Hemodialysis Unit | ur-HDU-01 Patients DPP | Apniieso: Al Hemodialysis Statt 1.0. Purpose: Ll. To establish criteria for safe admission of hemodialysis patients to the dialysis unit. 1.2. To provide high quality hemodialysis care for patients with acute and/ or chronie end stage renal disease. 20. Definitions: None 3.0, Policy Statement: 3. Hussein) Al Ali Hospital Hemodialysis Unit (HDU) provides acute hemodialysis, chronic hemodialysis to adult patients. The patients are categorized as having acute renal failure or end stage renal disease. 3.2, ‘The decision to initiate hemodialysis will be made by the Nephrologist after consultation. Procedure: 4.1. Criteria for Treatment of Acute Renal Failure: 4a. Patients identified by the Nephrologists with inadequate renal funetion to preserve life will have dialysis in Hemodialysis Unit 4:12, Patients who are unstable and do require continuous vital signs monitoring, continuous harcotie drips, IV anti-arthythmic medication requiring cardiac monitor or titration, mechanical ventilation, arterial line will have hemodialysis in ICU 413. Patients who are admitted through Emergency Room with hemodialysis related emergencies as in 4.1.1.) and are stable are treated in the HDU during normal hours of ‘operation, otherwise in ICU as in (4.1.2). 4.2. Criteria for Treatment of Chronic Renal Failure (ESRD) 42.1. Patients who meet the eligibility requirements for Hussein Al Ali Hospital are stable for ‘outpatient eare, 4.2.2. | Patients who are for renal transplantation are advised and referred to other Kidney Center. 423. ‘The unit utilizes the following nursing diagnostic and therapeutic modalities to facilitate patient care, 43.1. | Patient assessment pre-dialysis and post-dialysis. 4.3.2, | Dialysis equipment assessment pre-dialysis and post assessment. 433. | Vascular access care and venipuncture, 43.4, | Hemodialysis technology theory ineluding: 434.1. Fluid and electrolyte balance in general and pertaining to hemodialysis therapy. 4.34.2. Hemodynamic monitoring pertaining to dialysis machine functions. 435. Non-invasive blood pressure monitoring; invasive blood pressure monitoring in the ICU in collaboration with the ICU nurses. 43.6. Medication administrationHemodialysis Unit NUR-HDU-01 Title ‘Admission Criteria for Hemodialysis Patients DPP | applicsio: An emodiatysis stat 4.3.7. Anticoagulant therapy 42.8, |batey management 4.3.9. Psychosocial care 43.10. 43:11, Infection Control Patient and family education 43.12. |Multidiseiplinary meeting 43.13, Dietary and nutritional education T 5.0. Attachments} None 6.0, References: 6.1. htp://gb0.e1/6uH6Q9oe ie Hemodialysis Unit NUR-HDU-02 Title: Assessment of Patient on Hemodialysis, DPP | Applies All Hemodialysis Staff mannan 1.0. Purpose: 1 To establish standards of care for the assessment of patient's state of health and wellbeing before, during ag after hemodialysis. 30. Policy Statement: 3.1. All find 3.2. Apply i 33. Follow \2s documented in the Hemodialysis Sheet. fection control policy in Hemodialysis Unit. imission policy in Hemodialysis Unit. 34. A collection of biochemistry blood tests will be completed on every hemodialysis patient during the first ‘week of each month. Results are reviewed by the patients’ primary dialysis nurses, nepholists,decian and social worker. The pains overall health, resuits of blood tests, home issues, 3.5. Peripher 38.1. 352. 3.6. Review dications, responses to hemodialysis treatments, vascular access issues, nutritional al and family issues are discussed as scheduled and as necessary. I Arteriovenous fistulalgraft access: ood pressure or venipunctures are NEVER performed on the AVFYAVG access limb. “rcular oeclusive dressings are NEVER APPLIED on the AVF/AVG access limb. e patient medication after getting the laboratory results. 237. The pats heath and treatment plans will be discussed at the monthly hemodialysis meeting which i Iudes the social worker and dietician. 40, Procedure: 4a. Pre-dial 4d. 412. 