Home Haemodialysis: Improving Patient Safety Judith Moore Pre Dialysis and Home Therapies Team Leader Belfast City Hospital

Facts

Facts Population of 1.8 million Host of the recent 2013 World Police and Fire Games (WPFG). “The friendliest games ever” – WPFG Federation President.

Contents Background Home Haemodialysis (HHD) in Northern Ireland Biomed Central Report 2012 Identified Area of Change Conclusion Acknowledgements

Background Belfast City Hospital - 200 in-centre HD patients. Sub-regional units - 500 in-centre HD patients. Belfast City Hospital (BCH) encompasses Northern Ireland’s Regional Dialysis, Nephrology and Transplant Service. There sub-regional dialysis units in Northern Ireland providing in-centre HD for another 500 patients.

Home Haemodialysis (HHD) in Northern Ireland Established 10 years 77 patients trained Approx 45% transplanted Current total of 33 patients 69% monthly reviews by BCH HHD team 31% monthly reviews by sub-regional community dialysis teams HHD has been established in Northern Ireland for 10 years. Since 2003 there has been 77 patients trained to undertake HHD. Approx 45% of these 77 patients have been transplanted At present there are 33 patients actively enrolled on the programme. 70% of these patients dialyse with an arterio-venous fistula (AVF) cannulated via the button-hole technique. 30% of these patients dialyse with a central venous catheter (CVC). 30% of the patients who dialyse via a CVC also have an AVF. Some of these patients are awaiting further surgery to take place on their AVF before it can be utilised. 69% of the monthly reviews are undertaken by the Belfast City Hospital (BCH) Home haemodialysis (HHD) team in the patients own home. The other 31% of the monthly reviews are undertaken by the community dialysis teams in the sub-regional units.

Map depicting the geographical location of the current HHD patients in NI. Existing Patients

Biomed 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: 30 years experience 80 patients MDT selection Train 20-25 patients per year Average approx 3-4 months training per patient Monthly visits and support HHD established in Auckland for 30 years with 80 patients enrolled on the programme. Patients are selected by MDT ensuring that they are functionally, physically and medically capable. Team train between 20-25 patients per year. Training is rigorous – average is 110 days. Frequent support provided by team post training through telephone calls/monthly visits.

Biomed Central Nephrology Report 2012 Key Points of the report relating to the patient: 67 year old male AVF 20 weeks successful training Contact with case manager on morning of death Death occurred due to misconnected bloodlines 2.3L of blood Hypovolaemia Patient was a 67 year old retired businessman who lived with his wife, children and his mother. He had an AVF as his HD access. HHD training completed successfully over a 20 week period. 1 month of uncomplicated HHD prior to the event. On the morning of his death he had contacted his case manager to propose a decrease in his target weight and the removal of more fluid than prescribed. He was advised against this. Death occurred during the “open circuit” wash-back procedure method as a result of misconnected bloodlines. Patient connected the saline wash-back line to the venous needle instead of the arterial needle. Approx 2.3L of blood was pumped from the patient in to the saline wash-back bag resulting in hypovolaemia and death from exsanguination.

Biomed 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 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 Despite intensive competency based training for our HHD patients, some reported that they had incorrectly connected the venous line to the wash-back line during disconnection. The patients were able to indentify and corrected their mistake otherwise the consequences could have been fatal. In light of the fatality in the New Zealand report and what had occurred with some of our patients we introduced a change in wash-back procedure for all the HHD patients. Use of a Y-connector with 2 clamps was introduced to all current and new HHD patients.

Introduction of Y-Connector for all HHD Patients with an AVF

Introduction 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 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 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 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 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 Procedure

Use 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-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 74% off the HHD population as of July 2013 with AVF’s have been re-trained on the use of the Y-piece. All patients have been informed as to why the implementation of the Y-connector has occurred and that it is for their safety. Re-training and the information given to the patient is recorded in their nursing notes on the Renal Database Emed. All new patients commenced on HHD since July 2012 are been trained in the use of the Y-connector as part of their training. Patients have found this new procedure beneficial. Some have stated that “it makes sense” and is “easily understood”. 22% of the patients do not like using the Y-connector. Patients have stated that it is too heavy. If the patient chooses not to use the Y-connector it is documented in their nursing notes. There have been no reports of misconnected bloodlines since the introduction of the Y-connector as part of the wash-back procedure.

Conclusion 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

Acknowledgements HHD patients and their families Colleagues and friends at the Belfast City Hospital Baxter Healthcare Amgen