Professional Documents
Culture Documents
IMPROVEMENT STUDY
DELAYED VASCULAR ACCESS PLANNING RESULTING TO
HIGH INCIDENCE OF CATHETER RELATED
COMPLICATIONS AT THE HEMODIALYSIS UNIT OF
UNCIANO COLLEGES AND GENERAL HOSPITAL, INC.
FROM JANUARY 2016 TO MAY 2016
STAFF NURSES:
KYLIE ZARLA A. ESCALONA, RN, CNN
EMMANUEL M. GILLA, RN
NOELLE M. MARZO, RN, CNN
INTRODUCTION
The majority of dialysis patients use hemodialysis (HD) for renal
replacement therapy. At any given time, a patient will have one or more
vascular access in place. Still a large percentage of patients start dialysis
with a dialysis catheter in place and, often times, no other vascular
access. An organized approach to the management of vascular access
has been found to be effective in reducing the amount of time a patient
has a catheter in place. Creating a plan for vascular access management
is the best way to ensure an organized approach that will lead to catheter
freedom for your patients.
When an access plan has been created this will decrease the use of
HD catheters and preserve existing accesses for continued use. While the
primary focus of vascular access planning is for patients who are new to
hemodialysis, it is also important to work with all patients on HD who do
not have an access plan or are dialyzing with a catheter. The dialysis care
team (DCT) must create an access plan and checking, using routine
access monitoring that supports early intervention when access
problems are identified. This will decrease the use of HD catheters and
preserve existing accesses for continued use. An access event requiring
intervention or changes to the access plan may provide an opportunity
for the DCT to explore different treatment options with the patient.
Health status and other factors may limit the options available for an
individual patient, but taking the time to evaluate these choices is
recommended. Choices may include:
Peritoneal dialysis (PD) - a home dialysis method.
Kidney transplant- receipt of a kidney from a living or deceased
donor.
The DCT should provide information and arrange for the necessary
referrals in support of patients who want to explore other options.
A vascular access is a hemodialysis patients lifeline. It makes lifesaving hemodialysis treatments possible; it should be in place weeks or
months before the first hemodialysis treatment. Patients should set up a
vascular access well before starting hemodialysis, as AV fistulas and AV
grafts both need time to mature before they are ready for use.
ABSTRACT
The course of this study is ranging from January to May 30, 2016
at Unciano Colleges and General Hospital, Inc., Dialysis Unit (2 nd Floor)
at Antipolo City.
The scope of this study focused on determining the underlying
factors regarding the high incidence of catheter related hemodialysis
complications, which leads us to come up with the topic Delayed
Vascular Access Planning Resulting to High Incidence of Catheter-related
Hemodialysis Complications at Hemodialysis Unit of Unciano Colleges
and General Hospital, Inc.
This quality improvement study also focused on improving the
awareness of patients and relatives regarding the importance of having a
permanent vascular access as soon as primary option for maintaining
hemodialysis treatment.
OBJECTIVES
At the end of this quality improvement study by the end of June
30, 2016 onwards, the researchers from DIALYSIS UNIT (2 nd Floor) of
Unciano Colleges and General Hospital, Inc. aims the following:
MI
SI
Av
Ef
Fe
Id
Total
1
3
2
2
1
2
1
2
2
1
2
2
9
12
16
Scale:
3 High Rating
Legend:
2 Medium Rating
1 Low Rating
concerned are the delay and failure of the permanent vascular access to
mature and maintain long term patency.
MONTH
Total
No. of
Census
January
47
Total No. of
Patients
Awaiting for
Vascular Access
Implant
8
Februar
y
51
March
April
54
55
6
6
6
4
3
2
May
TOTAL
55
4
31
2
25
2
16
Total No.
Incidence of
Catheter
Infections
4. HD NOD
monitors the
vascular
access for
signs of
infection and
Standard
Performances
HD NOD
determines the
total number of
patients that are
candidate for AVF
or AVG implant.