413. 4d. 415. sis Patient Assessment: Veleome patient in a proper manner to the unit. Direct patient to his! her dialysis location, ‘ommunicating with patient. Evaluate anxiety, level of consciousness, speech, emotional tatus, confusion or disorientation may be attributed to high ammonia, high aluminum or sypoglycemia. sk patient specific questions about problems and / or symptoms since last hemodialysis «. headache, nausea, vomiting, fever, muscle cramps, dizziness, fatigue. erform a physical assessment like examine client for fluid overload ~ edema on hands, fet, eyelids or abdomen, 4.1.5.1. Distended neck, veins in standing or 45 degrees sitting position, 4.1.5.2, Shortness of breath and tachypnea, Elevated blood pressure. ‘Adjust dry weight downward if client has edema, hypertension, congestion, neck vein distention. Dat Appa[ale] Hemodialysis Unit NUR-HDU-02 Bor Assessment of Patient on Hemodialysis DPP | Applies All Hemodialysis Staff 41.6, 447. 41.9. 4.1.10. 4.1.8.5. Adjust dry weight upward if client has eramping, hypotension or dizziness or feels very tired after dialysis, sasure Pre-dialysis, 44.6.1, Weight in kilogram 4.1.6.1.1, Take accurate recording of client weight 4.1.6.2. Calculating target weight loss or dry weight. 4.41.62.1, Dry weight is the post dialysis weight of client when all excess ‘body fluid has been removed. . Client should have no edema (swelling in the body, tissues i.e hands, fet, ankles or eyelids) or fluid inthe lung. 4.1.6.2.3. The blood pressure is normal 4.1.6.2.3.1. Hypertension may indicate fluid overload. 4.1.6.2.3.2. Hypotension may indicate dehydration. Check for Temperature: i4.1.7.1. Many renal patients have below ~ normal temperature. 44.1.7.2. Temperature elevation suggestion or other complication. theok respiration for one minute 44.1.8.1. Evaluate the rate shythm and quality to identify arrhythmia. Tachycardia and bradycardia compare apical and radial pulse. 14.1.8.2. Increase in respiratory rate may indicate excessive fluid gain. Respiratory rate and rhythm are also affected by patient's activity level, emotional state and ‘medical condition. '4.1.8.3. Identify respiratory distress or changes like tachypnea, bradypnea shortness of breath. (Check pulse for one minute 4.1.9.1. Evaluate the rate, rhythm, tachycardia, and bradycardia and compare epical and radial pulse, theck for Vascular Access Integrity. 4.1.10.1. Check poteney of internal access 4.1.10.2, Feel for presence of pulse. 4.1.10.3, Feel for presence of thrill, 4.1.10.4, Observe previous needles sites and stage of healing. 4.1.10.5, Listen with stethoscope for bruit. 4.1.10.6. Observe for dryness. | rea] SERB Dera qHemodialysis Unit NUR-HDU-02 Baar Assessment of Patient on Hemodialysis. DPP | Applies jo: All Hemodialysis Staff 4a. 412. 4.1.13. 4d. 41.18. 41.16, 41.17, 4.1.18. 44.1.10.7. Check for bleeding below the surface of the skin, {1.1.10.8. Check for presence of any enlargement or expansion of blood vessel. heck that Vascular Access is free from Infection K.LL1. Absence of redness/pus H4..11.2. Absence of tenderness 4.1113. Absence of swelling heck Current Medication Theck gastrointestinal status , ask if client have had any problem with: |113.1. Nausea or vomiting 1.1.13.2. Diarthea or constipation sess and evaluate supplies and equipments lient preparation and assessment pre-dialysis, prior to initiation of dialysis; prepare alysis cannulation set up. On a clean working bedsides table prepare. 4.1.15. Fistula needle (arterial-venous) (17, 16, 15, and 14 g, as ordered by physician), {1.1.15.2. ‘Two 10 ml sterile syringes filled with saline solution, 4.1153. 