P1558THE “HOME JAIL HEMODIALYSIS” PROJECT IN MILAN, ITALY: AN UNIQUE EXPERIENCE ABLE TO SAVE MONEY AND IMPROVE SECURITY
Authors: Cosmai Laura , Stocco Matteo , Lari Cesare , Galassi Andrea , Stucchi Andrea , Zoni Ulisse , Ippolito Michela , Frittoli Michela , Cozzolino Mario 
Published: June 2020

Abstract

Background and Aims
Chronic kidney disease (CKD), and especially end-stage renal disease (ESRD) are relevant worldwide public health problems, since they are linked to poor quality of life, serious adverse health outcomes (including cardiovascular diseases, infections, duration of hospitalization and, more importantly, overall mortality), as well as increased healthcare costs. Moreover, renal replacement therapy with either dialysis (both hemodialysis and peritoneal dialysis) or kidney transplantation represents the economic burden of ESRD, which continues to grow substantially. Future projections are for an increasing prevalence of ESRD globally. Worldwide, more than 2.5 million people were treated for ESRD in 2015, and this number is projected to more than double, thus reaching the astonishing number of 5 million by 2030.

Method
In our San Paolo Hospital, in Milan, a Division of Penitentiary Medicine has been established, allowing us to serve, with wide medical and surgical support, all the four prisons present in the Milan area, since several years. During the last decade, we were required to comprehensively manage renal patients as well. In particular, we followed also a number of ESRD patients on replacement treatment with hemodialysis thrice weekly. The Dialysis Unit received prisoner patients and treated them under the security control of several penitentiary policemen. Among them, we had also two high-surveillance prisoners who needed as many as six higly armed policemen each for security. The presence of these agents caused a relevant discomfort to both the other patients, as well the whole medical and nursing staff. After a long period of organization, we started an innovative project called ‘Home Jail Hemodialysis’. Since July 2018 until now, hemodialysis sessions for these two high-surveillance prisoners (on separate days) have been performed within one prison, with the need of just one policeman to control them. Nurses had to be provenly skilled for a comprehensive care for hemodialysis patients and were also specifically trained for the management of patients subjected to high-surveillance detention, as particular behavioral and relational precautions are obviously essential. After a run-in period, in which management protocols/procedures were shared with those of our hospital, all the activities started taking place only within the prison’s Health building. The care setting includes single security rooms, with a nurse present throughout the treatment period; once monthly, a Nephrologist re-evaluates the patients, updates the treatment, and shares with the nursing coordinator all eventual issues.

Results
The feasibility and safety of this approach, aimed at integrating the penitentiary structure with the hospital with a decentralized assistance, was tested using two indicators of performance: the number of adverse events reported in 12 months (about 310 dialyses), and costs. In 12 months of observation, there were no serious adverse events. Furthermore, in just one year approximately 1,000,000 € were saved (considering that the cost of traveling to the hospital and of high-level surveillance for detained patients is close to € 500,000 per year).

Conclusion
The ‘Home Jail Hemodialysis’ thus appears an easy way to save money and improve security.