Home Haemodialysis: Improving Patient Safety Judith Moore Pre Dialysis and Home Therapies Team...

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