Overview of Hemodialysis Units Included in Study.

Case-study hemodialysis services
Three hemodialysis units: 1 in-hospital and 2 satellite units affiliated with a large hemodialysis program in western Canada were selected. The study sites include in-hospital and satellite hemodialysis as well as in-center nocturnal and home hemodialysis. These areas were purposively selected to determine whether care provision and experiences varied across different sites. All of the units provided 3 dialysis sessions a day, 6 days a week, Monday to Saturday. The in-center unit also offered nocturnal dialysis. Due to the increasing demand for services in this area, the program has recently opened a number of units on a Sunday. Nephrologists rotate to cover outpatient hemodialysis care. At the time of this study, 31 nephrologists were included on the rota and covered the 5 weekdays, a week at a time. A nephrologist rounds on all the hemodialysis units once a week. Issues addressed during rounds are typically acute problems and/or dialysis related [observed]. More complex or longstanding problems are usually shared with (and managed by) the patient’s primary nephrologist who provides office-based appointments every 3 months or as required. At the end of each week, the rounding nephrologist shares any ongoing issues with the nephrologist following on the rota. The number of weeks a nephrologist spent covering dialysis was dependent upon their specific rota. Some rotas included only 1 week of dialysis a year. Some fee for service nephrologists work primarily in dialysis. Fee for service nephrologists was overly represented on the rota. There are generally 2 nurses (a Registered Nurse and Licensed Practice Nurse) allocated to a group of 5 patients each dialysis shift. They provide the dialysis treatment and associated care and complete the documentation. Aides will assist, undertaking activities such as gathering equipment, weighing the patient, and cleaning machines. In general, nurses are assigned their patients on a shift-by-shift basis and have no ongoing responsibility for planning or organizing care beyond the immediate dialysis session. Each shift is coordinated by a nurse clinician who has a list of patient issues that require attention and is responsible for liaising with the medical and nursing staff. There is no general verbal handover or sharing of information between the nurses during the shift. Nurses will document concerns in the patient’s medical record and relay these to the nurse clinician, who will add these to the daily sheet of patient issues. Observing rounds during the study period confirmed individual nephrologists have their own ways of working in terms of when they do their rounds and how they do them. Some will speak to each patient in turn and others will review only those identified by the nurse clinician as having a problem. The nurse clinician typically accompanies the nephrologist when rounding. No multidisciplinary rounds were observed, with dieticians, social workers, and pharmacists rounding separately. Similarly, although the nurses were often very knowledgeable about individual patients, there were no formalized opportunities to regularly share/record this collective knowledge. Apart from the nocturnal and home dialysis program, none of the patients had management plans.
Satellite unit 1
Registered patients 91 Observation of practice over 5 visits As with all the units included in the study, the timing of rounds in this unit varied depending on individual nephrologists and their workload.
Home hemodialysis
Registered patients 81 Observation of practice over 5 visits Patients who dialyze at home were sent the study information by the unit manager by post. Once discharged, home patients dialyze at the training unit when they require an iron infusion or cannot dialyze at home, for instance if there is a problem with their machine. During their training, patients are assigned to individual nurses, who remain their named nurse on discharge. Participants were opportunistically recruited during their visit to the training unit and interviewed at the program’s home training unit.
Nocturnal hemodialysis
Registered patients 31 Observation of practice over 5 visits In-hospital nocturnal hemodialysis was notably different from the other dialysis services. The relatively small number of patients meant they were well known to staff. Four nephrologists were responsible for rounds which were scheduled every 2 weeks, when each patient was reviewed. A multidisciplinary sit-down round was held every 8 weeks. In contrast to other units, all the patients had management plans.
In-center hemodialysis
Registered patients 110 Observation of practice over 15 visits This unit has the largest number of patients and at the time of the study, all patients new to hemodialysis start here. In addition, patients who are clinically or cognitively unsuitable to dialyze in a satellite unit or are aggressive and/or abusive are treated here. The turnover of patients here tends to be higher than in other units and many nurses found it a stressful place to work.