Quality Improvement Study 2016 Final Repaired

7/25/2019 Quality Improvement Study 2016 Final Repaired

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QUALITY

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

PREPARED AND PRESENTED BY: HEMODIALYSIS UNIT

ROMEO A. LAZARTE JR., RN, CNNHEAD NURSE

STAFF NURSES:KYLIE ZARLA A. ESCALONA, RN, CNN

EMMANUEL M. GILLA, RN

NOELLE M. MARZO, RN, CNN


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JOHN LOUIE S.T. SOLITARIO, RN


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INTRODUCTION

The majority of dialysis patients use hemodialysis (HD) for renalreplacement therapy. At any given time, a patient will have one or m ore

vascular access in place. Still a large with a dialysis catheter in place and, often times, no other vasculaccess. An organized approach to the management of vascular accesshas been found to be effective in reducing the amount of time a patienthas a catheter in place. Creating a plan for vascular acces s m anagementis t he best way to en sure an organized a pproach that will lead to ca theterfreedom for you r pa tients.

When an access plan has been created this will decrease the use ofHD catheters a nd preserve existing accesses f or con tinued use. While t heprimary focus of vascular access p lanning is for p atients who are n ew tohemodialysis, it is al so important to work with all patients on HD who donot have a n access p lan or are d ialyzing with a catheter. The d ialysis ca reteam (DCT) must create an access plan and checking, using routineaccess monitoring that supports early intervention when accessproblems are identied. This will decrease t he use of HD catheters andpreserve exi sting accesses f or con tinued use. An access event requiringintervention or changes to the access p lan may provide an opportunityfor the DCT to explore different treatment options with the patient.

Health status and other factors may limit t he options available for anindividual patient, bu t taking the time to evaluate these choices isrecommended. Choices may include:

Peri toneal dialysis (PD) - a home d ialysis m ethod. Kidney transplant- receipt of a kidney from a living or d eceased

donor.

The DCT should provide information and arrange for the necessaryreferrals in support of patients who want to explore ot her op tions.

A vascular access is a hemodialysis patients lifeline. It makes lsaving hemodialysis treatments possible; it should be in place weeks ormonths before the rst hemodialysis treatment. Patients sh ould set up a

vascular access well before starting hemodialysis, as AV stulVgrafts both need time to mature before they are r eady for u se.


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If kidney disease has progressed quickly, a patient may not havetime for placement of an AV stula or AV graft before startinghemodialysis treatments. Venous catheters are not ideal for long-termuse. With a venous catheter, a patient may develop a blood clot, aninfection, or a scarred vein, causing the vein to narrow.

This quality improvement study focuses on the underlying factorsregarding high incidence of catheter com plications in the hemodialysisunit, having the delayed vascular acces s p lanning as ou r main cause. Wealso aim to formulate strategies to provide an efficient treatment an dpromote patients sa fety and satisfaction as well, by means of developinga reliable and effective access p lan, for those who are n ewly diagnosed

with End Stage Renal Disease and regular hemodialysis patients.

ABSTRACT

The course of this study is ranging from January to May 30, 2016at Unciano Colleges and General Hospital, Inc., Dialysis Unit (2 nd Floor)at Antipolo City.

The scope of this study focused on determining the underlyingfactors regarding the high incidence of cat heter related hemodialysiscomplications, which leads us to come up with the topic DelayedVascular Access Planning Resulting to High Incidence of Catheter-relatedHemodialysis Complications at Hemodialysis Unit of Unciano Collegesand General Hospital, Inc.

This quality improvement study also focused on improving theawareness of patients a nd relatives regarding the importance of having apermanent vascular access as soon as primary option for maintaininghemodialysis t reatment.

OBJECTIVES

At the end of this quality improvement study by the end of June30, 2016 onwards, the researchers from DIALYSIS UNIT (2 nd Floor) ofUnciano Colleges a nd General Hospital, Inc. aims t he following:


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1. Identify the contributory factors resu lting to the h igh incidence ofcatheter related infections.

2.Determine the roles of the entire Dialysis Care Team (DCT),together w ith the patient, on eradicating the increasing morbidityand mortality rates co ncerning catheter r elated complications b ymeans of creating an effective vascu lar a ccess p lan, as well as toinvolve t he p atients in the p lan of care.

3.Formulate best strategies t o improve the process o f vascular accessplanning through patient ed ucation, strong collaboration of theentire Dialysis Care Team (DCT), and continuous monitoring andevaluation of the va scular acce ss o f the p atients.

