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Wrexham - BCUHB Serial No.: Ref. No.: BLUP1/MED/00 POLICY Home Haemodialysis Draft No: …1... Date: 17/02/2009 Number Of Pages Ratification Information Ratified By Chairperson Ratifying Medicine Directorate Date TBA (Named Person) Body Management Team Ratified In accordance with the Validation & Ratification Schedule which was approved by Trust Board Document Responsibilities Originator / Author Senior Sister Julie Oliver (Person Responsible and the Home Therapies For Review) Team Jackie Williams Owning Renal Department, Department Medicine Directorate. Validated By Dr Drew Date Validated TBA Document History First Operational 11/12/03 Previously Reviewed N/A (Updated At Review - Yes/No) N/A Next Review Date Operational Date Yes / No Yes / No Yes / No N/A N/A TBA TBA Yes / No Summary Of Current Review Changes N/A Contains References to the following Documents Document Title & Reference Universal blood and body fluid precautions. Document Title & Reference Permission granted by Fresenius to use all their policies within the operators’ manual. Their policies have been adapted for the use of the renal therapies team. Document Title & Reference Document Title & Reference Document Title & Reference 1 Wrexham - BCUHB 2 Wrexham - BCUHB Table Of Contents 1. Mission Statement............................................................................................... 5 1.2 Purpose........................................................................................................ 5 1.3 Scope ........................................................................................................... 5 2. Orientation / Patient Information.......................................................................... 5 2.1 Medications .................................................................................................. 5 2.2 Labs ............................................................................................................. 6 3. Clinical Records/Documentation ......................................................................... 6 3.1 Treatment Records ...................................................................................... 6 3.2 Hospitalizations ............................................................................................ 6 3.3 Clinic/Home Visits ........................................................................................ 6 4. Training ............................................................................................................... 7 4.1 Staff Training................................................................................................ 7 4.2 Patient Training ............................................................................................ 7 4.4 Access Management & Evaluation .............................................................. 7 5. Infection Control .................................................................................................. 8 6. Equipment ........................................................................................................... 8 6.1 Dialysis Machine and RO Unit - AQUA UNO ............................................... 8 6.1.2 Machine Settings .................................................................................. 8 6.1.3 Routine Procedures .............................................................................. 8 6.1.4 Alarms & Troubleshooting..................................................................... 8 6.1.5 Maintenance ......................................................................................... 9 6.1.6 Water Treatment. .................................................................................. 9 7. Equipment Preparation ....................................................................................... 9 7.1 Pre- Treatment Preparation ......................................................................... 9 7.2 Treatment..................................................................................................... 9 7.3 Post- Treatment ........................................................................................... 9 8. Complications during Home Dialysis ................................................................. 10 9. Contacts ............................................................................................................ 10 10. Procedures .................................................................................................... 10 AIR EMBOLISM ....................................................................................................... 11 AIR TRAP LEVEL MONITORING ............................................................................ 12 BLOOD LOSS .......................................................................................................... 13 DIALYZER BLOOD LEAK ........................................................................................ 14 DIALYSIS INTERRUPT AND RECIRCULATION ..................................................... 15 GIVING SALINE FLUSH MANNUALLY – If patient on HD or online bolus not available ................................................................................................................... 16 DISASTER - FIRE .................................................................................................... 17 DRAWING POST U & E ........................................................................................... 18 FEVER AND/OR CHILLS ......................................................................................... 19 HAEMOLYSIS .......................................................................................................... 20 HYPOTENSION ....................................................................................................... 21 MANUAL SALINE RINSEBACK ............................................................................... 22 MONITOR THE DIALYSIS TREATMENT ................................................................ 24 MUSCLE CRAMPS .................................................................................................. 25 NEEDLE INFILTRATION ......................................................................................... 26 PROCEDURE FOR THE INSERTION OF SHARP NEEDLES FOR DIALYSIS ....... 27 CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE STANDARD AV FISTULA NEEDLES ........................................................................................... 29 3 Wrexham - BCUHB POWER LOSS ......................................................................................................... 32 PREPARE FOR DIALYSIS ...................................................................................... 34 RINSEBACK POST-DIALYSIS ................................................................................ 37 ARTERIAL PRESSURE DEVICE DOES NOT OPEN WHEN LINE GUIDE IS INSERTED ............................................................................................................... 38 HAEMOCONCENTRATION WARNING................................................................... 39 COLLECT WATER SAMPLE SAMPLE FOR RESIDUAL CHEMICAL ANALYSIS .. 40 COLLECT WATER SAMPLE FOR CHLORINE TESTING ....................................... 