2 pieces 4x4 sterile gauze }1.1.154. Non sterile gloves 41.155. Betadine swab \urse preparation pre-cannulation procedure {1.1.16.1. Proper hand washing technique using antiseptic liquid soap. 441.16.2. Wear mask with eye shield 1.1.16. Wear disposable non-sterile gloves H4.1.164. Never use the same gloves for 2 different patients, 4.1.16.5. Hands must be washed after removing gloves & before touching any environment surface such as machine knobs, charts, telephone or other ‘equipments. elect puncture sites 4.1.7.1. Check the presence of bruit or thrill 44.1.17.2. Palpate over the entire length of the fistula 44.1.17.3. Occlude vessel with finger feel for pulse form the Nephrologist ofall abnormal findings ——oe Hemodialysis Unit NUR-HDU-02 Baio = Assessment of Patient on Hemodialysis DPP | applies All Hemodialysis Staff 4.2, Intra-Dialysis Assessment and Monitoring: 42.1. 42.2. 423. 43. Post-Dial 43.1. hurpose: L2.1.1, Provide safe and effective care during dialysis 2.1.2. Continuous monitoring of elient and Hemodialysis machine 1.2.1.3, Continuous monitoring of client during Hemodialysis treatment lonitoring Client During Treatment 1.2.2.1. Vital Signs record B.P. and H.R, every 30 minutes (or as per doctor's order) if client unstable, record vital more frequently. Monitoring of the client general condition continuously and level of Vascular access continuous assessment ofthe poteney and funetioning. Document client response to treatment. Observe for any abnormal physiological reaction 4.2.2.8.1, Itching, Dizziness, Shortness of breath, Cramps, Hypotension, Flushing, Fever and chills, Restlessness and confusion Invtability 12.2.6. Report any complication to Nephrologist and give the appropriate nursing interventions. Check the access site (fistula or permicath) if there is bleeding ‘or oozing every 30 minutes. lonitoring Hemodial 2. js Machine During Treatment: 1. Perform machine safety checks every 30 minutes, record blood pressure (BPR), blood pump, venous pressure (VP), arterial pressure (AP), ‘Transmembrane pressure (IMP), ultrafiltrate (UF) removed. 12.3.2, Use 12.3.3. Regularly check for integrity of the dialyzer and extra corporeal circuit 12.34, Attend to machine alarms prompily and detect malfunction before they affect the client. lysis concentrate and dialyzer as preseribed 3.5. When unable to troubleshoot the machine problems, discontinue hemodialysis treatment and return the blood to client sis Assessment: jost-dialysis- discontinue dialysis: |3.L.1. Check blood pressure and pulse just before discontinuing dialysis (usually 5 minutes before termination). 2. Increase or decrease in blood pressure may influence the amount of fluid that will be used to return the patient blood,Hemodialysis Unit NUR-HDU-02 3.1.6. 31.7. Title: Assessment of Patient on Hemodialysis, Applies fo: All Hemodialysis Staff (3.13. Tum off heparin pump several minutes 30 min, to one hour before the end of the session if heparin pump was used, Reduce blood flow rate and negative pressure. Use aseptic technique to protect against accident blood exposure with the use cof non-sterile gloves and facemask and eye shield. Rinse with normal saline (NS 0.4% Or DS % NS) the dialyzer and bloodlines. Remove the needles 43.1.7. Venous needle is first needle to be carefully untapped and removed and gentle pressure is applied to the puncture site. 423.1.7.2. Arterial needle is removed after the venous site is dressed the patient bleeding must be stopped. In 4.3.1.7.1 and 4.3.1.7.2 use only gentle pressure to prevent total ‘occlusion of the blood access. 43.1.7.4. Apply moderate direct pressure to the puncture site by hand until the bleeding stops. Clean and dress the access according to your facility procedure. Sterile Band-Aids or sterile non-occluding 2x2 dressing can be used and applied securely. 4.3.1.7.6. Catheter ports are locked with heparin 5000 IU/ml according 10 the fill volume of the catheter 43.2. Perform post dialysis assessment: 13.21. Check post weight (should be lower than it was before dialysis because of the fluid removed). 13.2.2. Observe behavior and general condition of the patient post dialysis. Listen to patient complaints, 13.2.3. Assess patient and record patient post dialysis vital signs and fluid status. 