I. PROBLEM IDENTIFICATION AND SELECTION

I.A. Identication of Potential Problems

A.Unavailability and Delayed delivery of stocks resulting to delayedtreatments

B.Defective/Outdated Machines affecting Treatment Efficiency

C.Delayed Vascular Access Planning Resulting to High Incidence ofCatheter Related Complications

I.B. Prioritization and Selection of Problems

PotentialProblem

MI SI Av Ef Fe Id Total

A 1 2 1 1 2 2 9B 3 2 2 2 1 2 12C 3 3 2 3 2 3 16

Scale:3 High Rating 2 Medium Rating 1 Low Rating

Legend:


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MI M edical Importance of the problemSI S ocial Importance of the p roblem

Av A vailability of safe a nd effective m ethod for sol ving the p roblemEf E ffectiveness an d efficiency of the currently used m ethod

Fe F easibility of carrying out remedial actionsId I dentiable o f the p roblem

I.C. Selection of the Problem

Delayed Vascular Access Planning Resulting to HighIncidence of Catheter Related Complications

I.D. Statement of the Problem

Based from the data collected, there were 55 total number ofpatients admitted from January 20 16 to May 2016 at the Dialysis Unit ofUnciano Colleges and General Hospital Inc. During these dates, theresearchers col lected the total number of patient awaiting for a vascularaccess implant, undecided to undergo the procedure, and the incidenceof catheter r elated complications.

From January 2016 to May 2016, there were 16 total number ofcatheter rel ated hemodialysis complications. The highest incidence ofincomplete treatments occurred during January 1 -31, 2016, which is 5(31.25%).

These incidences of catheter related complications are highlyassociated with the delay of having a permanent vascular access inplace. More importantly, these data reect a combination of factors,including absent or l ate placement of the permanent vascular access(AVF, an d AVG) due to late referral of patients for nephrological care,patient anxiety and resistance t o accepting and participating in plans forrenal replacement therapy, lack of funding for patients with theopportunity to have a vascular access placed before t he n eed for d ialysis,and challenges p osed by the inability to precisely predict the occurrenceand timing of imminent dialysis therapy. Other contributory factors


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concerned are t he delay and failure of the permanent vascular access t omature and maintain long t erm patency.

MONTH Total

No. ofCensus

Total No. ofPatients

Awaiting for Vascular Access

Implant

Total No. of Patients

Undecided to Undergo Vascular Access Implant

(AVF,AVG)

Total No.

Incidence ofCatheter

Infections

January 47 8 7 5Februar

y51 7 6 4

March 54 6 6 3 April 55 6 4 2

May 55 4 2 2 TOTAL 31 25 16


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I.E. FORMULATION OF THE SYSTEM


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II-A. Process of the System

Key Task StandardPerformances

Indicator Target

1. HD NODidenties t hecandidates f orpermanent

vascularaccessimplant.

HD NODdetermines t hetotal number ofpatients t hat arecandidate for AVFor AVG implant.

No. of times HD NODidenties t he can didatesfor perm anent vascularaccess i mplant / No. ofincidence o f catheter related complications x100

100%

2. HD NODeducatespatientregardingadvantages,options, andprocess o fobtaining apermanent

vascularaccess.

HD NOD educatesthe importance ofhaving apermanent accessavailable forhemodialysistherapy.

No. of times HD NODeducates p atientregarding advantages,options, and process ofobtaining a p ermanent

vascular access / No. ofincidence o f catheter related complications x100

100%

3. HD NOD

refers patientto TCVS for

vascularmapping andfurthersurgicalevaluation.

Patient is ref erred

to TCVS for vascular mapping

and furthersurgicalevaluationregardingchoosing theapplicablepermanent

vascular access.

No. of times HD NOD

refers p atient to TCVS for vascular mapping and

further surgicalevaluation / No. ofincidence o f catheter related complications x100

100%

4. HD NODmonitors t he

vascularaccess f orsigns o finfection and

HD NOD performs vascular access

monitoring andassessment tocheck for an ysigns o f infection

No. of times HD NODmonitors vascu lar accessintegrity andmaturation / N o. ofincidence o f catheter related complications x

100%


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maturation and maturation ofthe a ccess.

100

5. HD NODeducates

patientregardingproper care of

vascularaccess

HD NOD educatesthe patient

regarding theproper se lf monitoring andcare o f their

vascular access.

