hours of dialysis are performed twice weekly with 2 CordisDow dialyzers in-series. A 4-hour dialysis is performed in the Center once weekly. This method provides approximately 22 square meter hours of dialysis weekly even when deducting 25 per cent efficiency loss of the second dialyzer. We found patient acceptance of the shorter dialysis times to be extremely high. Cancellations have been infrequent during the first 6 months of operation. Two runs were missed because of severe weather conditions and 1 run was canceled because of mechanical problems in the unit. The scheduled patients were contacted by phone and arrangements were made for dialysis to be carried out that day or the following day at the Center. No apparent inconvenience, hostility or resentment has developed to date and a social-psychological questionnaire has indicated complete patient acceptance of the mobile hemodialysis concept. No medical emergencies have occurred to date, nor has there been any need for local physician consultation. The enthusiasm encountered by the patients, families, local hospitals and physicians has been outstanding. Initial cost analysis would indicate that the treatments are comparable or slightly less expensive than hospital treatment charges. The basic supply costs are fixed but the unit overhead is much less then hospital space. Gasoline has been available and less gasoline is used when patients do not drive private cars into the Center. In conclusion, we believe that the mobile hemodialysis unit is fulfilling its purposes as initially set forth: 1) to reduce the long distances with the concomitant time and monetary losses of patients to achieve hemodialysis therapy in such a sparsely populated area, 2) to make the atmosphere of the dialysis setting as home-like and casual as possible, 3) to provide variability in the dialysis setting so as to help minimize the monotony and depres-
MOBILE HEMODIALYSIS NETWORK IN NORTHERN MICHIGAN
sion that hemodialysis patients often encounter and 4) to provide economical hemodialysis services within a cooperative framework in this comprehensive health planning council area. We strongly believe that home hemodialysis is not the answer for each non-transplantable patient with renal failure or each transplant candidate who
671
may have a long waiting period. Many not accept the concept of home hemodialysis. Family, social and emotional problems often ne gate home dialysis as a realistic possibility. We foresee the mobile hemodialysis concept as a. reasonable and frequently superior alternative conventional modes of dialysis how being used.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
A MOBILE HEMODIAL YSIS NETWORK IN NORTHERN MICHIGAN JOHN W. HALL
AND
H. ALLAN RANKIN
From the Burns Clinic Medical Center, Petoskey, Michigan
Recent advances in hemodialysis technology have helped solve many social and psychological factors involved in hemodialysis. The time required for each dialysis is becoming shorter and maintenance hemodialysis is a tolerable existence. For many patients the time in dialysis represents only a short interval before transplantation. Home training has also provided many patients the advantage of low cost dialysis with minimal disruption of normal living habits. There is a group of patients who do not fit into the aforementioned categories. The potential cadaveric transplant recipient faces a waiting period of weeks, months or years. Some programs start immediate home training of these patients but this seems like a wasted effort and expense if transplantation can be achieved within a reasonable interval. Every hemodialysis center also has a group of patients for whom home training is inappropriate. Elderly patients without a family have provided many problems. Other sociologic, psychologic and intellectual problems have made some younger patients unsuitable for home training at our Center. This applies even to the group of patients considered most ideal for renal transplantation. Hence, there are some patients who require low cost maintenance hemodialysis with some level of technical assistance. Such a group has developed in the sparsely populated areas of Michigan's northern Lower Peninsula and eastern Upper Peninsula (fig. 1). This area, with a population of 400,000, stretches over 250 miles. The dialysis load in this area is quite variable. Furthermore, as patients undergo transplantation or die the patient load becomes quite unpredictable. One potential solution to the problem of supplying hemodialysis to this population base would have been the development of small local dialysis units. However, these units would have been inefficient and trained personnel would have been idle as the load varied. Also, such a plan would have required extensive local physician retraining. The economy of bulk purchasing would have been lost and valuable hospital space would have been inefficiently used. Initially, a centralized unit, the ideal solution in areas of high population density, was developed. It worked well but the patients had to drive long distances, up to 250 miles round trip 3 times weekly. The centralized unit proved to be a tre-
mendous hardship on our patients and their families. The inclement weather in our area added further to the problems of these chronically ill patients. Hence, the need developed for a mobile hemodialysis system that could be taken to various satellite hospitals on a regularly scheduled basis. This schedule would be predicated on the patient load at any time and in any given area. It would require the establishment of a single unit to be
Accepted for publication August 2, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974.
