(touch to enlarge) Hemodialysis Fluid Leaks and ICU Drains Facilities: Rick Marini, Gary Bernard, Kevin Lincoln Infection Control / Hospital Epidemiology:

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(touch to enlarge) Hemodialysis Fluid Leaks and ICU Drains Facilities: Rick Marini, Gary Bernard, Kevin Lincoln Infection Control / Hospital Epidemiology: Bernadette Sullivan, Graham Snyder Hemodialysis team, Critical Care nursing and physician leadership Hemodialysis Fluid Leaks and ICU Drains Facilities: Rick Marini, Gary Bernard, Kevin Lincoln Infection Control / Hospital Epidemiology: Bernadette Sullivan, Graham Snyder Hemodialysis 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 Interventions The 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: (touch for details) 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 (touch to return) Commode unit (Acorn unit) in a typical ICU patient room Water and drain source for HD Water source Drain for HD effluent Flange to secure HD effluent drain tubing ( PSI)

Retrospective Review of Possible Hemodialysis-associated Leaks (touch to return)