No. of times HD NODeducates p atient

regarding vascular a ccesscare / No. of incidence o fcatheter r elatedcomplications x 1 00

100%

6. HD NODplans for t heremoval ofcathetertogether w ith

the p atient

HD NOD plans thetimetable for t heremoval ofcatheter of thepatient

No. of times HD NODplans for t he removal ofcatheter / No. ofincidence o f catheter related complications x

100

100%

7. HD NODfollowscannulationprotocol andpermanent

vascularaccessmonitoring

andsurveillance.

HD NOD followsthe a lgorithm forcannulationprocedures andpermanent

vascular accessmonitoring andsurveillance.

No. of times HD NODfollows ca nnulationprotocol and permanent

vascular accessmonitoring andsurveillance / No. ofincidence o f catheter related complications x

100

100%

8. HD NODRe-evaluatesthe vascularaccess f or fullintegrity andmaturity.

HD NOD reassessthe read iness o fthe va scularaccess forpermanent usage

by inspecting fullmaturity a fter 3consecutive

successfulcannulations.

No. of times HD NOD Re-evaluates t he vascu laraccess for f ull integrityand maturity / No. ofincidence o f catheter related complications x100

100%

9. HD NODperformscatheterremovalaseptically.

HD NOD performsthe removal ofcatheteraseptically.

No. of times HD NODperforms cat heterremoval aseptically / No.of incidence of catheter related complications x

100%


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100

III. PROBLEM ANALYSIS

III-A. Verication of the Problem

KEY TASK

TOTAL NO. OFINCIDENCE OF

CATHETERRELATED

COMPLICATIONS

NO. OFINCIDENCE

MEASUREMENT TARGET

1. HD NODidenties t hecandidates forpermanent

vascular accessimplant.

16 7 (7/16) x 100= 43.75 %

100%

2. HD NODeducates p atientregardingadvantages,options, and

process o fobtaining apermanent

vascular access.

16 8(8/16) x 100

= 50 %100%

3. HD NOD referspatient to TCVSfor va scular

16 6 (6/16) x 100= 37.5 %

100%


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mapping andfurther surgicalevaluation.4. HD NOD

monitors t he vascular accessfor si gns ofinfection andmaturation

16 0(0/16) x 100

= 100 %100%

5. HD NODeducates p atientregarding propercare o f vascularaccess

16 13(13/16) x 100

= 81.25 %100%

6. HD NOD plansfor t he removal ofcatheter t ogether

with the patient

16 0(0/16) x 100

= 100 %100%

7. HD NODfollowscannulationprotocol andpermanent

vascular access monitoring andsurveillance.

16 8(8/16) x 100

= 50 %100%

8. HD NOD Re-evaluates t he

vascular accessfor f ull integrityand maturity.

16 6(6/16) x 100

= 37.5 %100%

9. HD NODperformscatheter removalaseptically.

16 4(4/16) x 100

= 25% 100%


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III-B. Verication of Factors C ausing th e Problem

III-B.1. Balloon Chart


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III-B.2. Ishikawa Diagram


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III-C. Validation of Probable Cause

III-C.1. Data C ollection

Frequency Distribution of Root Causes of Delayed Vascular Access

Planning Resulting to High Incidence of Catheter Related Complications At The Hemodialysis Unit of Unciano Colleges And General Hospit

ROOT CAUSESFREQUE

NCY PERCENTA

GECumulativ

e %

A.Patient undecided tohave Permanent Vascular

Access

1. Financial Constraints2. Low Socio-economicstatus3. Unemployment

1 6% 6%

B. Contamination ofCentral Venous Catheters

1. Exposure of CVC toexternal environment2. Dressing dressing comesoff/manually removed3. Dressing gets wet due tosweat/when taking a b ath;

Activity or during sleep

2 13% 19%

C. Patient anxiety &resistance toaccept/participate in HD

Treatment

1. Patient is u nprepared tohave HD2. Patient st ill in denial of

their presen t condition

1 6% 25%

D. Failure of PVAs(AVF/AVG) to mature

1. Encountered Vascularaccess complication (e.g.thrombosis2. Due to comorbidconditions (e.g. DM)3. Improper PVA care &monitoring

2 13% 38%

E. Delayed referral to

Nephrologist

1. Patient unaware of theirpresent condition

2. Lack of Knowledge aboutHD Treatment

1 6% 44%

F. NOD breaks asept ictechnique during ca theter dressi ng

1. Improper handwashingand not wearing/changingPPEs2. Time cramming andinavailability of stoc ks

3 19% 63%


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G. DefectiveExtracorporeal Circuit