41 COLLECT ONLINE SAMPLE FOR QA WATERS AND RO SAMPLE FOR QA AND CHANGE DIASAFE PLUS FILTERS........................................................................ 42 4 Wrexham - BCUHB 1. Mission Statement The home therapies team is committed in providing a service that is safe and appropriate to our patients needs. We will continue to review and improve our services and will benchmark with other agencies so that this can benefit our patients or the wider community. 1.2 Purpose To train a patient, safely, efficiently and competently in readiness to carry out home haemodialysis. 1.3 Scope Every trained nurse within the home therapies team. 2. Orientation / Patient Information Introduces the patient to the home therapies team. Potential new client’s checklist will be completed covering aspects such as vascular access, how Haemodialysis works and the benefits of dialysis, the training involved as listed in section 4.2, storage of equipment required for home dialysis, holidays, and educational tools to facilitate patient training. The patient will be informed of any necessary alterations that may be needed within the home and the Fresenius technician will carry out a preliminary home visit in the home to assess suitability of the Fresenius system. The technician will inform the patient of any alterations required and will also inform the Estates Department and Home Therapies team of all alterations necessary. Following identification of a suitable patient the patient will be informed of the time scale necessary prior to commencing home Haemodialysis. The patient will be informed of training objectives to be met prior to commencing dialysis at home, and will be required to sign his/her objectives to say they are happy to carry out their home therapy treatment. 2.1 Medications The home therapy team will discuss the medications used, explaining any potential side effects. This aspect is covered in the document:Home Haemodialysis client training objectives within the nursing care plan. The patient will be informed that drug dosages may be changed after a period of time on home Haemodialysis due to the frequency of dialysis. It will be explained to the patient that any alterations needed will be via GP via fax and phone calls. The patient will also be informed that if the acid concentrate is changed the old dialysate will need to be disposed of immediately. 5 Wrexham - BCUHB 2.2 Labs Frequency of required blood, and water testing will be explained to the patient. Request forms, details of blood tests and water testing will be included within the patient’s care plan and will be discussed during the training. 3. Clinical Records/Documentation Within the Nursing care plan documentation will be included:- Patient diagnoses, patient care plans and physician orders (meds, labs, and treatment settings). Dialysis Prescriptions Policies/Procedures include staff instructions/forms on recording, updating and maintaining these records. Home Haemodialysis Patient Training Schedule and Objectives forms. 3.1 Treatment Records Within the patients care plan documentation will be included: - Patient treatment Fresenius system prescription settings, maintenance information, due dates of bloods and water testing, blood forms and bottles required for specific tests. Water samples, and details required for specific tests, home dialysis policies, and useful contacts and telephone numbers. 3.2 Hospitalizations Documents dates, admitting diagnosis within the nursing care evaluation and progress report. The patient is also informed of any problems with their machine, to inform the home Haemodialysis team as the patient may require Haemodialysis on the renal unit whilst the machine is being repaired. This is discussed within the home Haemodialysis client training objectives. 3.3 Clinic/Home Visits Clinic appointments and where the clinics are held, what to bring along to clinic and who will be available to be seen are explained within the client training objectives document. Home visits and support is also explained within the client training objectives document. 6 Wrexham - BCUHB 4. Training 4.1 Staff Training Staff training is carried out over a three week period by a clinic nurse specialist from Fresenius. The staff are required to achieve the 5008 System Training Schedule and complete these objectives prior to training their clients. 4.2 Patient Training Documents patient home training program/skills assessment and continuing education/training and evaluation a) b) c) d Use of the Home Haemodialysis Patient Training Schedule and Objectives Home Haemodialysis information booklet Use of the 5008 Therapy System – Training and Resource Guide Use of the 5008 Therapy System Brief Operating Guide Once the patient is competent to carry out home haemodialysis, home modifications are complete, the Home Haemodialysis machine has been commissioned and passed microbiology and chemical analysis, the trained nurse will follow the patient home and spend the first few days ( 1 week ) with the patient to ensure that everything is in place and can competently carry out his or her dialysis, facilitating the transition from Hospital to Home. 4.3 Anemia Management & Evaluation The patient’s Haemoglobin and ferritin will be monitored every month and documented within the nursing care plan on the blood results document. Any changes in erythropoeitin doses are faxed to either GP or the appropriate home delivery company. I.V. iron clinics are carried out within the renal unit on an outpatient basis. The patient’s results are continually audited via our anaemia audit tool. 4.4 Access Management & Evaluation The access co-ordinator educates the patient to self-needle and care for his/her access. Where indicated Central Venous Catheter training will be carried out (if vascular access has failed or for those patients where Central Venous Catheter is their access). She explains correct needling technique, the importance of correct procedure and demonstrates the correct procedure. She identifies signs of infection of vascular access and the treatment of infection. This is taught in the home haemodialysis client training objectives. 7 Wrexham - BCUHB 5. Infection Control During patient training the importance of infection control will be highlighted, and the patient will be required to meet client training objectives. The area where home haemodialysis is to be carried out will be free from infection, the patient will also be advised on how to keep the area clean and tidy. The patient will be taught hand washing and hand hygiene and the importance of using the technique. Universal precautions will be discussed and the patient will need to meet the training objectives. Included, will be the importance of disposing needles and sharps, the patient will be taught the safe disposal of needles and sharps into the provided sharps bins. Clinical waste will be explained and the importance of disposing all clinical wastes into the correct bags, the patient will be informed of the procedure for clinical waste collection as per local and national guidelines. As the home haemodialysis machine is used for one patient only, the cleaning of the machine is to be as per recommendations from Fresenius. 