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Hemodialysis Fluid Leaks and ICU DrainsFacilities: Rick Marini, Gary Bernard, Kevin Lincoln

Infection Control / Hospital Epidemiology: Bernadette Sullivan, Graham SnyderHemodialysis team, Critical Care nursing and physician leadership

Aim/Goal

Lessons Learned

• Patients receive hemodialysis (HD) in the intensive care unit (ICU) when they are too unstable to travel to the HD unit (Farr 7)

• HD usually takes 3-4 hours. An alternative type of procedure, continuous renal replacement therapy (CRRT), is performed continuously and is commonly used in the ICU.

• Sentinel event: HD and ICU RNs noticed fluid overflowing into the adjacent ICU room during a HD procedure.

Results / Progress to Date

InterventionsThe Problem

Next Steps

To investigate recurrent leaks in ICUs during HD sessions, and prevent future recurrences.

Multidisciplinary meetings were held to assess and resolve the issue:Maintenance survey of ICU room drains• Staff observations during CRRT• Review of all off-unit non-ICU dialysis sessions for related issues• Staff asked to call ICU leaks to Service Response Center

Service Response Center Reports were reviewed for the preceding 12 months to identify the frequency of possible and definite HD-associated leaks:

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Potential and Actual Risks to Patient Care Operations:• Moisture mold patient infections: no known related

infections• Healthcare worker safety (falls): no known related falls• Patient safety (falls): no known related falls• Patient flow/bed management: room closures were required• Cost of Maintenance/Facility operations: hours of person-time

were expended

• Workarounds commonly occur when a problem arises; bringing issues to a multi-disciplinary discussion may reduce the inhibition of staff to raise a concern

• Standardizing practice (in this case, using the same method to drain, every time) may help remove risk of patient, facility, or employee issues.

• Planning for future construction should include consideration of clinical needs (drainage for HD) and infrastructure necessary to accomplish the task.

• Critical Care and HD communication channels are open for recurrent issues

• Semi-annual preventative maintenance to test each ICU dialysis drain using conditions more rigorous that normal

• Maintenance, Dialysis, Critical Care Nursing, and Infection Control / Hospital epidemiology will all have input in new construction plans when they arise.

Results of Facilities/Maintenance survey:• 58 rooms/drains evaluated: flowing water from cut length of

garden hose directly into dialysis drain box for 10 minutes, at higher pressure/volume than normal conditions

• 10 (17%) drains were found to be slow: all snaked, no issues on retesting

Preventative maintenance inspections performed in June & December 2014 have identified only 2 slow drains that resolved with snaking.

No known recurrent flooding/leak events.

Retrospective Review of Possible Hemodialysis-associated Leaks

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Commode unit (Acorn unit) in a typical ICU patient room

Water and drain source for HD

Water source

Drain for HD effluentFlange to secure HD

effluent drain tubing (100-120 PSI)

Retrospective Review of Possible Hemodialysis-associated Leaks

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