Introduction: Vascular access complications are associated with increased morbidity and mortality in home hemodialysis (HHD). Nurse‐administered vascular access checklist is a feasible quality improvement strategy aimed to lower HHD access errors. Methods: We conducted a prospective quality improvement initiative for consecutive HHD patients between April 2013 and December 2016 at the Toronto General Hospital. Vascular access audits were administered every 6 months during clinic visits and during retraining sessions after an infection. We aimed to (1) determine whether prospective serial administration of vascular audit will decrease in the number of errors performed by the patient and (2) to determine whether there is an association between the number of errors and vascular access related infection. Findings: A total of 370 audits were performed on 122 patients with a mean HHD vintage of 6.7 (0.8–19.5) years. The mean number of errors per patient decreased from 1.24 ± 1.75 (baseline) to 0.33 ± 0.49 (last follow‐up), P < 0.001. Among patients who had serial vascular access audits performed, there was a significant decrease in median number of errors (baseline median 1, [0–2] end of study median 0, [0–1] P = 0.01). Patients performing buttonhole cannulation made most proportion of errors as compared to CVC, 54% vs. 40% (P = 0.01) respectively; and as compared to rope ladder cannulation 54% vs. 37% (P = 0.008). We were unable to demonstrate an association between the change in patient reported errors and vascular access related infection. Discussion: Vascular access audit is a feasible quality initiative, which leads to a decrease in the number of patient reported errors in vascular access. The longitudinal clinical sequelae of this strategy warrants further examination.
Introduction: The provision of sufficient support contributes to home hemodialysis (HHD) technique survival. The need for backup treatment in incident and prevalent patients on HHD has not been well described previously, and is important from both technique survival and resource allocation. We aimed to quantify the amount of backup treatment given to patients in our HHD unit, and hypothesized that the provision of backup HD facilitated technique survival. Methods: This was a retrospective, single-center cohort study quantifying the provision of backup HD between January and December 2018. Electronic and paper medical records were accessed for data collection. Findings: One hundred and nineteen patients dialyzed independently at home during the study period (96 patient years of HHD). Seventy-eight (66%) patients required a total of 292 backup HD sessions in the HHD unit, representing an average of three backup HD runs per patient year of HHD. Fifty-three percent of backup HD runs were required for vascular access related issues. The most common clinical issue requiring assessment and backup HD was extracellular fluid volume management. An equal proportion (95%) of those that utilized backup HD and those that did not utilize backup HD maintained a positive disposition (transplant or ongoing HHD) in relation to technique survival in the short term. Conclusions: From a resource viewpoint, this program of approximately 100 HHD patients required the availability of one to two staffed HD stations each weekday for backup HD. The provision of backup HD was not a harbinger of HHD discontinuation.
Introduction: Venous needle dislodgement (or venous port disconnection) during hemodialysis (HD) may lead to catastrophic blood loss, particularly during unsupervised home HD. A prototype venous line clamp was developed for use in conjunction with the Redsense blood loss sensor. We hypothesize that this prototype device will provide additional safety to dialysis without excessive burden. Methods: This was a single‐center, prospective cohort study. Participants kept a log of bleeding, troubleshooting and clamp deployment events, and completed questionnaires before device first use and after device final use. The primary outcome was appropriate device function, evaluated by review of bleeding and clamp deployment events. The secondary outcomes were patient/nursing staff expectations and experience of the device. Findings: Fourteen patients used the device during a combined total of 214 HD treatments. Five participants (36%) had experienced a bleeding or disconnection event prior to study recruitment. All vascular access types were represented. The device was tested during incenter HD (n = 7 patients) and home HD (n = 7 patients). There were eight clamp deployment events, three of which were in the setting of minor bleeding at the venous access site. No other bleeding events were reported. The main troubleshooting issues were related to cumbersome device connections. Participants perceived additional safety with the device (median score 4.25 out of 5; range 1–5). However, the amount of additional work created was variable, and large in some cases (median score 2 out of 5; range 0–4.5). There was no association between HD vintage and device burden (P = 0.55). Discussion: This “proof of concept” study confirmed that a clamp on the venous line, operating in conjunction with a venous access blood detector, is feasible regardless of HD location or vascular access type. The device improved patient safety perception during HD but was burdensome. Design modifications could improve future device iterations.
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