One statement heard around the globe in dialysis units is: “Nurse! Nurse! I’m bleeding!”

Another common statement rolling off the tongue of many patients is: “Don’t stick there! It hurts more, you know!” Though these patients are ill, they are stable. Most do not have the traditional appearance of someone who is chronically ill, and they can hold jobs, drive, travel and enjoy living their lives, just as a healthy individual does daily. However, they are ill. They are the ones who have developed End Stage Renal Failure, and are now dialysis patients for life or until their transplant. They spend 12 hours and beyond every week in a dialysis chair, and their safety depends on a person they call “Nurse.”

Our job as dialysis nurses goes beyond the traditional nursing role when we step into the dialysis unit. We are the nurse, educator, dietitian, transportation provider, councilor and friend. We tie the safety and health of each patient together seamlessly. (Usually!)

What I want to look at is safety related to our patients’ dialysis treatment, their treatment safety! An important issue in a field where autonomy exists, mistakes can be hidden and decisions are made every second with every treatment, for good and bad.

Safety with medication administration

Example: A nurse was passing medication, iron 50 mg doses and 100 mg doses. Each syringe was labeled correctly. She was new to this dialysis facility and did not know each patient by sight or by chair location. She hung the iron doses on the lines of the sleeping patients, “forgot” the “5 rights of medication administration,” and gave the incorrect dosage to the wrong patients.

The first thought is, “it’s just iron! No harm, no foul!” But what if this had been a heparin dose? Or someone with an allergy to iron? The consequences could have been vast.

There are steps in place to keep errors from occurring. According to Alan S. Kliger, in the article, Maintaining Safety in the Dialysis Facility, he states, “safety as a primary goal, develop specific competencies in safe practice, create patterns of behavior or practice that foster patient safety, and measure the effectiveness of preventive measures. Teams of caregivers learn together to hold patient safety as a top priority and practice in a non-punitive, accountable, safe environment. Precepts include having a questioning attitude, asking clarifying questions, and being responsible both for one’s own behavior and the behavior of each other. Tools such as safety huddles, read-backs, and checklists help improve communication and minimize the likelihood of errors and harm” (1). When it comes to meds, and as nurses we have heard this over and over again, use the 5 rights! Read-back labels and match the name to the machine, then you know who is in that chair. It counts, even in dialysis.

Safety and infection control

Infection control is a big deal, and who does it start with? YOU and your tech! We are the ones who set the stage, reminding our patients about the importance of washing their access sites. Skin is our largest organ, as well as our largest infection entrance site.  Leading our patients to the sink for a good old fashioned soap and water scrub will aid in decreasing the rate of infection.

Dr. Steven Berman stated in his article, Infections in Patients Undergoing Chronic Dialysis, states, “To better understand the issue of infection in dialysis patients, we reviewed a 10-year experience of inpatient and outpatient medical records for 433 patients with ESRD requiring chronic hemodialysis. Twenty-four hundred (2,400) infections were identified, requiring 5,111 courses of antibiotics, averaging 10% of total days in chronic dialysis therapy. The most common infection involved hemodialysis vascular access (HVAD). Staphylococcus aureus, coagulase negative staphylococci (CONS), P. aeruginosa, E. coli, Klebsiella, and Enterobacter were the most frequent isolates. From infections of the HVAD, S. aureus and CONS were the most commonly isolated bacteria”(2). How do we help our patients with this risk? Well, it seems like a dark tunnel bound for infection, but there is a light. It is called hygiene. Dr. Berman confirmed in his article, “The chances of infection of the vascular access are increased in patients with poor personal hygiene, malnutrition, and inadequate dialysis. The type of vascular access is a major risk factor for infection”(3).

We wash our hands for meals, we wash our access for dialysis. This needs to be encouraged and become standard practice in all dialysis clinics. (I know we say it is, but I know it is not done). Not just part of the time, some of the time, but ALL of the time. Standard of care. Are you on-board with me? Yeah? I thought you would be! (Yes, your patients will grumble and fuss, but just think: who knows, you may be saving their life!)

