Management of Water Quality for Home Hemodialysis Programs in Canada
Creators: Dave, Sejal P
Publisher: name: University of Alberta Library
Year: 2023

<p>Background: Hemodialysis (HD) is a life-sustaining treatment for people with end-stage renal disease(ESRD). ESRD patients could experience severe adverse events when the water used during their HD treatments is not of the quality needed for its safe operation. The role of water quality in HD treatments is, therefore, critical. In Canada, home hemodialysis (HHD) as a treatment modality of HD is in great demand, creating the need to understand how water-related aspects influence its wide-scale implementation. <br>
Methods: This thesis included 2 studies: 1) a scoping review (SR) and 2) a qualitative analysis. The SR synthesized and contrasted the existing standards and guidelines on water-related aspects of HHD. The second study collected qualitative data through semi-structured interviews with 18 healthcare professionals from 6 Canadian HHD programs. Participants were asked to comment on the structure and process of managing HD water quality and identify perceived influencing factors to the delivery of safe water within them. A thematic analysis (TA) method was used to analyze interview data related to perceived enablers and barriers to water quality management. <br>
Results: The scoping review found 13 organizations that mandated HHD programs to establish the process surrounding the following 3 main water-related topics: quality criteria, water purification system, and quality management. The included organizations derived their statements based on other organizations, clinical studies, experimental studies, and expert opinions. Organizations varied in their established statements on (1) the number of parameters included in water quality criteria, (2) permissible levels for chemical parameters, (3) the type of microbial grade of water to be used for HD, and the monitoring plan. <br>
The qualitative analysis revealed 4 main themes: current practices for the HHD care process, perceived barriers of and facilitators to water quality management, suggestions discussed to overcome the identified barriers, and approaches to addressing non-compliance. In the first theme, participants identified the HHD care process steps in managing their programs&#39; water-related aspects. Mainly, the differences existed across the participating home programs on their approaches to implementing quality management of water quality. <br>
In the second theme, several factors connected to a built environment that created challenges/barriers were identified. In the third theme, the lack of resources was discussed as a barrier to microbial quality testing and device care, including cost for sufficient staffing, staff travel time, heavy workload requirements for sampling collections and transportation, and patient non-compliance. Participants viewed the requirements of the Canadian Standards Association (CSA) on microbial testing as impractical. <br>
Several facilitators overcoming the challenges of home modifications were identified, including source water suppliers and manufacturers for helping with customization of devices, and patients organizations and tax rebates providing financial help to patients in paying their utility bills. Implementing policies and procedures for tracking data and ensuring timely access to patients’ homes helped with device maintenance. The use of point-of-care testing for bacterial counts, when used by patients, was identified as a facilitator for performing testing. <br>
Conclusion: The organizations issuing statements on water-related aspects of HHD have covered all the essential topics needed for the safe delivery of HHD; however, most organizations have left the decision-making on how to implement them in individual dialysis facilities to a large extent. The variations across organizations on their established statements related to water quality criteria and microbial monitoring could lead to differences in patient outcomes and resource utilization. Therefore, this area needs further exploration. This thesis&#39;s qualitative study was conducted with the hope of generating evidence in that direction. It revealed several factors that hindered or created challenges in managing water-related aspects in Canadian HHD programs and implementing the CSA&#39;s statements. Such knowledge would provide a basis for HHD programs to initiate their efforts towards improving their implementation process by developing strategies targeted at overcoming them and for which the identified facilitators would be helpful. This research would also benefit the CSA organization to develop contextualized statements on managing HHD water quality by considering and addressing the local implementation issues in subsequent revisions. </p>