HD NOD educates
the importance of
having a
permanent access
available for
hemodialysis
therapy.
Patient is referred
to TCVS for
vascular mapping
and further
surgical
evaluation
regarding
choosing the
applicable
permanent
vascular access.
HD NOD performs
vascular access
monitoring and
assessment to
check for any
signs of infection
Indicator
No. of times HD NOD
identifies the candidates
for permanent vascular
access implant / No. of
incidence of catheter
related complications x
100
No. of times HD NOD
educates patient
regarding advantages,
options, and process of
obtaining a permanent
vascular access / No. of
incidence of catheter
related complications x
100
Target
100%
100%
100%
100%
maturation
5. HD NOD
educates
patient
regarding
proper care of
vascular
access
6. HD NOD
plans for the
removal of
catheter
together with
the patient
7. HD NOD
follows
cannulation
protocol and
permanent
vascular
access
monitoring
and
surveillance.
8. HD NOD
Re-evaluates
the vascular
access for full
integrity and
maturity.
9. HD NOD
performs
catheter
removal
aseptically.
and maturation of
the access.
HD NOD educates
the patient
regarding the
proper self
monitoring and
care of their
vascular access.
HD NOD plans the
timetable for the
removal of
catheter of the
patient
HD NOD follows
the algorithm for
cannulation
procedures and
permanent
vascular access
monitoring and
surveillance.
HD NOD reassess
the readiness of
the vascular
access for
permanent usage
by inspecting full
maturity after 3
consecutive
successful
cannulations.
HD NOD performs
the removal of
catheter
aseptically.
100
No. of times HD NOD
educates patient
regarding vascular access
care / No. of incidence of
catheter related
complications x 100
No. of times HD NOD
plans for the removal of
catheter / No. of
incidence of catheter
related complications x
100
No. of times HD NOD
follows cannulation
protocol and permanent
vascular access
monitoring and
surveillance / No. of
incidence of catheter
related complications x
100
No. of times HD NOD Reevaluates the vascular
access for full integrity
and maturity / No. of
incidence of catheter
related complications x
100
100%
100%
100%
100%
100%
100
KEY TASK
1. HD NOD
identifies the
candidates for
permanent
vascular access
implant.
2. HD NOD
educates patient
regarding
advantages,
options, and
process of
obtaining a
permanent
vascular access.
3. HD NOD refers
patient to TCVS
for vascular
TOTAL NO. OF
INCIDENCE OF
NO. OF
CATHETER
MEASUREMENT TARGET
INCIDENCE
RELATED
COMPLICATIONS
16
(7/16) x 100
= 43.75 %
100%
16
(8/16) x 100
= 50 %
100%
16
(6/16) x 100
= 37.5 %
100%
mapping and
further surgical
evaluation.
4. HD NOD
monitors the
vascular access
for signs of
infection and
maturation
5. HD NOD
educates patient
regarding proper
care of vascular
access
6. HD NOD plans
for the removal of
catheter together
with the patient
7. HD NOD
follows
cannulation
protocol and
permanent
vascular access
monitoring and
surveillance.
8. HD NOD Reevaluates the
vascular access
for full integrity
and maturity.
9. HD NOD
performs
catheter removal
aseptically.
16
(0/16) x 100
= 100 %
100%
16
13
(13/16) x 100
= 81.25 %
100%
16
(0/16) x 100
= 100 %
100%
16
(8/16) x 100
= 50 %
100%
16
(6/16) x 100
= 37.5 %
100%
16
(4/16) x 100
= 25%
100%
FREQUE
NCY
PERCENTA
GE
Cumulativ
e%
A. Patient undecided to
have Permanent Vascular
Access
1. Financial Constraints
2. Low Socio-economic
status
3. Unemployment
6%
6%
B. Contamination of
Central Venous Catheters
1. Exposure of CVC to
external environment
2. Dressing dressing comes
off/manually removed
3. Dressing gets wet due to
sweat/when taking a bath;
Activity or during sleep
13%
19%
1. Patient is unprepared to
have HD
2. Patient still in denial of
their present condition
6%
25%
D. Failure of PVAs
(AVF/AVG) to mature
1. Encountered Vascular
access complication (e.g.