Safety continues with cannulation of fistulas and grafts

EXAMPLE: I sent a patient to Interventional Radiology to have a fistulagram. He had reduced dialysis adequacy (Kt/V) and prolonged bleeding post dialysis treatment. The evening after his procedure, I received a call from the IR doctor. The conversation went something like this:

Doctor: He has a large aneurysm that is being stuck repeatedly. Tell everyone who sticks an aneurysm to stop! They will become thin and the fistula will be placed at risk. Patient XYZ’s aneurysm is so thin it will not take much for it to burst, if that happens it will be a blood bath and we have lost the whole thing! Remind everyone to LADDER their sticks.

Me: I sure will do so. I realized he had an aneurysm, I did not realize it was to that point. I will place this order now and begin education with my staff.

Doctor: UMMM…Thanks

Referring back to the article, Infections in Patients Undergoing Chronic Dialysis, I found Dr. Berman stating, the AVF “may become dysfunctional because of the development of venous aneurysms, and poor venous flow from stenosis. Repair is difficult and the AVF may be unusable as a result of these complications” (4). We provide education to our patients regarding the proper method of cannulation. Knowledge is power! If they understand the reason for laddering their “sticks” they may not complain as much, which will make it easier on us. I know it increases the “stick” pain level. Got that! LOUD and CLEAR! However, if I can increase the life of their fistula by many years, isn’t it worth the pain? Just my thought process.

In an article from the Clinical Kidney Journal, from August 2015, written by Anna Mudoni et al., they discuss cannulation, aneurysm, and pseudo-aneurysms. Here is a bit: “The etiology of true aneurysms in AVFs is less clear. Repeated needling results in multiple small fibrous scars in the vessel wall, which may expand with time and result in localized aneurysmal areas. In areas where needling has not been performed, aneurysmal dilation can occur and the high flow through the vessel may result in abnormal shear stress, which promotes outward remodeling and gradual dilation with grossly increased caliber of the vessel. Histological examination of resected fistula aneurysms shows extensive infiltration of collagen with thickening and altered architecture of the vessel wall.” You know when you look at an aneurysm and the skin is shiny and you can see the different texture? That is what they are talking about here! DON’T STICK IT! Look back at my conversation with my IR doctor and use the Ladder method.

In conclusion, I find that these hurdles are a great tool for communication. They allow me to communicate with my entire staff. Once my first shift is on before people begin to head for breakfast, we take 5 minutes to discuss what patients have called in, who is having cannulation issues, washing accesses, laddering sticks, low Kt/V’s, jobs for the day, and any other issue that may pop into my head. Try it! It takes a bit to get used to, but it will help improve your overall communication and patient safety for your clinic!

“LADDER AND LOVE IT” is a fun phrase to begin using in your dialysis clinics.

Dialysis Nursing – The new critical care adrenaline rush – You either love it or hate it!

I LOVE IT

Works Cited:

1.     Alan S. Kliger; Maintaining Safety in the Dialysis Facility Clinical J Am Soc Nenphrol,2015 Apr 7; 10(4): 688–695, Published online 2014 Nov 6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386259/

2.    Steven Berman, M.D. Infections in Patients Undergoing Chronic Dialysis, Antimicrobe, 2017, published online 2010-2017.http://www.antimicrobe.org/e41.asp

3.   Steven Berman, M.D. Infections in Patients Undergoing Chronic Dialysis, Antimicrobe, 2017, published online 2010-2017.http://www.antimicrobe.org/e41.asp

4.   Steven Berman, M.D. Infections in Patients Undergoing Chronic Dialysis, Antimicrobe, 2017, published online 2010-2017.http://www.antimicrobe.org/e41.asp

5.   Anna Mudoni, Marina Cornacchiari, Maurizio Gallieni, Carlo Guastoni, Damian McGrogan, Francesco Logias, Emiliana Ferramosca, Marco Mereghetti, Nicholas Inston; Aneurysms and pseudoaneurysms in dialysis access, Clinical Kidney Journal, Volume 8, Issue 4, 1 August 2015, Pages 363–367, https://doi.org/10.1093/ckj/sfv042