6. Equipment 6.1 Dialysis Machine and RO Unit - AQUA UNO The home haemodialysis team during training will define the technical requirements for the dialysis machine and the use of RO unit. a) b) Technical requirements The patient will be briefly taught how the haemodialysis machine and the Aqua Uno RO works 6.1.2 Machine Settings During the patient training the patient will be taught how to enter/change treatment, prescription and machine settings on the dialysis machine as per Fresenius training checklist. 6.1.3 Routine Procedures Describes how to perform general and / or more frequent procedure 6.1.4 Alarms & Troubleshooting Describes how to respond to- information message (Info), Warning message (Warning) and Alarm message (Alarm) alarms and to perform troubleshooting procedures. Use of 5008 Haemodialysis System Operating Instructions. a) b) Problem solving – issues that may arise Brief guide and troubleshooting for the Fresenius 5008 8 Wrexham - BCUHB 6.1.5 Maintenance Every 12 months the technician carries out Function Check and Electrical Safety maintenance on the home haemodialysis machine, and every 2 years Major service is carried out. a) Fresenius maintenance programme. 6.1.6 Water Treatment. Describes the water treatment system (water pre-treatment and RO) and importance of water treatment. Instructs staff/patient on monitoring, maintenance and documentation. Policies/procedures may include instructions/forms re monitoring. Procedures: a) Monthly QA waters from machine and RO as per policy b) Monthly change of Diasafe Plus Filters c) 6 monthly waters for Trace Elements from RO d) Disinfection of RO and machine as per policy 7. Equipment Preparation 7.1 Pre- Treatment Preparation Describes procedures performed during dialysis preparation in conjunction with Patient Prescription. Procedures: – a) T1 Test and Preparing and lining the dialysis machine b) Preparation of the treatment area and consumables for needling c) Patient preparation d) Completion of pre treatment checklist and dialysis data record sheet 7.2 Treatment Describes procedures performed during treatment. Procedures: a) Monitoring the prescribed Dialysis treatment b) Discontinuation of the prescribed dialysis treatment 7.3 Post- Treatment Describes procedures performed during treatment. Filling in the dialysis data sheet and records any problems encountered. Reports any problems to the Home Therapies Nurse / Technician. 9 Wrexham - BCUHB 8. Complications during Home Dialysis Describes how to treat patient complications and natural events that occur during dialysis. Procedures: Air embolism – Page 10 Disaster- fire – Page 20 Haemolysis – Page 23 Muscle cramps – Page 28 Power loss – Page 31 Dialyzer blood leak – Page Blood loss – Page Fever and/or chills – Page Hypotension – Page Needle infiltration (needle blow ) – Page Haemoconcentration – Page Arterial Pressure Device - Page 9. Contacts Renal unit home therapies telephone numbers 01978 727101 / 727103 between 9am-5pm. 24 hr on call service out of hours ring 01978 291100 and ask switch board to put you through to the on call home therapies team / CAPD nurse on call. The patient is issued with our contact numbers and the Fresenius technicians telephone numbers on commencement of training. 10. Procedures 10 Wrexham - BCUHB Procedure AIR EMBOLISM Description This procedure describes how to treat an infusion of air into the patient’s bloodstream Purpose Loose or cracked arterial connections, separation of arterial blood tubing from arterial needle or catheter can introduce air into the blood tubing and dialyzer. Operator error when troubleshooting venous air in blood alarms or machine malfunction may inadvertently allow air to enter the patient. Not correcting Air / Blood levels in venous bubble trap, venous blood line not inserted correctly in Blood air optical detector. The dialysis machine safety monitors, and secure and tight connections along the access, dialyzer and blood tubing can prevent an air embolism. Procedure Rationale Call 999 Stop the Blood pump. Clamp the patient’s access and blood tubing lines. Place the patient on left side with head down and feet up higher than head. Monitor patient’s vital signs i.e. Blood pressure and pulse. Do not panic. Stops blood pump and closes arterial and venous clamps. Traps air in right atrium and minimizes risks to the patient. Call home training nurse. 11 Wrexham - BCUHB Procedure AIR TRAP LEVEL MONITORING Description This procedure describes how to monitor for any loose connection in the blood tubing set via the blood/air optical detector seated below the venous bubble trap. Purpose Loose connections between the blood tubing, injection site and access lines can cause air to leak into the blood tubing and result in frequent air trap leveling and blood tubing set error alarms. Reference Fresenius 5008 Operators Manual –Alarm Processing 2 parts (1)Air detected below the Venous Bubble Catcher (2)Micro Bubbles detected below the Venous Bubble Catcher Supplies None Procedure If the blood level is lower than 1cm from top of bubble trap PRESS Blood System key and use the arrows to raise the level or PRESS Level Set Key – machine will set automatically. Check that all the connections are secure. If required the machine will request the user to follow informational messages on the screen to remove the air. If necessary disconnect from dialysis, connect the arterial and venous blood lines to a bag of normal saline, until air is removed form lines following instructions on the dialysis machine. If, after careful observation, the above conditions continue, discontinue treatment and call Fresenius Technical Service Center and the renal unit. If in HD Mode prime with 1.0L to reduce the risk of air bubbles. Rationale Discontinuing a treatment earlier than prescribed may require the patient’s schedule to be adjusted. During the air removal procedure the blood pump will run at a rate of 50ml/min N.B. The blood pump speed will require increasing back to prescribed speed 12 Wrexham - BCUHB Procedure BLOOD LOSS Description This procedure describes what to do in the event of a needle slippage, or tubing disconnection. Purpose Reference Supplies Recirculation Reinsertion of a new needle None Procedure Rationale Stop the Blood Pump by pressing the red LED key on left of monitor. If the needle is dislodged immediately apply pressure on the site. Clamp access lines and blood tubing. Assess blood loss and check vital signs i.e. blood pressure and pulse. Follow procedure for recirculation Circulation key right hand side of monitor Commence recirculation - using recirculation band Blood will be pulled from the intact access/blood tubing assembly as air is pushed out of the disconnected tubing. N.B. The blood pump speed will require increasing back to prescribed speed Insert a new needle by following the reinsertion of a new needle procedure. Following reinsertion of new needle reconnect blood lines to access to resume dialysis. Remembering to clean the patient connector on the blood tubing with an alcohol wipe prior to reconnection (to reduce the risk of infection). NOTE: Patient’s blood in the tubing may be at risk for clotting therefore if this occurs discontinue dialysis NOTING therapy time remaining and UF remaining. Notify the home training unit. 13 Wrexham - BCUHB Procedure DIALYZER BLOOD LEAK Description This procedure describes what to do in case of dialyzer rupture. Purpose Leaks or tears in the dialyzer membrane can cause red blood cells to cross over into the dialysate. When this occurs treatment must end. Reference Supplies Fresenius 5008 Operator’s Manual Procedure Rationale When the machine detects blood in the dialysate a blood leak warning alarm is displayed on the touch screen. 