1. Cracked/ improperlytted caps2. Manufacturer defect

1 6% 69%

H. Clotted catheters

1. Catheter i s n ot properlyheparinized2. Patients are kn ownclotters

1 6% 75%

I. Contaminated Supplies

1. Exposure to a ir2. Not p roperly sterilized orcovered well3. Lack of timemanagement

1 6% 81%

J. Accumulation of dirt &hairaround the d rressing

1. Improper hygiene/Presence of pets at home

2. Lack of patienteducation

1 6% 88%

K. Presence of AirbornePathogens w ithin thefacility

1. Contaminatedcirculating air around thepremises2. Irregular terminalcleaning or sa nitation ofthe en tire u nit

1 6% 94%

L. Presence of AirbornePathogensinside the Pts h ouse

1. Contamination ofPatients

belongings 2. Unclean home

1 6% 100%

TOTAL 16 100%


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IV. OBJECTIVE SETTINGS

Target S etting:

To decrease the incidents of catheter related complicationstargets to aim the following by the en d of June 2016, in the Dialysis Unit (2 nd

Floor) of Unciano Colleges a nd 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 1 Low Rating

Legend:MI M edical Importance of the problem


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D. Failure of PVAs(AVF/AVG) tomature

1. Encountered Vascular access

complication (e.g.thrombosis

2. Due to comorbidconditions (e.g. DM)3. Improper PVA care &monitoring

1. Referral to nephrologistor TCVS for appropriatemedical/surgicalintervention2. Referral to a ttendingphysician for managementof other con ditions3. Educate p atientregarding proper care andregular m onitoring of their

vascular access

3 3 3 3 3 3 18

E. Delayed referralto Nephrologist

1. Patient unaware oftheir presen t condition2. Lack of Knowledge

about HD Treatment

1. E arly consultation andreferra l to n ephrologist todetermine their currenthealth condition.2. Patient educationregarding the benets ofcomplying withhemodialysis treatment.

3 3 2 2 3 3 16

F. NOD breaksaseptic technique during ca theterdressing

1. Improperhandwashing and not

wearing/changingPPEs2. Time cramming andinavailability of stoc ks

1.NOD must observe andcomply on proper hand

washing and wearing /changing PPEs at alltimes2. Practice ti memanagement at all timesand notify m anufacturers

ahead of time.

3 3 3 3 3 3 18

G. DefectiveExtracorporealCircuit

1. Cracked/ improperlytted caps2. Manufacturer defect

1. NOD to double checkcaps to be u sed2.abruptly informsuppliers ab out defectivesupplies

3 2 3 2 3 3 16

H. Clotted catheters

1. Catheter i s n otproperly heparinized2. Patients are kn ownclotters

1. NOD must always checkproper heparinization ofcatheters.2. Referral to n ephrologistfor medical interven tion.

3 2 3 3 3 3 17

I. ContaminatedSupplies

1. Exposure to a ir2. Not prop erlysterilized or cov ered

well3. Lack of timemanagement

1. Ensure t hat al l supplies were covered or sealed

properly.2. Proper steri lization ordisinfection of su pplies.3. Practice ti memanagement at all times.

3 1 3 2 3 2 14


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J. Accumulation dirt & hairaround thedrressing

1. Improper hygiene/Presence o f pets a thome2. Lack of patienteducation

1. Encourage maintenanceof proper hygiene an dminimize exposu re t o pets.2. Educate p atientsregarding p roper care oftheir cen tral venouscatheters.

1 3 1 1 1 3 10

K. Presence of Airborne Patogens within

1. Contaminatedcirculating air aroundthe premises2. Irregular terminalcleaning or san itationof the en tire u nit

1. Maintain regu lar airsanitation by u sing a irsanitizers or UV lamps.2. Maintain regularcleaning a nd sanitation ofthe en tire u nit.

1 3 3 3 3 3 16

L. Presence o f Airborne Patogens

inside th e P tshouse

1. Contamination ofPatients

belongings2. Unclean home

1. Encourage p atients t oregu larly cl ean or disinfecttheir bel ongings.2. Advice p atient andrelatives t o maintaincleanliness at home.

1 3 3 3 3 3 16

IV-C. Action Plan

ACTIVITY IMPLEMENTOR TARGET

GROUP TIMEFRAME

EXPECTED RESULT

Identifying p atients th at arepossible ca ndidates f or analternative a ccess.

