Good practices for dialysis education, treatment, and eHealth: A scoping review

Background Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. Methods Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words ‘kidney failure’, ‘dialysis’, and ‘good practice’. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. Results Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. Conclusion Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients’ contribution in the implementation of their dialysis treatment, and advanced care planning.


Introduction
According to the latest estimates, more than 320 million patients are treated with dialysis worldwide [1]. In most developed countries, patients start dialysis after having received education on different treatment options (i.e. dialysis, transplantation, and conservative care) [2][3][4]. Recommendations regarding education and dialysis treatment are given in various (inter) national guidelines [5][6][7][8][9][10]. These, preferably evidence-based, recommendations assist health care professionals in the guidance and treatment of chronic kidney disease (CKD) patients in order to provide the best possible care.
Guidelines should ensure that complete and objective education is provided to CKD patients about all treatment options [5]. In addition, guidelines should assure that practical execution of a specific dialysis treatment (i.e. hemodialysis (HD) or peritoneal dialysis (PD)) is more or less the same in all centers. However, this does not always seem to be the case. In 2010, it was shown that variation in center-specific factors (e.g. number of patients, in-center HD treatment capacity, and availability of a late dialysis shift) in the United States influenced the utilization of home dialysis (i.e. home HD and PD) [11]. This also appears to be true for many other countries when looking at the variation in PD utilization [12]. In addition, practice variation within a country seems to associate with a broad range in the percentage of dialysis patients treated with home dialysis [13]. Probably part of this variation can be explained by socalled 'good practices' which are developed locally.
The term 'good practice', also referred to as 'best practice', denotes '. . .a practice that has been proven to work well and produce good results, and is therefore recommended as a model.' [14,15]. Good practices are practices that are developed locally and with which health care professionals have good experience, but are not evidence-based and therefore not added to (inter)national guidelines [14,15]. As a result, these practices are not distributed and applied nationally, such as the recommendations from (inter)national guidelines. Although not evidence-based, good practices can have additional advantages and are therefore worthwhile exploring. Moreover, local good practices for dialysis education and treatment could potentially explain the previously mentioned practice variation.
An overview regarding these good practices is lacking in current published literature. Thus, we performed a scoping review to identify and summarize the available literature describing good practices for dialysis education, treatment, and electronic health (eHealth).

Search strategy and selection criteria
Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice' (Table 1).
After removal of duplicates, two authors (AES and SV) independently screened titles and abstracts. Articles were eligible for inclusion if they provided a thorough description of the content of a good practice regarding dialysis education, treatment or eHealth for adult patients. Articles of all study types were included, however articles that described a guideline, review or meta-analysis were subsequently excluded after being screened for additional references.
Articles were excluded if they referred to a practice already covered in (inter)national guidelines, or if they reported on implementation projects, diabetes mellitus care or exercise programs for dialysis patients. In addition, articles were excluded if no full text or only a published abstract was available or if they were written in a language other than English.
The remaining articles were read full text by two authors (AES and SV) and screened for additional references. Final inclusion was based on consensus between the two authors (AES and SV) based on the previously mentioned in-and exclusion-criteria. In case of disagreement, the opinion of a third author (ACA) was decisive.

Study characteristics
Characteristics of the 19 included articles are presented in Tables 2-4. Twelve articles described good practices for dialysis education (Table 2), three for dialysis treatment (Table 3), and four for eHealth ( Table 4). All articles were published during the past 20 years and 47% of them came from the United States of America (USA). Most studies (58%) had a qualitative design, while the others were cohort studies (21%), case-control studies (11%), and randomized controlled trials (11%).