668
Fm. 1
shared by all satellites. It would allow the healthy to bring care to the ill. In March 1973 initial steps were taken to activate this idea. With the cooperation of the Kidney Foundation of Michigan and Michigan Department of Public Health, a mobile hemodialysis unit was established in a 26-foot recreation vehicle purchased by Little Traverse Hospital in Petoskey, Michigan (fig. 2). A 1973 General Motors Corporation motor home was selected because of its quality, craftsmanship, ease of renovating and
MOBILE HEMODIALYSIS NETWORK IN NORTHERN MICHIGAN
FIG. 3
669
670
HALL AND RANKIN
FIG. 4
non-confining interior. Remodeling was accomplished by the Hospital Maintenance Shop. The Kidney Foundation of Michigan furnished 2 Drake-Willock artificial kidney units and a complete water purification system (fig. 3). The Michigan Department of Public Health provided a grant for training personnel, staffing the unit for a year and for vehicle maintenance. The total cost of this effort was approximately $45,000. A network of satellite hospitals was then established. Contact was made with the cooperating hospital administrators and medical staff to solicit support and cooperation. Each hospital had to install an adequate water supply, a drainage line for used dialysate and a power source. The unit was preferentially located near the hospitals' emergency rooms and thus local physician coverage through the emergency room was insured. A mobile hemodialysis unit is staffed by a registered nurse trained in hemodialysis procedures (fig. 4) and by a male dialysis technician who also serves as the driver and maintenance expert. Dependable, stable and innovative personnel are required to fill these positions. They work 10-hour days and are able to provide 4 patients with dialysis on each trip. All patients have hospital charts with a complete set of orders. Each patient is dialyzed twice weekly on the mobile unit and once weekly in the Center, at which time medical re-evaluation is made and orders are revised as indicated, including dialysis time, ultrafiltration requirements and so forth. Therefore, close supervision of each patient is maintained. Laboratory tests can be obtained at the Center, eliminating the need for any blood testing on the mobile unit except for microhematocrits. To allow for the optimal number of dialysis per day in a limited work day, shorter dialysis times were necessary. We had had considerable experience using in-series dialyzers. With the square meter hour hypothesis for adequacy of hemodial-
ysis as well as clinical parameters, 3 to 3 ½ hours of dialysis are performed twice weekly with 2 CordisDow dialyzers in-series. A 4-hour dialysis is performed in the Center once weekly. This method provides approximately 22 square meter hours of dialysis weekly even when deducting 25 per cent efficiency loss of the second dialyzer. We found patient acceptance of the shorter dialysis times to be extremely high. Cancellations have been infrequent during the first 6 months of operation. Two runs were missed because of severe weather conditions and 1 run was canceled because of mechanical problems in the unit. The scheduled patients were contacted by phone and arrangements were made for dialysis to be carried out that day or the following day at the Center. No apparent inconvenience, hostility or resentment has developed to date and a social-psychological questionnaire has indicated complete patient acceptance of the mobile hemodialysis concept. No medical emergencies have occurred to date, nor has there been any need for local physician consultation. The enthusiasm encountered by the patients, families, local hospitals and physicians has been outstanding. Initial cost analysis would indicate that the treatments are comparable or slightly less expensive than hospital treatment charges. The basic supply costs are fixed but the unit overhead is much less then hospital space. Gasoline has been available and less gasoline is used when patients do not drive private cars into the Center. In conclusion, we believe that the mobile hemodialysis unit is fulfilling its purposes as initially set forth: 1) to reduce the long distances with the concomitant time and monetary losses of patients to achieve hemodialysis therapy in such a sparsely populated area, 2) to make the atmosphere of the dialysis setting as home-like and casual as possible, 3) to provide variability in the dialysis setting so as to help minimize the monotony and depres-
MOBILE HEMODIALYSIS NETWORK IN NORTHERN MICHIGAN
sion that hemodialysis patients often encounter and 4) to provide economical hemodialysis services within a cooperative framework in this comprehensive health planning council area. We strongly believe that home hemodialysis is not the answer for each non-transplantable patient with renal failure or each transplant candidate who
671
may have a long waiting period. Many not accept the concept of home hemodialysis. Family, social and emotional problems often ne gate home dialysis as a realistic possibility. We foresee the mobile hemodialysis concept as a. reasonable and frequently superior alternative conventional modes of dialysis how being used.