AttendingPhysician,HemodialysisHead Nurse andStaff Nurses

PatientsMay 31,

2016onwards

Decreased incidence ofcatheter i nfections a ndfurther complications onHD access.

Routine CKD education:Standard CKD and vascularaccess edu cation withcoordinated referral from thephysicians o ffice f or a llpatients.

AttendingPhysician,HemodialysisHead Nurse andStaff Nurses

PatientsMay 31,

2016onwards

Patients will become more

aware o f their presen tcondition and understandthe importance of accesscare and monitoring, as

well as they express their willingness to be involved

in the t reatment plan.


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Automatic education andreferral for vasc ular mappingand surgical evaluation uponadmission of catheter pa tientto the dialysis facility.

AttendingPhysician,

Thoraco-CardiovascularSurgeon (TCVS),HemodialysisHead Nurse andStaff Nurses

PatientsMay 31,

2016onwards

Patients will become moreaware of the importance of

vascular mapping andsurgical evaluation beforeobtaining a p ermanent

vascular access.

Construct and ImplementCatheter Reduction Program,involving the patients i n theplan of care.

AttendingPhysician,

Thoraco-CardiovascularSurgeon (TCVS),HemodialysisHead Nurse,Staff Nurses,and Patients

PatientsMay 31,

2016onwards

All the members of theDialysis Care Team (DCT),as w ell as th e p atient, will

be able to achievereduction of catheters byimplementing permanent

vascular access implant.

Continuous m onitoring an dsurveillance of vascu laraccess use.

AttendingPhysician,

Thoraco-CardiovascularSurgeon (TCVS),HemodialysisHead Nurse andStaff Nurses

PatientsMay 31,

2016onwards

Dialysis C are Team will beable to a ssess t heprogress of the maturationand readiness of theparticular vascular acc essto b e u sed for long-termtherapy.

Monthly meeting of the

dialysis team.

Hemodialysis

Head Nurse

Hemodialysis

Staff Nurses

Every 4 th

Week of theMonth

(May-December,

2016)

All members of thedialysis team will be a bleto a ssess t he st rengths

and weaknesses of therecently implementedprogram.

Continuous m onitoring an devaluation of theeffectiveness of proposedactivities andrecommendations

HemodialysisHead Nurse &Staff Nurses

HemodialysisHead Nurse

and StaffNurses

May 31,2016

onwards

All Staff Nurses willadhere to the proposedactivities andrecommendations.


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V. BENEFITS OF THE STUDY

After solutions were made to solve problems regarding complications on

hemodialysis access, this quality improvement study have come up withsolutions in decreasing incidence among patients undergoing hemodialysistreatment which is l isted as follows:

1.Constant observance of proper PPE use among dialysis staff decreasescontribution to hemodialysis complications.

2.Continuous health education aids in enforcing proper access care inorder t o prevent infections a nd further com plications.

3.The emphasis of proper care of their h emodialysis a ccess l eads to betteraccess p atency t hus p romoting better health status.

4.Regularly updating HD staffs on ways and means to decrease furthercatheter complications.

5. Providing patients options on alternative access p lacement in case t hecurrent access f ails thus con tinuing HD treatment to prevent furthercomplications regard ing th eir h ealth.

6. Emphasizing compliance on HD medications such as blood thinners,antibiotics and hypertensive meds that prevents HD accesscomplications.


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VI. INSTITUTIONALIZATION

Upon achieving the study, the entire Dialysis Care t eam recognized theimportance to be presented for the benet of t he patients of the entireinstitution, as well as the staffs of Unciano Colleges and General Hospital, Inc.

The researchers recommended that the prompt implementation of catheterreduction program by emphasizing the importance of obtaining a permanent

vascular access is the main key to decrrelated complications. And these goa ls will be achieved by means of educatingpatients regarding the importance of having a permanent access for use, as

well as to involve them to

Patient education greatly provides awareness to patients on how cantheir h ealth status b e improved. Regularly updating patients a bout their h ealthcondition makes them more cooperative and active about their healthmanagement. When patients are well informed they are more likely toparticipate in their health care needs and are actively compliant to healthregimens. When patients are aware of the dos and donts in healthmanagement this tends them to have a p ositive outlook on their health status.

Moreover, it is important as well to recognize patients readiness andacceptance of their h ealth condition so a s h ealth management will be effective.

Acceptance from patients plays a vital romanagement. It provides them positive views in life and hope to gain anoptimum level of self-worth thus m aking them actively participate.

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Quality Improvement Study 2016 Final Repaired

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