2 Check the dialyser for signs of blood in the dialysate fluid Check Dialysate line ( blue) draining away from the dialyser If you can identify blood (rusty or pink ) in dialysate fluid STOP blood pump, clamp machine lines and patient lines. DO NOT WASH BACK. The redundant filtering system protects against contamination of the ultrapure dialysate that is infused into the patient. Disconnect. Flush needles. Discard blood circuit and dialyser Contact nurse on call Home Therapies. If there is no evidence reset alarm. If blood leak alarm continues x3 presume you have a microscopic blood leak and wash back. Discard blood lines and dialyser. Note the time left and amount of UF left to be removed Put machine through heat disinfectant BEFORE restarting next dialysis session 14 Wrexham - BCUHB Procedure DIALYSIS INTERRUPT AND RECIRCULATION Description This procedure describes how to temporarily disconnect a patient from the 5008 Fresenius machine during treatment, recirculate blood in the Extracorporeal circuit (EC), reconnect a patient and continue with dialysis. Purpose Dialysis can be temporarily interrupted when the patient needs to disconnect from the extracorporeal circuit. Dialysis will continue after the patient is reconnected to the extracorporeal circuit. Reference Supplies Fresenius 5008 Operator’s Manual 1 – Recirculation connector 2 – 2 x 10 ml syringes with saline for flushing needles Procedure Rationale Use alcohol rub and universal precautions when performing this procedure. Ensure all connections are secure when connecting and disconnecting the blood tubing set. 1. Disconnect and Prepare for Recirculation. Gather supplies. Press the options menu and select circulation. Press recirculate.This will automatically stop pump and switch off UF. Clamp the arterial blood line and arterial needle. Clamp the venous blood line and the venous needle. Disconnect both lines from both needles and connect to the recirculation connector. Attach a 10ml syringe of saline to the arterial and venous needles, flush needles as necessary. Release the clamps on arterial and venous blood lines and press recirculate on screen. Ensure a primed bag of normal saline is connected to the circuit. Warnings every 5 mins alert the user to the fact that the circuit is recirculating. .To go back on dialysis…… 1. Press “stop recirculation” 2. Clamp the saline. 3. Clamp the arterial and venous blood lines 4. Disconnect the arterial blood line from the connector and attach to the arterial needle. 5. Transfer the 10ml syringe to the connector. 6. Disconnect the venous line from the 7. Connector and attach it to the venous needle. 8. Release the clamps on both needles and both blood lines. Pauses the machine N.B. Increase pump speed back to Prescribed pump speed. CHECK FOR AIR IN BLOOD TUBING AND NEEDLES When you are happy recommence the blood pump and recommence UF. 15 Wrexham - BCUHB GIVING SALINE FLUSH MANNUALLY – If patient on HD or online bolus not available Description Saline flush may be needed during dialysis if patient records a low blood pressure or experiences symptoms of a low blood pressure i.e. Clammy, warm or sweaty. Dizzy, light headed, nauseous, visual disturbances or Reference hearing disturbances. Procedure Procedure Saline restores your blood pressure by increasing the volume in your circulation. To give saline…. 1- Reduce the speed of the blood pump by 5mmhg to open the top arterial pressure guard, and the lower venous pressure guard. 2- Turn UF off 3- Ensure saline is attached to the circuit, line is primed , then release clamp on the saline port. Giving saline alters the venous and arterial pressure. 4- Give as much saline as you need (check blood pressure) 5- Increase the blood pump speed to the original setting 6- Clamp the saline port. The venous and arterial pressures will return to the original level. 7- Recheck your blood pressure. 8. If patient still unwell post infusion dial 999 Rationale To prevent arterial alarms while infusing the saline. This opens the lower arterial guard and the top venous pressure guard. 16 Wrexham - BCUHB Procedure DISASTER - FIRE Description This procedure describes how to safely disconnect from the machine in the event of an earthquake, fire or severe weather. Purpose To assure that the patient can safely move away from the machine to find shelter. Reference None Procedure 1. 2. 3. 4. 5. 6. 7. Stop blood pump. Turn off the power supply to the machine Clamp the arterial and venous access lines Clamp the arterial and venous blood tubing Disconnect or cut the arterial blood tubing Disconnect or cut the venous tubing Keep the patient close to the floor and move to a safe area and leave building. 8. Secure the patient’s access and check for injuries. Call for help. 9. Contact renal unit for arrangement of dialysis on the unit. Rationale Stops all pumps and closes all clamps 17 Wrexham - BCUHB Procedure DRAWING POST U & E Description This procedure describes how to take blood samples for monitoring delivered dose of dialysis. Purpose Reference Supplies For the purpose of monthly blood results. Appropriate blood bottles and 10 ml syringe. Procedure 1. Prior to Washback - prepare supplies needed to collect sample. 2. When time remaining equals 0 3. Lower the pump speed to 50mL/min. 4. Wait 15 seconds. 5. Press the Red Stop pump LED key. 6. Clamp the venous needle clamp and clamp the venous blood tubing clamp. 7. Disconnect the venous blood tubing from the venous needle. 8. Place a 10ml syringe at the end of the venous needle, then unclamp venous needle and withdraw post blood sample. 9. Clamp venous needle clamp, then remove syringe and place blood sample in appropriate blood bottle. 10. Reconnect venous needle to venous blood tubing making sure that connection is secure. 11. Unclamp venous blood tubing clamp and venous needle clamp. 12. Machine will show “Reinfusion” and follow on screen instructions, and washback as normal. 13. Following treatment please bring sample to the unit within an hour of taking the blood sample. Rationale Lowering the blood flow rate prevents the potential for collecting recirculated blood. Allows systemic blood to reach sample port. To minimize inaccurate blood results. 18 Wrexham - BCUHB Procedure FEVER AND/OR CHILLS Description This procedure describes what to do when a patient complains of fever and / or chills. Reference Fresenius 5008 Operator’s Manual Procedure Check patient’s vital signs i.e. blood pressure and pulse. Note the temperature of the dialysate on the screen. Cover patient with blanket. Determine when symptoms started. Discontinue treatment if a pyrogen reaction is suspected. Notify the home training unit for further instructions. Rationale An elevated temperature before dialysis and between dialysis may indicate infection. A normal temperature with shivering may indicate dialysate that is too cold for the patient. An elevated temperature within the first 30 to 60 minutes of starting dialysis may indicate a pyrogen reaction. 