How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients

Prolonged exposure to continuous renal replacement therapy in patients with acute kidney injury

BACKGROUND

Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes.

METHODS

We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90 days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group.

RESULTS

Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200 ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90 days, OR 3.1 (95% CI 1.23-8.3 p = 0.017).

CONCLUSIONS

Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.

A Review for the Practicing Clinician: Hepatorenal Syndrome, a Form of Acute Kidney Injury, in Patients with Cirrhosis

The hepatorenal syndrome type of acute kidney injury (HRS-AKI), formerly known as type 1 hepatorenal syndrome, is a rapidly progressing renal failure that occurs in many patients with advanced cirrhosis and ascites. Accumulating evidence has led to a recent evolution of diagnostic criteria for this serious complication of end-stage liver disease. The aim of this review is to provide an overview of disease-related characteristics and therapeutic management of patients with HRS-AKI. Relevant literature was compiled to support discussion of the pathophysiology, diagnosis, prognosis, associated conditions, prevention, treatment, and management of HRS-AKI. Onset of HRS-AKI is characterized by sudden severe renal vasoconstriction, leading to an acute reduction in glomerular filtration rate and rapid, potentially life-threatening, renal deterioration. Although our understanding of disease pathophysiology continues to evolve, etiology of HRS-AKI likely involves systemic hemodynamic changes caused by liver disease, inflammation, and damage to renal parenchyma. There is currently no gold standard for diagnosis, which typically involves a clinical workup, abdominal imaging, and laboratory assessments. The current consensus definition of HRS-AKI includes proposed diagnostic criteria based on changes in serum creatinine levels tailored for high sensitivity, and rapid detection to accelerate diagnosis and treatment initiation. The only potential cure for HRS-AKI is liver transplantation; however, vasoconstrictive agents and other supportive measures are used as needed to help maintain survival for patients who are awaiting or are ineligible for transplantation. The severity of HRS-AKI, complex pathology, limited treatment options, and range of associated conditions pose significant challenges for both patients and care providers.

Factors related to hemodialysis safety culture: integrative literature review

OBJECTIVE

To analyze the factors involved in nursing care that are related to the safety culture of chronic renal patients on hemodialysis.

METHOD

Integrative literature review, carried out through the steps: problem identification, bibliographic research, data evaluation, data analysis, and report. We adopted the guiding question: "What scientific evidence is there about the factors related to the safety culture in hemodialysis clinics, according to the nursing team?" The search was carried out in the LILACS, Medline / PUBMED, Scopus, CINAHL, Cochrane, and Web of Science (WOS) databases.

RESULTS

The sample of this review was composed of five studies. The factors found were: 8 predisposing, 13 disabling, 11 precipitating, and 18 reinforcing.

CONCLUSION

The analysis of literary productions allowed an understanding of the main factors linked to nursing practices that influence the safety culture of patients on hemodialysis.

The impact of the COVID-19 pandemic on renal transplantation in the UK

COVID-19 is impacting provision of renal transplantation in the UK with a reduction in clinical activity. Publicly available Renal Registry and NHS Blood and Transplant reports were analysed to model the number of missed transplant opportunities, waiting list size and change in dialysis population over a six-month period starting 5 March 2020. An estimated 1,670 kidney transplant opportunities may be lost, which will lead to 6,317 active patients on the kidney-alone waiting list, compared to 4,649 based on usual activity estimates. This will result in 1,324 additional patients on dialysis who would otherwise have been transplanted. COVID-19 will lead to a marked loss of transplant opportunities and a significantly larger national waiting list. The existing strain on dialysis capacity will be exacerbated as patients remain on dialysis as the only available form of renal replacement therapy. These findings will help inform policy and service specific strategies.

Achieving dialysis safety: The critical role of higher-functioning teams

The potential for harm from errors and adverse events in dialysis is significant. Achieving a culture of safety in dialysis to reduce the potential harm to patients has been challenging. Recently, improving dialysis safety has been highlighted by Nephrologists Transforming Dialysis Safety (NTDS), a national initiative to eliminate dialysis infections. Other aspects of dialysis safety are important, though less measurable. Approaching dialysis safety from a systematic thinking view helps us to understand the need for leadership and high-functioning teams to deliver safe, reliable care in dialysis facilities. Resilience in healthcare is embodied by strong teamwork-interdependent professionals working together with clarity of goals and communication. This paper reframes the role of dialysis facility medical directors as leaders of these high-functioning teams. Alignment between nephrologists and dialysis management is necessary for these teams to function. This will require nephrologists to embrace their leadership roles as medical directors and for dialysis facility management to provide adequate operational support. The accountability for dialysis safety is shared between the nephrologists and dialysis organizations; coleadership is required for safety culture and high-functioning dialysis teams to develop.