Dialysis education
Four of the twelve articles that described good practices for dialysis education, focused on providing objective predialysis education for CKD patients (Table 2) [31,32,40,45]. Fortnum et al. [40] presented the 'My Kidneys, My Choice' decision aid, a patient-centered tool to support the education of CKD patients and promote shared decision making. Health care professionals found the decision aid to be helpful for understanding treatment options and patients' priorities, and for supporting decision making. Lacson Jr. et al. [31] initiated a standardized predialysis treatment options education program that consisted of education provided during a single group class session, followed by contacts after 30, 90, and 180 days during which treatment options were repeatedly discussed. Compared to controls, patients who followed the standardized education program were significantly more likely to choose PD (odds ratio (OR) 5.13) or to start in-center HD with a fistula or graft (OR 2.06), and had a lower mortality (OR 0.61) during the first 90 days of dialysis treatment [31].
Manns et al. [32] developed a two-phase patient-centered educational intervention, showing manuals and a video for self-care dialysis (i.e. PD, home HD, and self-care HD) in phase 1 and conducting a small group session in phase 2. The intervention significantly increased the proportion of patients who intended to initiate self-care dialysis (intervention group 82.1% vs. standard care group 50%).
Wu et al. [45] presented a multidisciplinary predialysis education program consisting of quarterly individual nurse-led lectures for CKD patients stage 3 and 4, while this was intensified to monthly lectures for CKD patients stage 5. Compared to controls, patients who followed the multidisciplinary education program had a significant lower risk of requiring dialysis (hazard ratio (HR) 0.117) and lower mortality (HR 0.103) after a mean follow-up of 11.7 months.
Five of the twelve articles that described good practices for dialysis education, focused on PD patients [33,[37][38][39]41]. Luongo et al. [41] described a five-step approach (i.e. preparation, environment, special considerations, interview, and special concerns) for nurses to interview CKD patients who may choose PD as dialysis treatment. The goal of the interview was to reduce stress and anxiety in the patient and to promote shared decision making. Although this approach has not been tested, the authors concluded that it guides PD nurses in providing correct information to future PD patients without overwhelming them.  Qualitative N = n.a.
Home visit for PD patients • Goals: • Visit prior to training: assess home environment, social and family dynamics.
• Visit after training: assess application of PD procedures. • Components � Before visit: establish home visit policy, explain reason for visit to patient, secure directions to patient's home, verify visit, review violence prevention, notify supervisor of planned visit.
� During visit: review reason for visit, asses home (clean work area, adequate lighting, running water/soap, draft free room, free of pets, storage of supplies), survey equipment, compliance issues, family dynamics/adaptation skills, assessment of procedures/technique, medicines, provision of patient education, review of findings/ recommendations.
� After visit: review results with health care team and brainstorm to resolve problems, follow up on any issues that need to be resolved, track results of home visits over period of time, identify trends and opportunities for improvement.

n.a.
A home visit is a valuable tool and gives PD staff opportunity to monitor the environment where dialysis is performed. n.a. After completion of the PD training syllabus, the PD nurse will have provided education to a patient and/ or caregiver such that the patient/ caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively.
Features of successful nurse-led APD training • Setting and staff: dedicated staff members, training patients in clinic (home-like atmosphere, all necessary materials), home visit soon after training, then annually.
• APD training content: minimal educational materials, more complex topics at slower pace with simplified language and practical examples.
• Delivery of APD training: verbal explanation of APD cycler, return demonstration by patient, instructions for washing hands/setting up supplies/starting cycler/preparing solution bags/loading set/ connecting bags/priming and connecting patient/disconnecting patient/emergency disconnection/shut down cycler/clean and care for cycler, monthly education through verbal/written quizzes.
n.a. Patient training programs should focus on basic and essential information patients need to master in order to dialyze successfully and safely at home. Clinics reinforced learning by several methods, including written quizzes to asses and document patient learning, and reviewing the quiz to reinforce learning and disseminate more information.
(Continued )   b. Based on Knowles's principles for adult education: 1) adults are internally motivated and self-directed; 2) adults bring life experiences and knowledge to learning experiences; 3) adults are goal-oriented; 4) adults are relevancy oriented; 5) adults are practical; 6) adult learners like to be respected [50]. c. 6-step approach of Buckman and Kayson for breaking bad news: 1) give news in person, in private, with sufficient time, without interruption; 2) find out what the patient's preexistent knowledge is; 3) find out what the patient wants to know; 4) give a warning first, then provide a small amount of information in simple language at an appropriate pace for the patient; 5) respond to the patient's feelings and concerns; 6) determine the next steps, identify sources of support, and make an early followup appointment [51].
Telehomecare for PD patients The PERKA a service supports data collection and transmission from a patient's home via phone or data networks to the PD clinic for monitoring and archiving: • PD data: PD method, PD prescription, actual PD daily treatment schema conducted (number of fluid exchanges, duration, solute type/ volume, UF volume).
• General biometric data and biosignals: body weight, blood pressure, heart rate, oxygen saturation, temperature (if required, ECG and glucose levels).
• Free text or sound report and/or response to a structured questionnaire.
The system contains a patient unit, a data collection unit, a web-based portal application, a database for patient data and a database for administrative data. n.a.
The PERKA system enables telehome-care services for all PD patients.

