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During World War II, Dr. Willem Kolff revolutionized medicine by creating the first “artificial kidney” from everyday objects such as juice cans, sausage casings, and old washing machine parts. This wartime innovation laid the foundation for modern dialysis, a lifesaving treatment for patients with kidney failure.
Currently, the Department of Veterans Affairs is working on improving dialysis, which could be just as revolutionary.
“The population of veterans with chronic kidney disease and end-stage renal disease is constantly growing,” said Rita Tassinari. Phoenix, Virginia Specialty Procedures Nurse Manager. “Dialysis is a life-saving and life-changing procedure for patients.”
Dialysis patients often receive treatment three times a week for three to four hours each session, sometimes for years while awaiting a transplant or other outcome. With so much at stake, it is important to prevent complications.
Addressing critical safety concerns
In 2008, the National Center for Patient Safety (NCPS) in Virginia analyzed clinical reports of bleeding incidents and found that disconnected blood lines were the leading cause of dialysis leaks. They issued patient safety advisories and provided recommendations for early detection and prevention of lineage breaks.
In 2010, a patient alert was also issued emphasizing the need to keep access sites visible and explaining the protective value of using the Fresenius Hemaclip in areas where the Fresenius lineage is employed. Ta.
“We are focused on evidence-based solutions to address the unique safety challenges of veterans,” explained biomedical engineer Rabe Hijazi.
These leaks can be dangerous, especially considering that hemodialysis pumps operate at 400 to 500 milliliters per minute.
To reduce this risk, NCPS-preferred facilities evaluate the compatibility of Hemaclips with existing catheters. “It's a plastic piece that acts as a bottom lock,” said Bobby Jose, president of the Phoenix chapter of the American Association of Nephrology Nurses.
Jose's support for HemaClip stems from a tragic experience early in his career in which a patient lost his life due to the lack of such safety measures. “We've never had anything like that happen here, but it's the kind of thing that if it did happen, it would almost always be catastrophic.”
Simulation: The key to safety innovation
Despite HemaClip's potential, clinicians faced hurdles. The manufacturer states that it is intended for Fresenius blood tubes only. To address this limitation, NCPS collaborated with frontline clinicians and the Simulation Learning, Evaluation, Evaluation, and Research Network (SimLEARN) to conduct a thorough evaluation and application of the product to a variety of tubes. did.
“Simulations provided an opportunity for real-time feedback and debriefing. This process helped us identify areas for improvement, strengthen effective practices, and address gaps in knowledge and skills. ” Hijazi added.
The team developed a simulation scenario to test Fresenius Hemaclip on tubes from four different manufacturers. “We tried countless ways to make it fail, and it didn't fail,” Tassinari said. “By recreating realistic clinical scenarios, the simulation helped staff recognize and understand potential safety issues and error-prone situations associated with Fresenius Hemaclips and pedigrees.Simulation It gives you the opportunity to try different things before you try them on real patients. It also gives you permission to fail. You can also try things that are not limited to.
Based on these simulation results, NCPS will provide technical information to approximately 250 VA nephrologists to make informed decisions, serving more than 6,000 outpatient Veterans and numerous patients requiring acute care. affected inpatient care.
A personal connection to your service
For Tassinari, this work is of particular significance. “My father was a World War II veteran and passed away when I was young. Working here is the closest I've been to him in a long time.”
To learn more about how simulation can support frontline staff and improve patient care, please visit: Simran and subscribe to it Newsletter.
For more information about the National Center for Patient Safety, please visit: VHA National Patient Safety Center.
Endorsement Disclaimer
Reference herein to specific goods, processes, or services by trade name, trademark, manufacturer, or otherwise does not necessarily constitute or imply approval, recommendation, or endorsement by the U.S. Government.