Validação de instrumento de avaliação da segurança de pacientes renais em hemodiálise

Resumo Objetivo Construir e validar um instrumento de avaliação da segurança de pacientes renais crônicos em hemodiálise. Métodos Estudo metodológico que abrangeu elaboração do instrumento e validação de conteúdo por 14 juízes; e avaliação da compreensão, por nove enfermeiros. A construção foi fundamentada na legislação sanitária sobre hemodiálise e padrões internacionais de segurança de pacientes. Para análise da concordância dos juízes, foi calculado o Coeficiente de Correlação Intraclasse, Índice de Validade de Conteúdo e teste binomial. Resultados Os itens do instrumento do tipo Likert foram distribuídos nas seis metas internacionais de segurança de pacientes, obtiveram Coeficiente de Correlação Intraclasse de 0,98. O instrumento final ficou com 57 itens com Índice de Validade de Conteúdo de 0,96 e teste binomial ≥0,86. Conclusão O instrumento foi considerado compreensível, relevante e condizente com os padrões de segurança, tendo demonstrado validade de conteúdo e compatibilidade para avaliar a segurança do paciente em ambientes de tratamento hemodialítico.

PREVALÊNCIA E FATORES ASSOCIADOS PARA A OCORRÊNCIA DE EVENTOS ADVERSOS NO SERVIÇO DE HEMODIÁLISE

RESUMO Objetivo: analisar a prevalência e os fatores associados para a ocorrência de eventos adversos no serviço de hemodiálise. Método: estudo descritivo longitudinal com abordagem quantitativa, cuja amostra foi composta de 51 pacientes atendidos na unidade de hemodiálise entre maio e julho de 2016. Os dados foram obtidos por meio do registro diário de eventos adversos em um checklist e submetidos análise e, para as variáveis categóricas, foi realizada a análise bivariada, por meio do teste Qui-Quadrado de independência de Pearson. Resultados: foram registrados 1110 eventos adversos com prevalência em 98,03% dos pacientes, sendo os mais frequentes: erro de medicação (45,2%) e fluxo sanguíneo inadequado (42,9%). Quanto ao grau de dano, a maioria dos eventos foi de grau leve (93,8%), seguido do moderado (5,9%). A ocorrência do evento adverso esteve associada ao sexo feminino, idade menor que 40 anos, ausência de comorbidades, tempo de tratamento menor que um ano e uso de cateter venoso central de longa permanência. Conclusão: a prevalência de eventos adversos foi considerada alta, com predominância do grau leve. O estudo reforça a necessidade de estratégias de gestão e assistência para implantação de medidas de controle da ocorrência dos eventos adversos em hemodiálise, resultando em benefícios econômicos e sociais para a instituição e sua clientela.

Medical safety in the care of the person with end-stage kidney disease

Much is written about medical safety as it pertains to patients with chronic kidney disease, yet the transition to end-stage kidney disease and processes inherent to the receipt of dialysis present unique safety challenges in this population. Educational efforts in medical safety need to focus on the areas of greatest threat and where intervention can provide the greatest benefit. This study addresses such safety topics in the dialysis population and identifies potential strategies that may aid in harm reduction.

Ensuring Patient Safety During the Transition to ESRD

Patients with chronic kidney disease (CKD) are at risk for complications both inherent to the disease and as a consequence of its treatment. The dangers that CKD patients face change across the spectrum of the disease. Providers who are well-versed in these safety threats are best poised to safeguard patients as their CKD progresses.

Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study

BACKGROUND

Patients with end-stage renal disease are at high risk for medical errors given their comorbidities, polypharmacy and coordination of care with other hospital departments. We previously developed a hemodialysis safety checklist (Hemo Pause) to be jointly completed by nurses and patients. Our objective was to determine the feasibility of using this checklist during every hemodialysis session for 3 months.

METHODS

We conducted a single-center, prospective time series study. A convenience sample of 14 nurses and 22 prevalent in-center hemodialysis patients volunteered to participate. All participants were trained in the administration of the Hemo Pause checklist. The primary outcome was completion of the Hemo Pause checklist, which was assessed at weekly intervals. We also measured the acceptability of the Hemo Pause checklist using a local patient safety survey.

RESULTS

There were 799 hemodialysis treatments pre-intervention (13 January-5 April 2014) and 757 post-intervention (5 May-26 July 2014). The checklist was completed for 556 of the 757 (73%) treatments. Among the hemodialysis nurses, 93% (13/14) agreed that the checklist was easy to use and 79% (11/14) agreed it should be expanded to other patients. Among the hemodialysis patients, 73% (16/22) agreed that the checklist made them feel safer and should be expanded to other patients.

CONCLUSIONS

The Hemo Pause safety checklist was acceptable to both nurses and patients over 3 months. Our next step is to spread this checklist locally and conduct a mixed methods study to determine mechanisms by which its use may improve safety culture and reduce adverse events.

Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting

Interest in home hemodialysis (HD) is high because of the reported benefits and its excellent safety record. However, the potential for serious adverse events (AEs) exists when patients perform HD in their homes without supervision. We review the epidemiology of dialysis-related emergencies during home HD, and present a conceptual and practical framework for the prevention and management of serious AEs for those patients performing home HD. In addition, we describe a formal monitored and iterative quality assurance program, and make suggestions for the future development of safety strategies to mitigate the risk of AEs in home HD.