RCT N = 135
Post-discharge nurse-led telephone support for PD patients b Pre-discharge planning protocol (by nurse case manager): • Assessing patient's physical, social, cognitive, emotional needs.
• Conducting an individualized education program to strengthen and consolidate past learning experiences, clarify misconceptions and optimize health outcomes. Standardized 6-week post-discharge nurse-led telephone support: • Weekly telephone call for 6 consecutive weeks: first call within 72h after discharge to assess the patient's status and to give advice.
• Content of each telephone call is guided by the pre-discharge planning protocol and specific problems identified in pre-discharge assessment.
Post-discharge nurse-led telephone support is helpful for some aspects of quality of life and reducing clinic visits of PD patients.
Sicotte [49] Canada 2011 Telehemodialysis • Remote team of nephrologists and nurses provides specialized clinical supervision by tele-communicating with local care teams and patients.
• Electronical health record that allowed the remote team to view laboratory results, vital signs and medication taken by the patient, and observe variables recorded by the dialysis machine in real-time as the treatments were administered.
• Two organizational models: virtual patient rounds or telecase reviews with multidisciplinary teams. TeleHD can maintain the quality of care and can provide distant supervision while maintaining the level of care utilization. Different organizational models did not lead to differences in health condition or care utilization. [36] Italy 2020 Cohort N = 107 Videodialysis (VD) for assisted PD patients Components: • Remote Station (patient's home): video camera, monitor, microphone, technological box. • Control Station (center): webcam, computer, phone.

Viglino
• System connecting the 2 stations: real-time, high-quality audio-video transmission. Method of use: nursing staff can follow patients/caregivers during the phases: multi-user connection, acquisition and recording of dialysis parameters, performance of CAPD/APD procedure, filling dialysis sheets. VD sessions are also used for exit site care, assessing dialysis/ clinical issues, checking adherence to pharmacological/ dietary therapy.
• Self-care patients: 1/45.2 months. Time to first peritonitis not different between groups.VD: 17.6% reduction in transfer from PD to HD due to reduced compliance/lack of caregiver availability.
VD-assisted PD is a reliable, safe system which requires no technological know-how and is easy to use when self-care is not possible due to physical, cognitive or psychological barriers. The qualitative studies of Figueiredo et al. [38] and Firanek et al. [39] focused on PD training. Figueiredo et al. [38] provided a detailed description of a 5-day PD training course, with an introduction on day 1, supervised procedure practice sessions on days 2 to 4, and a review of the provided information and check of the patient's competence on day 5. The authors concluded that with this training course PD nurses ensure that the patient can perform PD safely and effectively. Firanek et al. [39] visited six centers to identify successful components of the PD training programs. Subsequently, they provided an overview of these successful components focused on setting and staff, training methods, educational documents, training structure, automated peritoneal dialysis (APD) training content, and delivery of APD training.
Successful home visit programs were described by Farina et al. [37] and Martino et al. [33]. The main similarities between the two programs were: assessment of the home where PD was performed, assessment of the PD procedure performed by the patient, and the patient's compliance to pharmacological and dialysis therapy. While Farina et al. did not examine the effect of the intervention, Martino et al. reported that PD patients who received a home visit had a significantly longer PD duration (52 weeks) and a lower technique failure rate (11.5%) compared with controls (PD duration 48.8 weeks, technique failure rate 23.3%) [33].
The last three articles focused on an educational program for HD patients [44] and conversations with dialysis patients [42,43]. Wingard et al. [44] described a 3-month educational program for HD patients that focused on health self-management, rehabilitation, nutritional counselling, and interventions for achieving goals such as anemia management, adequate dialysis dose, logistical, and psychosocial support. Compared to controls, patients who completed the program had significantly fewer hospitalization days per patient year (7.2 vs. 10.5) and a lower mortality (HR 0.59) after a maximum follow-up duration of 12 months. The authors concluded that the program not only reduced morbidity and mortality, but also increased job satisfaction for nurses.
Mandel et al. [42] described a 6-step guide for serious illness conversations with dialysis patients to discuss their prognosis. The guide consisted of the following steps: set up the conversation, assess the patient's illness understanding, share the patient's prognosis, explore key topics, close the conversation, and document the conversation. The article by Michel et al. [43] also described an approach for talking with dialysis patients about their prognosis based on four aspects: who to tell, when to tell, what to tell, and how to tell. The authors concluded that this approach can help discussing prognosis with dialysis patients, taking into account the patient's preferences.

