home haemodialysis: improving patient safety judith moore pre dialysis and home therapies team...
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Home Haemodialysis: Improving Patient Safety
Home Haemodialysis: Improving Patient Safety
Judith Moore
Pre Dialysis and Home Therapies Team Leader
Belfast City Hospital
Judith Moore
Pre Dialysis and Home Therapies Team Leader
Belfast City Hospital
FactsFacts
FactsFacts
Population of 1.8 million
Host of the recent 2013 World Police and Fire Games (WPFG).
“The friendliest games ever” – WPFG Federation President.
ContentsContents
Background
Home Haemodialysis (HHD) in Northern Ireland
Biomed Central Report 2012
Identified Area of Change
Conclusion
Acknowledgements
BackgroundBackground
Belfast City Hospital - 200 in-centre HD patients.
Sub-regional units - 500 in-centre HD patients.
Home Haemodialysis (HHD) in Northern Ireland
Home Haemodialysis (HHD) in Northern Ireland
1. Established 10 years
2. 77 patients trained
3. Approx 45% transplanted
4. Current total of 33 patients
5. 69% monthly reviews by BCH HHD team
6. 31% monthly reviews by sub-regional community dialysis teams
Existing Patients
Biomed Central Nephrology Report 2012Biomed Central Nephrology Report 2012
“Exsanguination of a home haemodialysis patient as a result of misconnected blood-lines during the wash back procedure: a case report” (Allocock et al, BMC Nephrology 2012, 13:28).
Key points of the report relating to the HHD programme:
1. 30 years experience
2. 80 patients
3. MDT selection
4. Train 20-25 patients per year
5. Average approx 3-4 months training per patient
6. Monthly visits and support
Biomed Central Nephrology Report 2012Biomed Central Nephrology Report 2012
Key Points of the report relating to the patient:
1. 67 year old male
2. AVF
3. 20 weeks successful training
4. Contact with case manager on morning of death
5. Death occurred due to misconnected bloodlines
6. 2.3L of blood
7. Hypovolaemia
Biomed Central Nephrology Report 2012 PicturesBiomed Central Nephrology Report 2012 Pictures
The saline bag found attached to the deceased’s dialysis machine
The weight of the bag was 3.3Kg – implying the addition of 2.3L of the patient’s blood to the saline bag during the wash-back procedure
Identified Area of ChangeIdentified Area of Change
Competency based training for our HHD patients
Reports of misconnected bloodlines
Identified and rectified mistake
Change in wash-back procedure
Introduction of a Y-Connector
Introduction of Y-Connector for all HHD Patients with an AVFIntroduction of Y-Connector for all HHD Patients with an AVF
Introduction of Y-Connector for all HHD Patients with an AVFIntroduction of Y-Connector for all HHD Patients with an AVF
Patient connects the Y-Connector to the arterial fistula needle and ensures the BLUE clamp is closed on the connector prior to needle insertion
Patient inserts venous needle as usual
Introduction of Y-Connector for all HHD Patients with an AVFIntroduction of Y-Connector for all HHD Patients with an AVF
Patient connects the arterial bloodline to the RED clamp side of the Y-connector
Patient connects the venous bloodline to the venous needle
Patient commences dialysis in the usual way
Use of the Y-Connector for Wash-Back ProcedureUse of the Y-Connector for Wash-Back Procedure
In preparation for the disconnection procedure, the patient removes the saline wash-back line from the dialysis machine
Use of the Y-Connector for Wash-Back ProcedureUse of the Y-Connector for Wash-Back Procedure
The patient closes the clamp on the ARTERIAL fistula needle
The patient attaches the saline wash-back line to the redundant BLUE leg of the Y-connector
Use of the Y-Connector for Wash-Back ProcedureUse of the Y-Connector for Wash-Back Procedure
The patient opens the roller clamp on the wash-back line and the BLUE clamp on the Y-Connector
Wash back commences
Use of the Y-Connector for Wash-Back ProcedureUse of the Y-Connector for Wash-Back Procedure
Use of the Y-Connector for Wash-Back ProcedureUse of the Y-Connector for Wash-Back Procedure
Patient closes the clamps on the bloodlines, venous fistula needle, Y-connector and the roller clamp on the saline wash-back line
Patient disconnects the Y-Connector from the arterial needle and the bloodline from the venous needle and attaches these to the circuit
Patient removes and discards the fistula needles in the sharps bin
Evaluation of the Y-ConnectorEvaluation of the Y-Connector
74% re-trained
Safety information given to the patients
Patients quote that “it makes sense” and is “easily understood”
22% are not using the Y-connector
Nursing documentation
No further misconnections have occurred
ConclusionConclusion
The Biomed Central Nephrology Report has highlighted a potential risk for all patients on HHD who dialyse with an AVF
Misconnected bloodlines during the wash-back procedure can be fatal
The introduction of a Y-connector to be used during the wash-back procedure can be a viable solution to improve patient safety on HHD and minimise the risk of exsanguination
AcknowledgementsAcknowledgements
HHD patients and their families Colleagues and friends at the Belfast City
Hospital Baxter Healthcare Amgen