Safety on Nocturnal Home Haemodialysis
Safety on NHHD is a key issue
The commonest NHHD question from and the greatest anxiety for patients is…“How can I be sure that sleeping through the night while on dialysis is safe?” The answers this question include:
· training procedures
· monitoring equipment
· technical support
Home-based therapy, is it new?
· Home-based, daytime, 4hr haemodialysis (HD) has been common in Australia, New Zealand and Canada for 40 years.
· It was also common in the US in earlier years and is still strongly supported in a few regions, particularly in Seattle, WA, Lincoln, NE, Lynchburg, WV and upper New York State
· Home-based, daytime HD has long been regarded not only as safe but as superior
Dialysis at home? – How could I ever learn to do that!
Just imagine climbing into the driving seat of a car … for the very first time
· You are confronted by a round rimmed wheel
· There are rows of dials and switches
· There are levers on the floor and at your side
· Lights flash … dials twitch and beep
But … right now, out in your garage, there is a car that you drive with certainty and ease. With training and familiarity, you have come to drive it without a second thought
· You don’t have to know what happens under the hood
· You don’t have to know how internal combustion works
· Yet, you drive that car safely.
· How? Because you were taught to do so!
· In just the same way, you can be taught to ‘drive’ a dialysis machine - and probably with much greater safety than you have behind the wheel of your car!
Training – An overview
· The average training program is 4-6 weeks, 5 days per week.
· At entry, trainees are changed from their standard 4 hours, 3 times/week schedule to a 4 hours, 5 day/week program under strict written and verbal protocols.
· All trainees learn at their own pace. There is no timetable, there are no deadlines
· Training is one-on-one, focusing throughout on safety and trouble shooting
Training – The issues
· The biggest hurdle for most is self-needling
· Self-needling is encouraged from the start yet, again, there is no force, no coercion
o Encouragement, praise and self-pride dominate the training rooms
o Self-needling is rarely a technical problem
o Self needling is a ‘mind-set’, and ‘mind-sets’ are made to be conquered
· The rest is practice and repetition
· The home-training room is a positive place and a great place to be
Training - Odds and ends
· Setting up and cleaning down are chores but are easily mastered
· Towards the end, trouble-shooting predominates as the trainee nears home
· Trainees learn that the machines have many fail-safes and protective devices
· Above all, training is ‘trust’ … trust in the equipment and in the training/support staff
Training - The home stretch
· Once passed ‘ready for home’, a few ‘sleep-over’ nights are spent at the hospital in a room set up to be ‘like home’.
· Trainees come in at 8.30 pm, set up, sleep the night on dialysis, come off, clean up and go home again. Not all programs do this but we think it is a good idea.
· The nurse who has guided the training program stays in the hospital too, out of sight and only ‘there if needed’.
· This in-hospital, sleep-over ‘home trial’ recurs for several consecutive nights - until the trainee feels self-assured and ready for home
· The first night at home is also accompanied by the training nurse … then its ‘on your own’
… but what about things going wrong during sleep?
Fail-safes and alarms
· Machines have lots of fail-safes and alarms. A machine will alarm to warn you and will switch off if:
o The ‘arterial’ pressure falls - 95% of alarms occur when a blood line is kinked as you roll over during sleep
o The ‘venous’ pressure rises - for the same reason
o There is a blood leak – rare indeed
o The conductivity (dialysate fluid ‘mix’) alters
o The temperature drifts up or down
· There are lots of safety nets built into machines. All you have to do is learn to recognize and correct them. This is part of the training process - to know what to do if a problem arises and what to do to correct it.
… so, will I be awoken, time and again?
· No … the average number of alarms per night is 1.5/night
· Think of an average 60 year old man with normal kidneys and a 60 year old prostate! He gets up in the dark, finds the toilet, gets cold, and often has to do this several times a night! All an NHHD patient must do is shake the fistula arm, un-kink the line and go back to sleep, feet never touching the cold floor!
· If all else fails, come off and go back to sleep … there is always the next night!
… in addition, there are other devices to offer protection.
NHHD procedural/monitoring safety
Several features can help ensure whilst-asleep dialysis safety. We use or have considered:
· An under-machine moisture sensing device to detect dialysate leaks
· An ‘electrode-impregnated tape’ under catheter connectors or around the AV fistula to detect blood leaks (See FAQ section) there are a number of like devices now with the RedSense detector being popular in the US. Which device doesn’t matter – but wearing one does. Some patients can get lazy and begin to leave their leak-detector off … all I can say is - DON’T!
· Clip-lock ‘connector boxes’ over catheter connectors to prevent disconnection. Though available, we do not routinely use these
· Light-weight ‘back-slabs’ to stabilise/protect AVF needles/insertion sites. Though potentially useful if the AVF is near the wrist or elbow, we do not routinely use these
· Modem/internet technology to feed machine data to centralised monitoring station. We do not use this system in Australia though the original Canadian program continues to do so
· Bedside telephone with logged numbers
· Back-up must be part of the support provided by your dialysis unit
o On-call dialysis nursing staff must be at the end of the phone
o Technical staff must be available the next morning to fix machine/water problems
o Regular servicing is vital to keep your machine running smoothly
· All this must be ‘set-up’ for a program to run well and efficiently
What about blood tests?
· We use a small, portable centrifuge which our patients collect, once every 6 to 8 weeks, to ‘spin-down’ their routine pre- and post dialysis bloods.
· We teach how to take a blood sample, how to spin it down and how to store it until the next day when the centrifuge and blood samples are returned to the training unit
· It’s easy!
The key to NHHD is trust
· Trust in your new skills and knowledge
· Trust in your machine and equipment
· Trust in your back-up staff and technicians
· Trust in your training program
· Trust in your family and home supports
· Trust in yourself
With training, support and trust, NHHD brings greater well-being,
new freedoms and improved self-esteem.
Authored by Prof John Agar. Copyright © 2012