Dialysis treatment
The three articles that described good practices for dialysis treatment were all qualitative studies (Table 3) [46][47][48]. Abdel-Aal et al. [46] provided a detailed description of the procedure for insertion of a PD catheter by interventional radiologists. Various aspects of pre-procedure preparation, such as bowel preparation and fasting, were discussed followed by a detailed explanation of the PD catheter insertion with explanatory photos. The procedure was described as a cost-effective and minimally invasive alternative to traditional surgical placement of a PD catheter.
Craswell et al. [47] described practices for insertion, maintenance, and removal of central venous catheters (CVCs) for HD. The practices for insertion consisted of patient education for insertion, anatomical site selection and decision-making, and training. The practices for maintenance consisted of education, dressing practices, and assessment and monitoring for infection. The practices for removal consisted of the decision for removal and complications of removal. The authors concluded that an interdisciplinary team is very important for patient education and catheter care.
Desai et al. [48] reported 155 good practices that could potentially improve outcomes of dialysis centers, such as dialysis dose and anemia management, and overall survival in dialysis patients. The 155 good practices were divided into the following domains: facility characteristics and amenities, facility-based health maintenance, staff working climate, general dialysis care practices, physician practices, nursing practices, technician practices, and miscellaneous practices. Through a survey among 342 respondents, a top 30 of good practices that had the most impact on overall outcomes in dialysis was compiled. The majority of the top 30 good practices focused on conducting a successful multidisciplinary team meeting, performing audits, training nurses, reviewing the performance of health care professionals, and enhancing communication and teamwork.

eHealth
Four articles described good practices for eHealth, one of which focused on HD [49] and three on PD (Table 4) [34][35][36]. The qualitative article on PD by Kaldoudi et al. [34] described the components of an eHealth system by which data could be collected such as PD method, prescription, body weight and hearth rate. Viglino et al. [36] described an eHealth system which led to a reduction in peritonitis episodes and a 17.6% reduction in the number of transfers from PD to HD because reduced compliance or lack of availability of a caregiver was no longer an issue. The authors concluded that this system can be a valuable tool for increasing the number of PD patients.
While Kaldoudi et al. [34] and Viglino et al. [36] focused more on the technical aspects of eHealth systems for PD patients, Li et al. [35] conducted a randomized controlled trial to investigate the effect of post-discharge telephone support for PD patients. Patients were included if they performed PD for a minimum of 3 months and were admitted to a nephrology department. The control group received routine care, while patients in the intervention group were visited by a nurse who assessed their needs and provided individualized education. After discharge from the hospital, the nurse called the patients from the intervention group every week during a period of 6 weeks to assess their status and to give advice. This approach led to a significant improvement of several health-related quality of life domains (e.g. symptoms, energy, work status) and a reduction in the number of hospital visits.
Finally, Sicotte et al. [49] reported two eHealth models for in-center HD patients: virtual patients rounds and telecase reviews with a multidisciplinary team. During the virtual patient rounds, a remote nephrologist and nurse had contact with a patient and his/her nurse at the dialysis center. During the telecase review, a remote nephrologist and nurse had contact with the general practitioners and nurses at the dialysis center via videoconference, without the patient being present. Both models led to a significant reduction in the number of medication changes per month during a follow-up of 2 years. The authors concluded that eHealth can provide distant supervision which improves the level of care utilization.

