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Haroon SWP, Lau TWL, Tan GL, Liu EHC, Hui SH, Lim SL, Santos D, Hodgson R, Taylor L, Tan JN, Davenport A. Risk assessment of failure during transitioning from in-centre to home haemodialysis. BMC Nephrol 2022; 23:406. [PMID: 36539703 PMCID: PMC9768953 DOI: 10.1186/s12882-022-03039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Introducing a de-novo home haemodialysis (HHD) program often raises safety concerns as errors could potentially lead to serious adverse events. Despite the complexity of performing haemodialysis at home without the supervision of healthcare staff, HHD has a good safety record. We aim to pre-emptively identify and reduce the risks to our new HHD program by risk assessment and using failure mode and effects analysis (FMEA) to identify potential defects in the design and planning of HHD. METHODS We performed a general risk assessment of failure during transitioning from in-centre to HHD with a failure mode and effects analysis focused on the highest areas of failure. We collaborated with key team members from a well-established HHD program and one HHD patient. Risk assessment was conducted separately and then through video conference meetings for joint deliberation. We listed all key processes, sub-processes, step and then identified failure mode by scoring based on risk priority numbers. Solutions were then designed to eliminate and mitigate risk. RESULTS Transitioning to HHD was found to have the highest risk of failure with 3 main processes and 34 steps. We identified a total of 59 areas with potential failures. The median and mean risk priority number (RPN) scores from failure mode effect analysis were 5 and 38, with the highest RPN related to vascular access at 256. As many failure modes with high RPN scores were related to vascular access, we focussed on FMEA by identifying the risk mitigation strategies and possible solutions in all 9 areas in access-related medical emergencies in a bundled- approach. We discussed, the risk reduction areas of setting up HHD and how to address incidents that occurred and those not preventable. CONCLUSIONS We developed a safety framework for a de-novo HHD program by performing FMEA in high-risk areas. The involvement of two teams with different clinical experience for HHD allowed us to successfully pre-emptively identify risks and develop solutions.
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Affiliation(s)
- Sabrina-Wong-Peixin Haroon
- grid.412106.00000 0004 0621 9599Division of Nephrology, National University Hospital Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228 Republic of Singapore
| | - Titus-Wai-Leong Lau
- grid.412106.00000 0004 0621 9599Division of Nephrology, National University Hospital Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228 Republic of Singapore
| | - Gan Liang Tan
- grid.508163.90000 0004 7665 4668Department of General Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Eugene-Hern Choon Liu
- grid.4280.e0000 0001 2180 6431Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Soh Heng Hui
- grid.412106.00000 0004 0621 9599Renal Centre, National University Hospital, Singapore, Singapore
| | - Siao Luan Lim
- grid.412106.00000 0004 0621 9599Renal Centre, National University Hospital, Singapore, Singapore
| | - Diana Santos
- grid.412106.00000 0004 0621 9599Medical Affairs-Clinical Governance, National University Hospital Singapore, Singapore, Singapore
| | - Robyn Hodgson
- grid.83440.3b0000000121901201Department of Renal Medicine, University College London, Royal Free Hospital, London, United Kingdom
| | - Lindsay Taylor
- grid.83440.3b0000000121901201Department of Renal Medicine, University College London, Royal Free Hospital, London, United Kingdom
| | - Jia Neng Tan
- grid.412106.00000 0004 0621 9599Division of Nephrology, National University Hospital Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228 Republic of Singapore
| | - FH HHD
- grid.83440.3b0000000121901201Department of Renal Medicine, University College London, Royal Free Hospital, London, United Kingdom
| | - Andrew Davenport
- grid.83440.3b0000000121901201Department of Renal Medicine, University College London, Royal Free Hospital, London, United Kingdom
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Long B, Koyfman A, Lee CM. Emergency medicine evaluation and management of the end stage renal disease patient. Am J Emerg Med 2017; 35:1946-1955. [PMID: 28893450 DOI: 10.1016/j.ajem.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/02/2017] [Accepted: 09/03/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis. OBJECTIVE This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population. DISCUSSION ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants. CONCLUSIONS Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.