thrombosis
2. Due to comorbid
conditions (e.g. DM)
3. Improper PVA care &
monitoring
13%
38%
E. Delayed referral to
Nephrologist
6%
44%
1. Improper handwashing
and not wearing/changing
PPEs
2. Time cramming and
inavailability of stocks
19%
63%
G. Defective
Extracorporeal Circuit
1. Cracked/ improperly
fitted caps
2. Manufacturer defect
6%
69%
H. Clotted catheters
6%
75%
I. Contaminated Supplies
1. Exposure to air
2. Not properly sterilized or
covered well
3. Lack of time
management
6%
81%
1. Improper hygiene/
Presence of pets at home
2. Lack of patient
education
6%
88%
K. Presence of Airborne
Pathogens within the
facility
1. Contaminated
circulating air around the
premises
2. Irregular terminal
cleaning or sanitation of
the entire unit
6%
94%
L. Presence of Airborne
Pathogens
inside the Pts house
1. Contamination of
Patients
belongings
2. Unclean home
6%
100%
16
100%
TOTAL
IV.
OBJECTIVE SETTINGS
Target Setting:
To decrease the incidents of catheter related complications, researchers
targets to aim the following by the end of June 2016, in the Dialysis Unit (2 nd
Floor) of Unciano Colleges and General Hospital, Inc.:
IV-A. Formulation of Solutions
A. BRAIN STORMING
B. ALTERNATIVE SOLUTIONS
C. SELECTION OF SOLUTIONS
Scale:
3 High Rating
2 Medium Rating
Legend:
MI Medical Importance of the problem
1 Low Rating
1. Financial
Constraints
2. Low Socio-economic
status
3. Unemployment
B. Contamination of
Central Venous
Catheters
1. Exposure of CVC to
external environment
2. Dressing dressing
comes off/manually
removed
3. Dressing gets wet
due to sweat/when
taking a bath; Activity
or during sleep
1. Patient is +
C. Patient anxiety &
resistance to
accept/participate
in HD Treatment
unprepared to have HD
2. Patient still in denial
of their present
condition
Potential Solutions
1. Provide referrals to
social serv
ice assistance and
politicians.
2. Encourage to find
alternative means of
gaining income.
1. Educate patient and
relatives to keep catheter
dressing intact and dry.
2. Advice patient to refrain
from sleeping on the side
where catheter is inserted
3. Educate patients
regarding maintaining the
catheter site dry and intact
at all times and
encouraged to have sponge
bath near the affected
area.
1. Patient education
regarding importance of
HD.
2. Assist patient to
accepting present
condition by reality
presentation.
M
I
S
I
A
v
E
f
F
e
I
d
TOT
AL
18
10
D. Failure of PVAs
(AVF/AVG) to
mature
1. Encountered
Vascular access
complication (e.g.
thrombosis
2. Due to comorbid
conditions (e.g. DM)
3. Improper PVA care &
monitoring
E. Delayed referral
to Nephrologist
1. Patient unaware of
their present condition
2. Lack of Knowledge
about HD Treatment
F. NOD breaks
aseptic technique
during catheter
dressing
1. Improper
handwashing and not
wearing/changing
PPEs
2. Time cramming and
inavailability of stocks
G. Defective
Extracorporeal
Circuit
1. Cracked/ improperly
fitted caps
2. Manufacturer defect
H. Clotted catheters
1. Catheter is not
properly heparinized
2. Patients are known
clotters
I. Contaminated
Supplies
1. Exposure to air
2. Not properly
sterilized or covered
well
3. Lack of time
management
1. Referral to nephrologist
or TCVS for appropriate
medical/surgical
intervention
2. Referral to attending
physician for management
of other conditions
3. Educate patient
regarding proper care and
regular monitoring of their
vascular access
1. Early consultation and
referral to nephrologist to
determine their current
health condition.