Discussion
This scoping review identifies 19 articles with good practices that could be used in addition to guidelines. The twelve articles with good practices for dialysis education endorse the importance of providing complete and objective predialysis education to CKD patients, assisting PD patients in performing PD adequately, educating HD patients on self-management, and talking with dialysis patients in general about their prognosis. The three articles with good practices for dialysis treatment provide practices regarding dialysis access devices and numerous candidate good practices for dialysis centers. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life.
Good practices are locally implemented practices with which health care professionals have good experience, but which are not necessarily evidence-based [14,15]. Therefore, they are generally not added to (inter)national guidelines. For dialysis treatment, there are many guidelines with proven treatment methods, while guidelines for dialysis education are scarce [10,52]. This probably explains why we have found many good practices for dialysis education and only a few for dialysis treatment.
Six of the 12 articles regarding dialysis education report a positive effect of the described good practice(s) [31-33, 40, 44, 45]. Complete and objective education to CKD patients by a multidisciplinary team decreases the dialysis incidence and mortality [45]. Moreover, it increases the use of home dialysis [31,32]. The European Renal Best Practice (ERBP) Advisory Board also underscores complete and objective education to enable CKD patients to choose a dialysis modality that is most suitable for them [5]. Another useful good practice is a decision aid for CKD patients, which supports the shared decision making process according to health care professionals [40]. A Cochrane review, describing 105 decision aids for patients facing various treatment or screening decisions, also states that decision aids increase participants' knowledge, decrease decisional conflicts, and facilitate active participation in decision making [53]. However, the review includes no decision aids specifically for nephrological care. A randomized study among 133 CKD patients concludes that an online decision aid can improve knowledge and decrease decisional conflict and uncertainty about choice of dialysis treatment [54]. So, decision aids are important for use during dialysis education.
A home visit also seems to be a very relevant tool for PD education, since Martino et al. [33] report that their home visit reduces technique failure and extends PD treatment. The positive effect of a home visit is also found in a French study of 359 patients on assisted PD, which found that it increases the probability of patients remaining peritonitis free from 33.9% to 50.8% at 3 years (p = 0.028) [55]. Home visits conducted in two other studies, with the aim of providing dialysis education for CKD patients, result in a higher probability for patients to receive home dialysis [56,57]. So, home visits seem to be important not only for PD patients, but also for CKD patients who have yet to make a treatment choice.
The articles regarding dialysis treatment provide guidance on PD catheter placement by interventional radiologists and the insertion, maintenance, and removal of CVCs [46,47]. The International Society for Peritoneal Dialysis (ISPD) guideline on peritoneal dialysis access only briefly mentions image-guided percutaneous PD catheter placement [58], so the procedure described by Abdel-Aal et al. can be a relevant addition [46]. The (inter)national guidelines for CVCs also describe insertion, maintenance, and removal practices [59][60][61], however only the most recent guideline [62] underscores the importance of patient education as Craswell et al. did [47]. Finally, the 155 candidate good practices reported by Desai et al. could lead to general quality improvement of dialysis care [48].
The articles regarding eHealth show that this good practice improves quality of care for HD patients [49], quality of life for PD patients [35], and reduces the number of peritonitis episodes [36]. In 2017, Rosner et al. [63] conducted a review on the use of eHealth in the care for dialysis patients. They found 19 articles describing mostly small, single-center studies published between 1999 and 2017, 13 articles for PD and 6 articles for HD. Most of the articles used video conferencing, remote monitoring, or monthly visits with physical examination (e.g. electronic stethoscopes) using eHealth as technology. All articles report positive results of their eHealth system on various outcomes such as patient independence, quality of life, and hospitalization. Rosner et al. conclude that there still is a lack of evidence regarding the use of eHealth, however they mention possible benefits for example increased uptake and acceptance of home dialysis, treatment monitoring in the home environment, improved patient satisfaction, and potential for cost savings [63]. In the current time with the coronavirus disease 2019 (COVID-19) pandemic, eHealth may play an important role through, for example, video conferences and remote patient monitoring [64][65][66].
Our review has several limitations. First, there is a probability that we have not identified all articles describing good practices. This is partly because many articles do not label their practice as 'good practice', making them less likely to appear in the search. However, by also using 'best practice' and 'practice guidelines' as a search topic, we believe that we have attenuated this problem. Second, most of the studies are qualitative in nature and describe no results, making it impossible to determine an effect of the described good practices. Finally, most of the studies that described results investigate a small number of patients and report on different outcomes, making mutual comparison impossible.
In conclusion, our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning. Good practices can inspire and support health care professionals to change their practices and this could possibly help to improve outcomes and quality of life for CKD and dialysis patients. Additional research on good practices could be useful to identify more good practices and determine the impact of these practices on CKD and dialysis patients.