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Affiliation(s)
- Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Courtney M Lee
- Joint Base Elmendorf Richardson Medical Center, Department of Emergency Medicine, 5955 Zeamer Ave, JBER, AK, 99506, United States
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Simon EM, Summers SM. Vascular Access Complications: An Emergency Medicine Approach. Emerg Med Clin North Am 2017; 35:771-788. [PMID: 28987428 DOI: 10.1016/j.emc.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Millions of central venous and arterial catheters are placed across the United States annually as mechanisms of obtaining advanced hemodynamic monitoring and facilitating acute resuscitation. Although presumably life saving or sustaining in many circumstances, current literature identifies the preprocedural and postprocedural complications of infection, thrombosis, embolism, and iatrogenic injury as resulting in patient morbidity and mortality. Today, through the application of aseptic technique, performance of operator training, and the utilization of ultrasound, emergency physicians may limit vascular access complications and improve patient outcomes.
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Affiliation(s)
- Erica Marie Simon
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio Military Medical Center, SAMMC, MCHE-EMR, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-6200, USA.
| | - Shane Matthew Summers
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio Military Medical Center, SAMMC, MCHE-EMR, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-6200, USA
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Simon E, Long B, Johnston K, Summers S. A Case of Brachiocephalic Fistula Steal and the Emergency Physician's Approach to Hemodialysis Arteriovenous Fistula Complications. J Emerg Med 2016; 53:66-72. [PMID: 27964855 DOI: 10.1016/j.jemermed.2016.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/04/2016] [Accepted: 10/14/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic kidney disease is common in the United States, with many patients maintained on hemodialysis (HD). The process of HD requires vascular access through an arteriovenous (AV) fistula, AV graft, or central venous catheter. Today, as a result of the National Kidney Foundation's "Fistula First" initiative, nearly 55% of HD patients utilize an AV fistula. As there is significant morbidity and mortality associated with fistula placement and recurrent fistula cannulation, emergency physicians must be equipped to recognize and treat fistula complications. OBJECTIVE To detail a case study of vascular insufficiency (vascular steal) presenting to an emergency department (ED) and provide an evidence-based approach to the emergency assessment and management of HD AV fistula complications. DISCUSSION A 66-year-old man presented to the ED with left upper extremity pain, paresthesias, and loss of grip strength of 1-week duration 15 days after placement of left upper extremity brachiocephalic fistula. He was diagnosed with dialysis access-associated steal syndrome and taken to the operating room for revision. Patients with HD fistulas may experience several complications, including vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, or pseudoaneurysms. Emergency physicians must be able to identify these complications and deliver timely treatment. CONCLUSIONS A comprehensive understanding of the appropriate management of AV fistula complications is paramount for the emergency physician. Early recognition and treatment of vascular insufficiency resulting from fistula creation, fistula hemorrhage, fistula infection, stenosis, thrombosis, and aneurysms or pseudoaneurysms is vital to reducing the morbidity and mortality associated with HD.
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Affiliation(s)
- Erica Simon
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Kyle Johnston
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Shane Summers
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
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Roseman DA, Schechter-Perkins EM, Bhatia JS. Treatment of life-threatening hyperkalemia with peritoneal dialysis in the ED. Am J Emerg Med 2014; 33:473.e3-5. [PMID: 25241357 DOI: 10.1016/j.ajem.2014.08.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 08/16/2014] [Indexed: 11/24/2022] Open
Abstract
Severe hyperkalemia (serum potassium N 7.0 mmol/L) is an uncommon electrolyte abnormality in patients undergoing maintenance peritoneal dialysis (PD). Hemodialysis (HD) has been suggested as the definitive therapy for severe hyperkalemia in this population,although there is limited data regarding renal replacement options.We report a case of life-threatening hyperkalemia with electrocardiogram changes in a nonadherent PD patient who was successfully treated with standard medical therapy and manual exchanges initiated by emergency department (ED) personnel. The patient did not require HD. This case demonstrates the potential utility of PD as a treatment option for severe hyperkalemia in established dialysis patients when EDs are prepared to deliver exchanges. This report maybe particularly relevant due to the increasing prevalence rate of PD and for centers with limited HD access.
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Affiliation(s)
- Daniel A Roseman
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA, USA
| | | | - Jasvinder S Bhatia
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA, USA.