19 Wrexham - BCUHB Procedure HAEMOLYSIS Description This procedure describes what to do in the event of Haemolysis. Purpose High negative pressures, kinked or defective tubing, improperly mixed, or overheated dialysate and contaminants from water used to make dialysate can cause haemolysis. The machines safety monitors and proper checks, observations and monitoring by the operator can prevent haemolysis from occurring. Reference Fresenius 5008 Operator’s Manual Procedure Stop the blood pump. Rationale Stops blood pump and closes arterial venous clamps. Clamp arterial and venous access lines. Ruptured red blood cells release Disconnect patient from the machine . DO NOT potassium that can cause abnormal heart return blood to the patient. rhythms. Monitor vital signs i.e. blood pressure, pulse, breathing rate. Patient may experience shortness of breath, hypotension and abnormal heart rhythms. If necessary, give saline to replace volume of blood lost – via saline IVI. Call home training nurse for instructions on care of the patient. Call Technical Assistance Center for assistance in troubleshooting the cause of haemolysis. If symptoms are severe, call 999 Patient may experience cardiac arrest. 20 Wrexham - BCUHB Procedure HYPOTENSION Description This procedure describes what to do when the patient’s blood pressure drops during treatment. Purpose Low blood pressure can be caused by rapid removal of fluid or other medical conditions. Low blood pressure during treatment can cause dizziness, vomiting, visual disturbances, loss of consciousness or seizures. Reference Procedure NB. If on haemodialysis and not HDF follow instructions for Giving Saline. Press Emergency button + Attach Blood pressure cuff Lower the patient’s head and raise their feet. Assess patient vitals signs i.e. blood pressure, pulse. Note signs and symptoms that led to hypotensive episode. . When solution infusion is complete and blood pressure is stabilized continue with dialysis. ENSURE UF IS SWITCHED ON AND BLOOD PUMP IS AT PRESCRIBED SPEED. If necessary, decrease target fluid to remove, or extend patient’s treatment. Document observations. Document total solution infusion given and any treatment setting changes. Rationale Switches off UF, reduces pump speed, takes blood pressure and gives bolus of online fluid 150 ml intervals. Assessment will determine intervention Querry reduce UF volume Lowers the ultrafiltration rate Solution infusion and changes to fluid to be removed is included in the post weight assessment. Low blood pressure may be due to other medical conditions. If patient’s blood pressure does not stabilize, notify home training unit – -Weight assessment may be required -Blood pressure medication may need adjusting 21 Wrexham - BCUHB Procedure MANUAL SALINE RINSEBACK Description This procedure describes how to manually return the patient’s blood during alarm conditions that prevent an automated rinse back. Purpose Alarms that require a manual saline rinse back include: Unrecoverable alarms Recoverable alarms that do not allow rinse back and online infusion not available Reference Supplies Power failure Fresenius 5008 Operators Manual 1 – 1,000 mL bag of sterile saline 1 – IV administration set with recirculation band connected 1 – IV pole on Machine Procedure Rationale Note: Use the alcohol rub and universal precautions when performing this procedure as taught during training. Ensure all connections are secure when connecting and disconnecting the blood tubing set. 1. Set up and Connection Hang the saline bag on the IV pole and attach the IV administration set with attached recirculation connector to the bag. (Make sure connections are secure). Close roller clamp and half fill the chamber with saline. Undo the roller clamp and fill the giving set and recirculation connector with saline. Close the roller clamp on the I. V. administration set, ensuring there is no air present in the set. Press the reinfusion button Select NaCl Follow on screen instructions for Nacl Close the pinch clamps on the arterial blood and arterial access line. Disconnect the arterial blood line from the arterial needle and attach it to the recirculation connectorat the end of the saline bag Once connected unclamp arterial clamps and open the roller clamp on the saline administration set and press ok 2. Rinse Back Blood Dialysis ends when clear fluid is detected below the bubble trap. Press continue if more is required and stop the pump using on screen control. Disconnect patient. 22 Wrexham - BCUHB Press remove lines button. Deal with access as appropriate. Empty dialyzer Replace concentrate suction tube and remove bibag when empty. Remove all blood lines ensuring substitute port is firmly closed. Close doors –machine will automatically go into disinfect. 23 Wrexham - BCUHB Procedure MONITOR THE DIALYSIS TREATMENT Description This procedure describes the dialysis parameters and safety monitors displayed during the treatment. Purpose Standard operating procedures in a clinic dictate that treatment records are documented and maintained. Reference Fresenius 5008 Operators Manual Supplies 1 – Haemodialysis flow sheet 1 – Patient prescription Procedure 1. Review the treatment parameters on the screen. Dialysis temperature and conductivity Blood and dialysate flow rate settings Fluid removed and ultrafiltration rate Treatment time remaining Arterial pressure Venous pressure Arterial and venous pressure trending on treatment key Heparin information OCM monitoring (OCM key – personal data for details of Kt/v Rationale Operator can verify that treatment information displayed on the screen matches the prescription or treatment settings. Operator can observe that the blood and dialysate circuit monitoring system does not exceed prescription limits. 2. If necessary press the Dialysate menu, UF menu or treatment menu 24 Wrexham - BCUHB Procedure MUSCLE CRAMPS Description This procedure describes how to treat cramping during dialysis. Purpose Muscle cramps can be caused by rapid removal of fluid or change in target weight. Reference Procedure Press the options key. Press the emergency key. Turn UF off. Press the bolus key. If necessary decrease the target fluid to remove, change back flush interval to zero or extend patient’s treatment. If necessary give further bolus as above Document observations. Document total solution infusion given and any treatment setting changes. Notify the renal unit. Inform the renal unit as your target weight may need changing. Rationale Target or dry weight may need reevaluation. 25 Wrexham - BCUHB Procedure NEEDLE INFILTRATION Description This procedure describes what to do in the event of an arterial or venous needle infiltration (needle blow) or hematoma. Purpose During needle insertion the needle tip may go into the graft or vein through the other side allowing blood to escape into the surrounding tissues. An infiltrated needle (blown needle) requires another needle stick. Reference Procedure Press the pump to stop immediately Press the options key. Press the circulation key to recirculate whilst addressing the blow. If heparin has not been given, pull the needle and hold pressure. If infiltration (needle blow) occurs after heparin has been given, leave needle in. If arterial needle infiltrated (blown), insert the new needle below the infiltration (blow). If the venous needle infiltrated (blown), insert the new needle above the infiltration (blow). Prior to inserting a new needle, flush the unaffected needle with 10mls of saline. Press the Green key to resume operation. Rationale Stops the blood pump and closes the arterial and venous clamps. Minimizes the risk of bleeding during dialysis. To prevent the unaffected needle from clotting during recirculation. 