How to improve dialysis unit

1. Maroof International Hospital
Dialysis Unit
IS OUR DIALYSIS UNIT SAFE? ARE THERE OPPORTUNITIES TO
IMPROVE SAFETY?
Dr Junaid Nazar
MBBS,MPH,FRSPH,MD INTERNAL MEDICINE, FWAMS, MSC NEPRHOLOGIST
Specialist Registrar Nephrologist/Chairman Nephrology Section WAMS
Maroof International Hospital, Islamabad, Pakistan
Email;dr.cmjnazar@live.co.uk

2. OBJECTIVES
 Identify and learn from incidents and risks
 Improve renal patient safety
 Pilot project with NPSA
 Experience Sharing

3. BACKGROUND
• 10% of patients in hospital experience suffer
from some type of patient safety incident
– Up to half are preventable.
• 60% of incidents related to equipment are as a
result of failure of usage
• Patient Safety is a must hospital priority

4. NPSA Incident Data Analysis
• NPSA data
• Estimated ~ 725 incidents/year occur in renal
units in England and Wales
– Result in death or potential death (n=55)
– severe harm (n=120)
– or moderate harm (n=550)
• 10 or more / unit / year
– ? Significant underreporting

5. Incidents and risk-prone situations
reported
 30 month period
 31 incidents and 5 risks identified
 Circulated by email to renal unit clinical directors and
lead nurses.
 Source of information about incidents
Renal units (42%) - incl. nurses and technologists
NPSA (28%)
MHRA (30%)
 17 were circulated as NPSA or MHRA alerts.

6. Incidents and risk-prone situations
reported
 The largest number of incidents (36%) were due to failure of dialysis
techniques or dialysis machine usage
 Failure of dialysis machines (19%)
 Failure of dialysis equipment or disposables
(22%)
 Medication (19%)

7. Failure of dialysis techniques
• Venous needle dislodgement
• Fatal Pulmonary Embolus from an attempt to
unblock an occluded arteriovenous fistula
• Air embolism from haemodialysis catheter
disconnection
• Bleeding from an infected fistula needling site
• Bleeding from removal of femoral line

8. Failure of dialysis equipment usage
Setting excessive ultrafiltration on HD
Lack of mixing of bicarbonate haemofiltration
bags (ICU)
Nikkiso conductivity setting (Na 170)
Fresenius dialysate line configuration

9. SANITARY ENVIRONMENT
Recommendations for Preventing
Transmission of Infections Among Chronic
Hemodialysis Patients.” (includes procedures
and comprehensive program)
Hand Hygiene
Gloves
Cleaning & Disinfecting of contaminated
surfaces, medical devices and equipment

10. HBV+ ISOLATION ROOM/AREA NEW
REGULATIONS
Effective Feb 9, 2009, every new facility MUST
include an isolation room for treatment of
HBV+ patients, unless the facility is granted a
waiver of this requirement
For existing units in which a separate room is
not possible, there must be a separate area
for HBsAg positive patients

11. CHRONIC DIALYSIS FACILITIES HAVE A SELF
AUDIT
 Survey of this Condition requires:
• observations of care delivery,
• interviews with staff and patients,
• review of medical records, facility logs, policies and procedures and quality assessment and
performance improvement (QAPI) documentation.
 Medical and administrative records should demonstrate recognition of any potential
infection and actions taken to decrease the transmission of infection within the dialysis
facility.
 If deficient practices noted in infection control, techniques are multiple, pervasive, or of an
extent to present a risk to patient health and safety, Condition level non-compliance should
be considered.

12. CHRONIC DIALYSIS CONDITIONS
Sanitary Environment:
 “Recommendations for Preventing Transmission
of Infections Among Chronic Hemodialysis
Patients.” (includes procedures and
comprehensive program
Hepatitis: “Recommendations for Preventing
Transmission of Infections Among Chronic
Hemodialysis Patients,” (precautions, testing,
immunization, isolation, surveillance, response,
training

13. HOSPITAL CONDITIONS IN INFECTION
CONTROL
The hospital must provide a sanitary environment
to avoid sources and transmission of infections
and communicable diseases.
 There must be an active program for the
prevention, control, and investigation of
infections and communicable diseases.
 The hospital’s program for prevention, control
and investigation of infections and communicable
diseases should be conducted in accordance with
nationally recognized infection control practices
or guidelines

14. COMMON PATIENT SAFETY COMPLAINTS
Staff are not washing their hands
 Staff do not change gloves between patients
 Staff not wearing appropriate PPE
Given the wrong medication
 Given the wrong dialyzer
 Staff not performing safe procedure (catheter
care)
Staff unskilled in cannulation
 Staff not performing appropriate patient
assessments

15. TEAM APPROACH HAS GREATER ROLE IN
SAFE PRACTICES
Personnel: All team approach
 Patient safety committee
 Time: management in shortage of staff
 Training staff
 Educating patients
 Evaluating ongoing patient safety
 Technology:
 Modifying systems as needed

16. Documentation
1. Computer
Online documentation
Labs Pre-dialysis and post dialysis monthly
follow ups
Patient records
Medications list
2. space
Increase number of machine

17. Protocols
 Hypotension
 Hyperkalemia
 Hypertensive emergencies and chronic hypertension
on hemodialysis
 Cardiac arrest on hemodialysis
 Emergency exit process
 Cramps
 Anticoagulation
 Anemia
 Air embolism
 Sepsis

18. Staff training
 The staff should receive initial and on-going education on the basic
principles and practices of dialysis, infectious risks and potential
adverse events, and IPC practices.
 The patient should receive education on access site and dressing
care, signs and symptoms of infection, and the importance of
reporting potential infections
 Staff should receive hepatitis B vaccination.
 Pathways need to develop
 Patients education
1. Diet
2. vaccinations
3. regular dialysis

19. SUMMARY
• Dialysis (HD or PD) is a lifeline for patients with ESRD or renal failure
and or awaiting kidney transplant.
• Patients receiving dialysis treatments are at increased risk of
infection. IPC programs includes:
• Hand hygiene,
• Appropriate PPE to provide a barrier to contact with blood,
• body fluids, Non-intact skin or mucous membranes,
• Immunization of patients & HCW’s,
• Aseptic technique----------------------------to reduce patient/client
exposure to microorganisms,
• Management of sharps, blood spills, linen, and
• Waste management to maintain a safe environment,
• Routine environmental cleaning.

20. Conclusion
Infection control is a responsibility of
everyone involved with the dialysis treatment
process.
Implementation of IPC procedures and a safe
environment including water, all are critical in
eliminating or mitigating infection risk for both
patients and HCW.
Patients’ education is also an essential to
prevent infections associated with dialysis.