2. Patient education
regarding the benefits of
complying with
hemodialysis treatment.
1.NOD must observe and
comply on proper hand
washing and wearing /
changing PPEs at all
times
2. Practice time
management at all times
and notify manufacturers
ahead of time.
1. NOD to double check
caps to be used
2.abruptly inform
suppliers about defective
supplies
1. NOD must always check
proper heparinization of
catheters.
2. Referral to nephrologist
for medical intervention.
1. Ensure that all supplies
were covered or sealed
properly.
2. Proper sterilization or
disinfection of supplies.
3. Practice time
management at all times.
18
16
18
16
17
14
J. Accumulation of
dirt & hair
around the
drressing
1. Improper hygiene/
Presence of pets at
home
2. Lack of patient
education
K. Presence of
Airborne Pathogens
within the facility
1. Contaminated
circulating air around
the premises
2. Irregular terminal
cleaning or sanitation
of the entire unit
L. Presence of
Airborne Pathogens
inside the Pts
house
1. Contamination of
Patients
belongings
2. Unclean home
1. Encourage maintenance
of proper hygiene and
minimize exposure to pets.
2. Educate patients
regarding proper care of
their central venous
catheters.
1. Maintain regular air
sanitation by using air
sanitizers or UV lamps.
2. Maintain regular
cleaning and sanitation of
the entire unit.
1. Encourage patients to
regularly clean or disinfect
their belongings.
2. Advice patient and
relatives to maintain
cleanliness at home.
10
16
16
IMPLEMENTOR
Attending
Physician,
Hemodialysis
Head Nurse and
Staff Nurses
Attending
Physician,
Hemodialysis
Head Nurse and
Staff Nurses
TARGET
GROUP
TIME
FRAME
Patients
May 31,
2016
onwards
Decreased incidence of
catheter infections and
further complications on
HD access.
May 31,
2016
onwards
Patients
EXPECTED RESULT
Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse and
Staff Nurses
Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse,
Staff Nurses,
and Patients
Attending
Physician,
ThoracoCardiovascular
Surgeon (TCVS),
Hemodialysis
Head Nurse and
Staff Nurses
May 31,
2016
onwards
May 31,
2016
onwards
Patients
May 31,
2016
onwards
Patients
Patients
Hemodialysis
Head Nurse
Hemodialysis
Staff Nurses
Every 4th
Week of the
Month
(MayDecember,
2016)
Hemodialysis
Head Nurse &
Staff Nurses
Hemodialysis
Head Nurse
and Staff
Nurses
May 31,
2016
onwards
V.
and
complications.
hypertensive
meds
that
prevents
HD
access
VI.
INSTITUTIONALIZATION
Upon achieving the study, the entire Dialysis Care team recognized the
importance to be presented for the benefit of the patients of the entire
institution, as well as the staffs of Unciano Colleges and General Hospital, Inc.
The researchers recommended that the prompt implementation of catheter
reduction program by emphasizing the importance of obtaining a permanent
vascular access is the main key to decrease the high incidence of catheter
related complications. And these goals will be achieved by means of educating
patients regarding the importance of having a permanent access for use, as
well as to involve them to the implementation of catheter reduction program.
Patient education greatly provides awareness to patients on how can
their health status be improved. Regularly updating patients about their health
condition makes them more cooperative and active about their health
management. When patients are well informed they are more likely to
participate in their health care needs and are actively compliant to health
regimens. When patients are aware of the dos and donts in health
management this tends them to have a positive outlook on their health status.
Moreover, it is important as well to recognize patients readiness and
acceptance of their health condition so as health management will be effective.
Acceptance from patients plays a vital role in order to proceed to effective
management. It provides them positive views in life and hope to gain an
optimum level of self-worth thus making them actively participate.