26 Wrexham - BCUHB PROCEDURE FOR THE INSERTION OF SHARP NEEDLES FOR DIALYSIS 1. Action Gather equipment: Basic procedure pack 2x 10ml syringes 10mls 0.9% saline 2x dialysis needles Tourniquet Alcohol wipe 2ml syringe Green needle Adhesive tape 2.Assessment and disinfection of fistula Wash Hands as instructed Examine fistula/graft prior to needle insertion. Use alcowipe/trigene wipes to clean fistula. Allow to dry 3.Insertion of needles Place the 10ml syringes on to the needles after priming syringes with saline Place tourniquet onto the upper arm and apply moderate pressure- fistulas only Insert the Arterial needle first Holding the needle by its wings , with the bevel of the needle facing up insert the needle at an angle of 25 degrees and a “flash back” of blood should be obtained Release the pressure on the tourniquet Thread the length of the needle into the fistula/graft and confirm the flow of the blood by pulling and pushing back on the syringe .Ensure no air is present prior to pushing back blood into the fistula/graft. Clamp the needle tubing and tape securely Rationale To ensure that all equipment is at hand. To prime needles Needle size is individual e.g. 15gauge A tourniquet is not needed for PTFE grafts To administer heparin To secure needles To prevent contamination Avoid any areas that feel problematic e.g. lump/,bumps, infection. To remove any bacteria. Applying pressure engorges the fistula with blood to make it firm and assist needle insertion This applies to fistulas and not PTFE grafts The “flash back” of blood confirms you are in the correct area The blood should flow in and out of the syringe freely. If it does not, then withdraw the needle slightly and rethread at a slightly different angle. i.e. deeper/more superficial. No pain should be felt at this point To prevent air embolism To prevent blood loss and needle becoming dislodged If the tape is too tight and the fistula is superficial it may impede the flow of 27 Wrexham - BCUHB the blood. Adjust tape if necessary Confirm the blood flow again with the syringe 4. Repeat the above steps to insert the venous needle 5.Draw up prescribed heparin using 2ml syringe and green needle. Remove 10ml syringe from the arterial needle and attach heparin syringe. Inject heparin prior to connection to dialysis circuit. 6.Dispose of all materials safely as per policy NB.The vibration or “thrill” of the fistula should be felt for every day. If the “thrill” has diminished or is absent contact the Renal Unit immediately. To prevent clotting of the dialysis circuit. Prevent cross infection and contamination The fistula may be at risk of stopping or have stopped. 28 Wrexham - BCUHB CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE STANDARD AV FISTULA NEEDLES What is Buttonhole Needling? With this technique the haemodialysis needles are inserted into the same spot, at the exact same angle and the exact same depth for each dialysis treatment. The buttonhole cannulation site needs to be established by the same person cannulating the site every time for approximately 8-10 cannulations until the track is established. A thorough assessment of the fistula must be completed to evaluate any potential or existing problems the access may possess. The site for buttonhole cannulation must allow for the needles to be placed a minimum of 6cms apart and in an area of the fistula that allows ease of insertion for both the nurse and the self cannulator. With NOTE : It takes approximately six to eight cannulations using a sharp needle to create a scar tissue tunnel track in a given site. Once a scar tissue tunnel track is well formed Dull Bevel needles can be used 29 Wrexham - BCUHB CANNULATION OF AV FISTULA USING BUTTONHOLE TECHNIQUE WITH DULL BEVEL NEEDLES ACTION Equipment 2x AV fistula needles 2x 10ml syringes 10mls 0.9% saline Basic procedure pack Tourniquet Sterile gauze 10mls 0.9% saline solution Alcowipe/Trigene wipes 2ml syringe Green needle 1. Select cannulation sites carefully. Consider straight areas, needle orientation, and the ability of the patient to self-cannulate. Sites should be selected in an area without aneurysms and with a minimum of two inches between the tips of the needles. 2. Remove any scabs over the cannulation sites using an aseptic technique as per renal unit protocol. 3. Disinfect the cannulation sites using alcohol wipe. 4. Prime each needle with 5mls saline. .Using a sharp AV fistula needle, grasp the needle wings, and removes the tip protector. Align the needle cannula, with the bevel facing up, over the cannulation site and pull the skin slightly taut. 5. Cannulate the site at a 25-30 degree angle. It is important to cannulate the constantsite in the exact same place, using the same insertion angle and depth of penetration.* This requires that a single cannulator perform all cannulations until the sites are well established. 6. A flashback of blood indicates the needle is in the access. Lower the angle of insertion. Continue to advance the needle into the fistula until it is positioned appropriately within the vessel. 7. Securely tape into position and repeat. RATIONALE Needle size as prescribed To prime needles If required To soak scabs to enable easy removal, if not using Emla cream To disinfect skin To administer prescribed heparin To avoid any potential cannulation/flow problems. The participation of a carer in the cannulation process is an advantage. Prevent infection and trauma to the insertion site. Helps prevent the tip of the needle clotting during insertion. A tract will only be properly formed using a single cannulator, thus removing any possible errors. Lowering the needle angle prevents infiltration of the vessel wall. 30 Wrexham - BCUHB ACTION Equipment 2x AV fistula dull needles 2x 10ml syringes 10 mls 0.9% saline Basic procedure pack Tourniquet Sterile gauze 20ml 0.9% saline solution Alcowipe/Trigene wipes 2ml syringe 1 green needle RATIONALE Needle size as prescribed To prime needles To soak scabs for easy removal if not using Emla cream To administer heparin as prescribed 1. Remove scabs over cannulation sites Prevent infection and to enable insertion using aseptic technique as per renal unit of dull needles. protocol. 2.Disinfect cannulation sites using alcowipe 3. Grasp the needle wings, and remove the tip protector. Align the needle cannula, with the bevel facing up, over the cannulation site and pull the skin taut. 4. Carefully insert the needle into the established cannulation site. Advance the needle along the scar tissue tunnel track. If mild to moderate resistance is met while attempting to insert the needle, rotate the needle as you advance it using gentle pressure. 5. A flashback of blood indicates when the needle is in the access. Lower the angle of insertion. Continue to advance the needle into the AV fistula until it is in the appropriate position within the vessel. 6. Securely tape into position and repeat. 31 Wrexham - BCUHB Procedure POWER LOSS Description This procedure describes how to return the patient’s blood in the event of power loss. Purpose Reference Supplies The dialysis machine will have battery back up and then will switch itself off. The UF pump stops, substitute pump stops and dialysis flow off therefore manual wash back is necessary. Fresenius 5008 Operators Manual 1 – 1,000 mL bag of sterile saline 1 – IV administration set with recirculation connector attached. 