Safety on Nocturnal Home Haemodialysis
Safety on NHHD is a key issue
The commonest NHHD question from patients … and their greatest anxiety is …
“How can I be sure that I will be safe
while sleeping through the night while on dialysis?”
The most important answers to this question include:
1. Training procedures – especially regarding needle fixation techniques
2. Monitoring equipment – especially of blood or machine leakage
3. Technical support – both during dialysis and for machine malfunction
First … Home-based therapy, is it new?
Home-based, daytime, 4hr conventional haemodialysis (HD) has been common, especially in Australia, New Zealand and Canada, for >40 yrs.
It also was common in the US in earlier years and remains strongly supported in some US regions with Seattle WA,, Lincoln NE, Lynchburg WV and upper New York State being just a few of the major home-friendly haemodialysis centres
The experience of these and other centres in home-based, daytime HD has shown home haemodialysis is both safe and, as all data confirms, as superior
Dialysis at home? – I will never be able to do that!
Just imagine climbing into the driving seat of a car … for the very first time. You will be confronted by …
A round-rimmed wheel
Rows of dials and switches
Pedals on the floor and levels at your side
Lights that flash and dials that twitch and beep
But … right now, out in your garage, there is probably a car that you drive with certainty and ease. Why? … because you have learned to do so, you have done it repeatedly for years and you are comfortable doing so.
Indeed, your lifestyle has come to depend on it!
With training and with ‘familiarity’, you have come to drive that car without a second thought
You don’t need to know what happens under the hood
You don’t need to know how internal combustion works
You drive that car safely.
Because you were taught to do so!
In just the same way, you can be taught to ‘drive’ a dialysis machine – and you will probably be much safer than you are behind the wheel of your car!
Training – an overview
Our average training program is 4-6 weeks, 4 days per week.
At entry, our trainees change from their standard ~4 hours, 3 times/week schedule to ~4-5 hours, 4 day/week guided by both written and verbal protocols. It is important to say that no two people train quite the same. Some like visual training, others like a written ‘manual’. Some combine DVD, white-board and/or written/pictorial material … all are available in our program and we tailor our training techniques to the individual. Our training team identifies each persons’ educational strengths and weaknesses and adapt their training in response.
All trainees learn at their own pace. There is no timetable. There are no deadlines
Training is always one-on-one, focusing throughout on safety and trouble shooting
Training – the issues
The biggest hurdle for most patients is … self-needling
We encourage self-needling from the start yet without force or coercion.
Despite the perception that ‘I could never do that’ … most patients have surprisingly little trouble when it comes down to it.
Encouragement, praise and self-pride dominate our training room
Self-needling is rarely a technical problem
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 really positive place. We like to think it is an uplifting place where patients clearly develop pride in their achievements … it is truly a great place to be
Training - odds and ends
Setting up and cleaning down are chores but these are easily mastered
Towards the end of training, trouble-shooting predominates as the trainee nears transfer to home
Trainees learn that the machines have many fail-safes and protective devices to ensure their safety. These safety practices have been learned over more than 50 years of machine and safety experience.
Above all, training is ‘trust’ … trust in the equipment and in the training/support staff
Training - The home stretch
Once passed as ‘ready for home’, we favour a few ‘sleep-over’ nights spent at the hospital in a room set up to be ‘like home’.
Trainees come in at 8.30pm, set up their machine, put themselves ‘on’, sleep through the night on dialysis, come off in the morning, clean up and go home again. Not all programs do this but we think it is a good idea and it seems our patients are reassured by it. We copied this idea from the Toronto group.
The nurse who has guided the training program for the patient ‘one-on-one’ also stays those nights at the hospital … but she stays out of sight down the hall and is only ‘there’ and ‘available’ if she is needed.
This in-hospital, sleep-over ‘home trial’ recurs for several consecutive nights … until the trainee feels self-assured and ready for home.
It also gives the treating team a chance to get pre- and post-dialysis blood samples from each dialysis and to thus fine-tune the amount of phosphate replacement needed – if the patient is planning on more than 4 nights per week treatment (where phosphate removal is usually so efficient that too much is removed and phosphate replacement is needed.
The first night at home is also accompanied by the training nurse – at least until the patient is on and in bed. Then, she quietly leaves.
Then … the newly ‘at home’ patient is on his or her own
But … what if things go wrong during sleep?
Fail-safes and alarms
Machines have a lot of fail-safes and alarm-systems. A machine will alarm to warn you and will switch off …
… if the ‘arterial’ pressure falls – 95% of all alarms occur when a blood line is kinked as you roll over on it during sleep and change the pressure in it
… if the ‘venous’ pressure rises – usually for the same reason
… if there is a blood leak – a rare event indeed
… if the conductivity (dialysate fluid ‘mix’) alters
… if 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. But, remember, you are taught how to do this … 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 feet, bumps his shin on the furniture … and often has to do this several times a night!
All an NHHD patient has to do is to shake the fistula arm, un-kink the line and go back to sleep, his feet never touching the cold floor!
If all else fails, you ‘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 your dialysis safety while you sleep. We either use or have considered using:
… an under-machine moisture-sensing device to detect moisture on the floor if the machine leaks any dialysate fluid. We use these
… an ‘electrode-impregnated tape’ which sits under catheter connectors (if catheter access is used) or around the AV fistula (especially the venous needle site) to detect any blood leakage (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!
… a clip-lock ‘connector box’ is used by some centres – these fit and clip over the catheter connection to prevent any unexpected disconnection. Though these are available – or can be made simply by any instrument maker – though we have not routinely used these and all but one of our patients has a native AVF
Light-weight ‘back-slabs’ (like those that are used by some orthopaedic services to immobilize wrist injuries) can be used to stabilize and/or protect the AVF needles and their insertion sites. We used these – or similar – in the beginning but haven’t, now, for some years though they do remain an option if the AVF is near the wrist or elbow.
Indeed, we encourage our patients to sleep normally, move normally during sleep, roll and turn as sleepers do. It isn’t natural to hold the arm stiff (or to protect it unduly) during sleep … so don’t. If your needling-stabilising tapes and techniques are correct, the needles will not be pulled out during sleep. Sleep is about relaxation so, you must learn to be confident (but never cocky) about your needling and securing methods … and relax.
Modem/internet technology can be used to feed machine data back to a centralized monitoring station. We do not use this system in Australia though the original Canadian program in Toronto continues to do so
A bedside telephone with logged ‘help’ numbers in a one-key-speed-dial system is essential
Back-up must be part of the support provided by your dialysis unit
On-call, trained and experienced dialysis nursing staff must be at the end of the phone. This is, in our view, a non-negotiable ‘must’
Technical staff must be available the next morning to fix machine/water problems
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 small, portable centrifuges which our patients collect, once every 8 weeks, to ‘spin-down’ their routine pre- and post dialysis bloods.
We teach the patients how to take blood samples, how to spin them down and how to store the blood until the next day when they return the centrifuge and blood samples to the training unit
The key to successful NHHD is … trust
Trust your new skills and knowledge
Trust your machine and equipment
Trust your back-up staff and technicians
Trust your training program
Trust your family and home supports
Trust … yourself
With training, support and trust
greater well-being, new freedom and improved self-esteem.
Authored by Prof John Agar. Copyright © 2012