Improving patient safety in haemodialysis

Thomas Inman (1820-76) wrote 'Practice two things in your dealings with disease: either help or do not harm the patient', echoing writings from the Hippocratic school. The challenge of practicing safely with the avoidance of complications or harm is perhaps only heightened in the context of modern medical settings such as the haemodialysis unit where complex interventions and treatment are routine. The current issue of CKJ reports two studies aimed at improving the care of haemodialysis patients targeting early use of arteriovenous grafts as access for haemodialysis and the implementation of a dialysis checklist to ensure the prescribed dialysis treatment is delivered. The further challenge of ensuring that such evidence-based tools are used appropriately and consistently falls to all members of the clinical team.

Maintaining safety in the dialysis facility

Errors in dialysis care can cause harm and death. While dialysis machines are rarely a major cause of morbidity, human factors at the machine interface and suboptimal communication among caregivers are common sources of error. Major causes of potentially reversible adverse outcomes include medication errors, infections, hyperkalemia, access-related errors, and patient falls. Root cause analysis of adverse events and "near misses" can illuminate care processes and show system changes to improve safety. Human factors engineering and simulation exercises have strong potential to define common clinical team purpose, and improve processes of care. Patient observations and their participation in error reduction increase the effectiveness of patient safety efforts.

Development of a hemodialysis safety checklist using a structured panel process

BACKGROUND

The World Health Organization created a Surgical Safety Checklist with a pause or "time out" to help reduce preventable adverse events and improve communication. A similar tool might improve patient safety and reduce treatment-associated morbidity in the hemodialysis unit.

OBJECTIVE

To develop a Hemodialysis Safety Checklist (Hemo Pause) for daily use by nurses and patients.

DESIGN

A modified Delphi consensus technique based on the RAND method was used to evaluate and revise the checklist.

SETTING

University-affiliated in-center hemodialysis unit.

PARTICIPANTS

A multidisciplinary team of physicians, nurses, and administrators developed the initial version of the Hemo Pause Checklist. The evaluation team consisted of 20 registered hemodialysis nurses.

MEASUREMENTS

The top 5 hemodialysis safety measures according to hemodialysis nurses. A 75% agreement threshold was required for consensus.

METHODS

The structured panel process was iterative, consisting of a literature review to identify safety parameters, individual rating of each parameter by the panel of hemodialysis nurses, an in-person consensus meeting wherein the panel refined the parameters, and a final anonymous survey that assessed panel consensus.

RESULTS

The literature review produced 31 patient safety parameters. Individual review by panelists reduced the list to 25 parameters, followed by further reduction to 19 at the in-person consensus meeting. The final round of scoring yielded the following top 5 safety measures: 1) confirmation of patient identity, 2) measurement of pre-dialysis weight, 3) recognition and transcription of new medical orders, 4) confirmation of dialysate composition based on prescription, and 5) measurement of pre-dialysis blood pressure. Revision using human factors principles incorporated the 19 patient safety parameters with greater than or equal to 75% consensus into a final checklist of 17-items.

LIMITATIONS

The literature review was not systematic. This was a single-center study, and the panel lacked patient and family representation.

CONCLUSIONS

A novel 17-item Hemodialysis Safety Checklist (Hemo Pause) for use by nurses and patients has been developed to standardize the hemodialysis procedure. Further quality improvement efforts are underway to explore the feasibility of using this checklist to reduce adverse events and strengthen the safety culture in the hemodialysis unit.

Delivering home hemodialysis: is there still a role for real-time treatment monitoring?

Remote real-time treatment monitoring for home hemodialysis (HHD) was driven by concerns over patient safety in the early era of HHD. However, decades of clinical experience supported by objective data suggest that HHD is very safe and that remote monitoring is unlikely to avert serious adverse events. As a result, such remote monitoring is not routinely offered in the current era and is generally considered an unnecessary expense. However, a one-size-fits-all approach to abandon remote monitoring may overlook potential opportunities: to improve the clinical care of patients dialyzing at home; and to give patients the confidence to perform HHD in an unsupervised setting.

Epidemiology, contributors to, and clinical trials of mortality risk in chronic kidney failure

Patients with chronic kidney failure--defined as a glomerular filtration rate persistently below 15 mL/min per 1·73 m(2)--have an unacceptably high mortality rate. In developing countries, mortality results primarily from an absence of access to renal replacement therapy. Additionally, cardiovascular and non-cardiovascular mortality are several times higher in patients on dialysis or post-renal transplantation than in the general population. Mortality of patients on renal replacement therapy is affected by a combination of socioeconomic factors, pre-existing medical disorders, renal replacement treatment modalities, and kidney failure itself. Characterisation of the key pathophysiological contributors to increased mortality and cardiorenal risk staging systems are needed for the rational design of clinical trials aimed at decreasing mortality. Policy changes to improve access to renal replacement therapy should be combined with research into low-cost renal replacement therapy and optimum clinical care, which should include multifaceted approaches simultaneously targeting several of the putative contributors to increased mortality.