1 – IV pole Procedure Note: Use alcohol rub and universal precautions as per training guidelines when performing this procedure. Ensure all connections are secure when connecting and disconnecting the blood tubing set. Rationale Handling the blood tubing and saline administration sets improperly can cause machine contamination and / or patient injury. Setup and connection 1. (a)Hang the saline bag on the IV pole and Attach the IV administration set with attached recirculation connector to the bag. (Make sure connections are secure). Close roller clamp and half fill the chamber with saline. Undo the roller clamp and fill the giving set and recirculation connector with saline. Close the roller clamp on the I. V. administration set, ensuring there is no air present in the set. Press the Re-infusion button Select NaCl Press the 1/O buttonFollow on screen instructions (b)Close the clamps on the arterial blood tubing and arterial access line. 1. Disconnect the arterial patient connector from the access line and attach it to the recirculation connector. To Rinse back blood 1. Open the roller clamp on the saline administration set. 32 Wrexham - BCUHB 2. Open the arterial clamp 3. Once connected press ok. 4. Dialysis ends when clear fluid is detected below the bubble trap. 5. Press continue if more fluid is required and stop the pump using on screen control. 6. Disconnect patient . 7. Press remove lines. 8. Deal with access as appropriate. 9. Empty dialyzer. 10. Replace concentrate suction tube and remove bibag when empty. 11. Remove all blood lines ensuring substitute port is firmly closed . 12. Close the door and the machine will automatically go into disinfect. 13. If power is lost and the machine turns off, when power is restored select the cleaning menu and select heat disinfect program. 33 Wrexham - BCUHB Procedure PREPARE FOR DIALYSIS Description This procedure describes how to connect a patient to the PHD System for dialysis. Purpose Standard operating Reference Fresenius 5008 Operators Manual and 5008 Therapy system Brief Operating Guide Insertion of needles for dialysis procedure 1 – sharps container Tape - narrow and wide Tourniquet 2 x dialysis needles Sterile green needle 1 x basic procedure pack 1 x alcohol wipe Trigene wipes 1 x 10 ml syringes 1 x 30 ml leur lock syringe 2 x Heparin 5000 iu per/ml or Clexane Sterile saline administration set with recirculation connector attached 1,000 mL bag of sterile saline Liquid Hand Washand Alcohol rub Concentrate and Bibag Dialyser and pack of 5008 BVM Lines Procedure Rationale Supplies Note: Using Trigene and Alcohol rub and universal precautions when performing this procedure as explained during training. 1. Switch on the machine 2. Select treatment ( or disinfection ) 3. Connect concentrate and bibag (ensure correct concentrate is selected in dialysate menu). 4. T1 test starts automatically. 5. Follow instructions for lining. Arterial lines first. Make sure you hear the sound when inserting the red plastic ‘alpha clip’ into the lineguide. Make sure placed correctly, dome in pressure device and line in arterial clamp. 6. Insert heparin syringe correctly and securely. 7. Attach venous line ensuring line below venous chamber is firmly placed in the blood/air detector groove. 8. Place safe line ( sub tubing ) into HDF pump, ensure the sound is generated on insertion of the clear plastic ‘alpha ‘ clip into the line guide, then connect the arterial line. 9. Connect the rinse connector to venous line. 34 Wrexham - BCUHB 10. On completion of T1-test, place insert safeline into the upper port (BLUE) and the rinse connector ( on the venous line) into the lower rinse port (GREY). 11. Any damaged items, cracked connections or casings, necessitates replacement of that item. 12. Close the doors. 13. Connect dialysate arms ( RED to BLUE BLUE TO RED ). 14. Press the blood pump button on the screen to commence prime. 15. Priming is complete when volume has reached 1000mls. 16. Enter U/F, treatment time, heparin data, Check conductivity, temperature, time and dialysate tank. 17. When full prime volume has been achieved stop the prime by pressing the blood pump button on the screen. 18. A message choices- ‘continue’ or ‘exit’ are displayed, press “exit”. 19. Follow on screen instructions 20. Hang ‘A’ and ‘V’ lines on the dialysate armand clamp both lines. 21. Insert needles as per policy. 22. Complete checklist to ensure safety i.e. 23. Isolators are securely attached 24. Clamps on venous ports are closed. 25. Blood pressure has been checked. 26. Heparin is set correctly and clamp removed. 27. U/F has been set to correct amount. 28. Dialysate has been been set to correct time. 29. Dialysate arms are attached to dialyzer. 30. Lines and needles are free from air. 31. Venous bubble trap is filled 1cm from the top. 32. Connect access to ‘A’ and ‘V’ lines. 33. Follow onscreen instructions for hook-up. 34. Ensure the rinse port is closed, close the doors, open clamps and confirm start blood pump message. 35. Dialysis commences when blood is sensed below the venous trap, confirm with button below message. 36. Increase blood flow to prescribed level. 37. U/F starts automatically if data is already set. 38. Heparin starts automatically, bolus needs to be given if required. 39. Check U/F has been switched on. 35 Wrexham - BCUHB 40. Spare bag of saline is within reach. 41. Spare syringes, clamps,tape,cottonwool and gauze are within reach. 42. Baseline observations are very important and values should be recorded i.e. start time,blood flow rate, Blood Pressure, Arterial and Venous Pressures, U/F rate, TMP. 36 Wrexham - BCUHB Procedure RINSEBACK POST-DIALYSIS Description This procedure describes how to rinse back the patient’s blood. Purpose Reference Supplies Fresenius 5008 Operators Manual Procedure Rationale Note: Use aseptic technique and universal precautions when performing this procedure. Ensure all connections are secure when connecting and disconnecting the blood tubing set. 1. When treatment goal is reached, collect equipment and prepare for disconnection. 2. message will appear on screen prompting next phase. 3. Press reinfusion and follow onscreen instructions. 4. Once connected press ok ( only press NaCl if you have run out of acid/bicarb and need to use manual saline to washback). 5. Dialysis ends when clear fluid is detected below the bubble trap. 6. Press continue if more is required and stop the pump using on screen control, clamp venous blood tubing. 7. Disconnect patient then press remove lines button. 8. Deal with access as appropriate. 9. Empty dialyzer. 10. Replace concentrate suction tube and remove bibag when empty. 11. Remove all blood lines ensuring substitute port is firmly closed. 12. Close doors . Machine automatically goes into hot disinfect. 13. EARLY DISCONNECTION 14. Press reinfusion button 15. Press ‘1/O’ button. Follow the above instructions from 4 onwards 37 Wrexham - BCUHB Procedure ARTERIAL PRESSURE DEVICE DOES NOT OPEN WHEN LINE GUIDE Description IS INSERTED To ensure arterial pressure devise opens to allow the line guide to be inserted or removed. Purpose Reference Supplies 30 ml syringe Procedure Rationale 1.Close and reopen door, press line guide to generate sound. 