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Use of dialysis access in emergent situations. J Emerg Nurs 2007; 34:37-40. [PMID: 18237665 DOI: 10.1016/j.jen.2007.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 03/21/2007] [Accepted: 03/22/2007] [Indexed: 11/22/2022]
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Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites. Forensic Sci Med Pathol 2007; 3:128-32. [DOI: 10.1007/s12024-007-0003-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2007] [Indexed: 10/23/2022]
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Sacchetti A, Stuccio N, Panebianco P, Torres M. ED hemodialysis for treatment of renal failure emergencies. Am J Emerg Med 1999; 17:305-7. [PMID: 10337896 DOI: 10.1016/s0735-6757(99)90131-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Patients with chronic renal failure (CRF) are at risk for unique medical emergencies, many of which require hemodialysis for their definitive treatment. This study describes the use of emergency department (ED) hemodialysis in the management of CRF patients. A retrospective chart review was conducted of patients who underwent ED hemodialysis at a regional dialysis center between April 1994 and September 1996. Data were collected on presenting complaint, ED diagnosis, indication for hemodialysis, ED pharmacologic treatment, ED airway management, cardiovascular stability, and disposition. Fifty episodes of ED hemodialysis were identified in 37 different patients. Presenting complaints included: shortness of breath, 38 (69%); weakness, 8 (15%); chest pain, 3 (5%); and other, 6 (11%). ED diagnoses included: congestive heart failure, 36 (65%); hyperkalemia, 13 (24%); and other, 6 (11%). Indications for hemodialysis included: cardiovascular instability, 33 (38%); respiratory distress, 22 (26%); cardiac monitoring, 16 (19%), timing, 13 (15%); and other, 2 (2%). Predialysis stabilization included: nitroglycerin, 29 (26%); sublingual captopril, 17 (15%); calcium chloride, 13 (11%); sodium bicarbonate, 12 (11%); insulin/dextrose, 11 (10%); none, 12 (11%); and other, 18 (16%). Airway support included: noninvasive pressure support ventilation (NPSV), 9 (18%); and endotracheal intubation, 6 (12%). NPSV was provided with a bilevel positive airway pressure system. Three of the endotracheal intubation patients were weaned to NPSV during dialysis, and all NPSV patients were weaned from respiratory support during their hemodialysis in the ED. Some patients had more than one problem. Sixteen patients (32%) were admitted, while 34 (68%) were discharged, including 3 NPSV patients and 22 initially unstable patients. ED hemodialysis in conjunction with additional medical care is a useful emergency medicine technique that can prevent hospital admission in patients with acute renal emergencies.
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Affiliation(s)
- A Sacchetti
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ 08103, USA
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Sacchetti A, McCabe J, Torres M, Harris RL. ED management of acute congestive heart failure in renal dialysis patients. Am J Emerg Med 1993; 11:644-7. [PMID: 8240572 DOI: 10.1016/0735-6757(93)90023-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
This is a descriptive report of the management techniques used effectively in the emergency department (ED) treatment of acute congestive heart failure (CHF) in renal dialysis patients. Study design included a prospective case series of consecutive renal dialysis patients who presented to the ED of a regional dialysis center in acute CHF. Clinical presentation, ED management, and outcome were recorded. Forty-six patients (38 hemodialysis and 8 peritoneal dialysis) were included in this study. Presentation classifications for these patients were minimal distress (13 patients), moderate distress (16 patients), and severe distress (17 patients). In addition to supplemental oxygen, treatment focused on pharmacological preload and afterload reduction. Patients received sublingual nitroglycerin (NTG) (30 patients), transdermal NTG (36 patients), captopril sublingual (10 patients) nifedipine oral (nine patients), nitroprusside (four patients), morphine sulfate (one patient), NTG infusion (one patient), and clonidine (one patient). There were no deaths in the study group, and 32 of the patients were able to be dialyzed and discharged, including seven patients in the severe group. Six patients required intubation, one of whom was extubated and discharged from the ED after dialysis. Intravascular access was obtained in 29 patients but was used in only six. All patients on nitroprusside drips were weaned during the course of their dialysis. Effective ED management of acute CHF in renal dialysis patients can be accomplished through preload reduction with nitrates and afterload reduction with captopril, nifedipine, and, in severe cases, nitroprusside.
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Affiliation(s)
- A Sacchetti
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ
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