2.If this does not resolve problem, open diasafe housing and locate small tube above the filters and instill approximately 30ml of air. This will push the mechanism forward. 38 Wrexham - BCUHB Procedure HAEMOCONCENTRATION WARNING Description During haemodialysis, the pressure across the membrane (transmembrane pressure) is related to it’s ability to allow fluid to pass through it. This will be higher or rise as it becomes more difficult for fluid to pass across the Purpose dialyser. Reference Supplies None Procedure Rationale The pressure is likely to rise if; 1. the patient is nearing their dry weight and fluid is no longer available to remove 2. the patient has poor refilling 3. Arterial pressure is low (<-200mmHg) 4. the patient has a high haematocrit due to an increased blood count through use of erythropoietin 5. the dialyser has a low KUf and a high Uf rate is being used 6. there is insufficient anticoagulation 7. combinations of the above 8. the patient is nearing their dry weight and fluid is no longer available to remove 9. the patient has poor refilling 10. Arterial pressure is low (<-200mmHg) In Haemodiafiltration, the Uf rates are higher in the kidney to create convection. A formula is used to calculate the safe HDF fraction and on 5008, this is calculated for you. In post dilution HDF, there is a risk of haemoconcentration to the point that the blood may start to clot. Part of the online program is looking at the transmembrane pressure and this is constantly monitored. If a rise of 20mmHg occurs then the Substitution rate will be reduced by (%age). If this occurs three times there will be an alarm and a message in a red box will state “Haemoconcentration Warning”. The remedy is to eliminate the cause, increase heparin, assess dry weight, assess fluid management during treatment, reduce epo etc. All of the above 7 points (individually or in combination) could contrive to cause clotting but there is an added risk in HDF post dilution due to the higher UF rate. If this alarm appears you have several options (as well as those mentioned above). Worst case scenario is a lost circuit. Post dilution HDF results in better middle molecule removal. However, if clotting is a risk Pre dilution, where the clearance is a little less efficient, may be the safer option. Change the mode and change the safeline position to the pre dilution position. Generally a little more anticoagulation is required in HDF, a bolus might help to offset clotting acutely and reassessment of maintenance dose can be done (ACTs are useful). If the problem persists in this mode change to Haemodialysis for the rest of the treatment. 39 Wrexham - BCUHB Procedure COLLECT WATER SAMPLE SAMPLE FOR RESIDUAL CHEMICAL ANALYSIS Description This procedure describes how to collect a water sample post RO to check for any residual chemical following chemical disinfection of the RO. Purpose Reference Supplies The Aqua UNO RO unit is chemically disinfected each month , to prevent bacterial growth. Reverse Osmosis Aqua UNO Operators Manual (section 5-19 ) Peracetic Acid Test Kit RO connector 1 sample collection container Procedure Rationale 1.Read the Peracetic Acid Test Kit instructions carefully before using the test kit. 2.Check the content of the kit for any expiration dates. Expired test kits can give inaccurate results. Following disinfection of RO BEFORE re connecting RO back to machine - connect RO connector which will allow water to flow from RO and use test dipstick to sample post RO water. 40 Wrexham - BCUHB Procedure Description COLLECT WATER SAMPLE FOR CHLORINE TESTING This procedure describes how to collect a water sample post RO to test for chlorine or chloramine removal. Purpose Pre RO Carbon filters have a limited capacity to remove chlorine and chloramine. Failure to detect chlorine or chloramine breakthrough results in the degradation of RO effectiveness. To meet Renal Association Standards – Chlorine < or = 0.1 Reference Reverse osmosis Fresenius Aqua UNO manual Supplies As needed - Chlorine Test Kit (Aquachek water quality test strips) 1 - Sample collection container RO connector Procedure Rationale Testing of post RO water for Total Chlorine and Free Chlorine should be done daily or each day they are dialyzing. 1. Read the chlorine test kit instructions carefully before using the test kit. 2. Check the content of the kit for any Expired test kits can give inaccurate expiration dates. results. 41 Wrexham - BCUHB Procedure COLLECT ONLINE SAMPLE FOR QA WATERS AND RO SAMPLE FOR QA AND CHANGE DIASAFE PLUS FILTERS Description To monitor the infused dialysate solution for injectable quality criteria. Purpose The sample should meet a microbial limit of < 0.1 CFU / mL and an endotoxin level of no more than 0.03 EU/ml To meet European Pharmacoepia and Renal Association Standards. Reference 5008 Fresenius Operators Manual Supplies Chlorhexidine spray Five sterile 50ml, pyrogen-free sample collection containers 1 Sterile alcohol wipes 1 Sterile 50ml Luer lock Syringe 1 Pair of sterile gloves 1 Basic procedure pack ready for preparation for dialysis. 2 Diasafe Plus Filters Procedure Rationale On completion of T1 test Set up the machine for an Online treatment. Once Rinse Volume has been achieved ( 1000 mls) ; 1. Set supplies up following the dialysis center’s procedure for sample collection 2. Wash hands using liquid soap and use alcohol rub as explained during training. 3. Open sterile pack and place on sterile gloves. 4. Open the left hand door ENSURING the Sub pump is still rotating. 5. Swab the end of the arterial port above the BVM monitor and remove cap (keep clamp closed). 6. Attach sterile syringe and ensuring sub pump is rotating take sample. 7. Ensure all three pots are full of sample water following a non touch technique 8.Replace a new cap onto arterial port, close doors and proceed with dialysis OR discontinuation of treatment. If treatment is being discontinued PRESS Blood System Key and PRESS Remove Lines. Select cleaning screen. 9. Press change filters. Follow instructions on screen and change both diasafe filters. 10. Leave machine switched on. 11.Swab injection port on RO line and spray with chlorhexidine and allow to dry. .12. Ensuring no contamination, aseptically take samples x2 with sterile needles and syringes. 13.Disconnect RO from machine 42 Wrexham - BCUHB 14. Press right hand side key on the RO and select ‘stand by-on’ 15. Select ‘disinfect ‘ and keep finger on button until ‘injection’ comes on screen. 16. Inject 200mls of Dialox or 100mls Puristerile into RO,You have 2 minutes. Remember goggles and gloves. 17. Machine will automatically change to ‘Rinsing In’.( takes 2 hours to rinse in) 18. Once rinsing is complete reconnect RO to machine and put machine through heat disinfect. 19.Place the samples with the ice packs into the cool box provided 20. Ensure the sample arrives at the unit they must arrive in quality assurance in pharmacy within 1hr 30minutes. Sample to be sent with renal porter. 21.The samples must be labeled with the patients name, machine and RO identification number, time and date of sample, so quality assurance can identify machine and test to correct levels. 22.Staff to inform Claire / QA Staff in quality assurance that sample is on its way down. 23.Results will be monitored as per water policy. 43