3.2.4. Compare post-dialysis data with pre-dialysis data & treatment goal 13.2.5. Check blood pressure (lying) 13.2.6. Measure temperature 3.2.7. Measure pulse rate 13.2.8. Ifpatient vital signs are within normal parameters, he/she does not feel dizzy 5.0, Attachments: None 6.0, References: 6.22. hetpsl/ 6.1. http://g09,eligZq%le Li6uH6Q9 nSHemodialysis Unit NUR-HDU-03 Oe Be Title: Routine Intervention DPP | Applies All Hemodialysis Staff —}—— 1.0. Purpose: LL. To facilfate an immediate intervention and collection of diagnostic data prior to the arrival of the clinica 1.2, To prov le guidelines for the hemodialysis staff nurse in non-code emergency situations. 1.3. To maintain patient safety in the hemodialysis unit. 2.0, Definitions: 21, Diagnostic studies: Tests or procedures that aid in identifying a disease process or provide a means 2.2. Emerg the arri 23. Nurse i evaluating the effectiveness of medical/nursing interventions. t: The sudden deterioration of a patient's condition requiring immediate action before | of a clinician. terventions: Activities! procedures! orders initiated by the hemodialysis staff nurse in jency situation prior to the arrival of a elinician to ensure rapid intervention for the safety an emer and card the patient 3.0, Poliey Stater Bal Only act ent: ities’ procedures’ laboratory tests that have been agreed upon by the nephrologists will be carrigd out before the arrival of the clinician, 3.2, The attending clinician or cl jan on-call should be notified immediately of changes in the patient's condition, Cliniciat Allfirbians wil greet stated appropriate action by the musing sta s will review and sign all nurse interventions. ‘The henjodi ineian shall write an order for any authorized nurse intervention after arriving to the unit is nurse shall Initiates appropriate nursing action and/or order appropriate diagnostic studies based on the guidelines in the HDU policy. 4.2.2, |Notifies the appropriate clinician immediately and obtain a written order when the clinician arrives. 5.0, Attachments: S.1. Routine Blood Work for Hemodialysis Patients 5.2. HDU Pr fessional Nurse Role in a Non-Code Emergency Priot to Arrival of the Clinician 6.0, References: 6.1, hutp://edp.gViA9BO}—_—_—__— Hemodialysis Unit NUR-HDU-03 EAD r- Routine Intervention DPP | Applies jo: All Hemodialysis Staff Jan [Feb | Mar | Apr | May: i Routine Blood Work for Hemodialysis Patients Jun | Jul | Aug | Sep et | Nov | Dee © HBsAg © HCV Abs Hv, * Blood Urea & post) © S, Creatinine a Bic = CBC ©HCT © Ret, Count 2 Ca © PO, BI, Sugar © A. Albumin Total Proteins :Hu EPO/ weelHemodialysis Unit | NUR-HDU-03 Title: Routine Intervention rm 1.0. Respiratory 1.2. Init masks 13, Initia 14. Ensure 15. Notify| All Hemodialysis Staff jional Nurse Role in a Non-Code Emergency Prior to Arrival of the Cli Qistress- patient alert and conscious: LL. Place i high Fowlers position unless contraindicated by a prior underlying condition, : loxygen therapy at flow rate appropriate for underlying condition, Use non-rebreather for COPD patients until respiratory therapist sets up a Venturi mask, [pulse oximetry [patient IV access through Hemodialysis circuit herapist. 2.0. Respiratory 241. Maint 23. Positi 24, Turn 25. Admit 2.6. Wait 27. Ifno circuit 2.8, Initia masks 2.9. Return] 2.10. Initiat 21. Call Nt 2.12. If neces 2.2. Place ted in flat or semi Fowler's position. adequate ventilation. istress- secondary to hypotension jn patent airway/ insert oral or nasal airway. patient in recovery position, Monitor blood pressure, "UF" Ultrafiltrate on Hemodialysis machine, monitor BP. ster fast IV bolus of 100-200ml of Normal Saline via Hemodialysis circuit. 110 seconds, monitor BP. sovery, administer second bolus of 100-200m! Normal Saline via Hemodialysis oxygen therapy at flow rate appropriate for underlying condition, Use non-rebreather for COPD patients until respiratory therapist sets up a Venturi mask. Monitor BP. 1ood in Hemodialysis cireuit back to patient and terminate treatment. pulse oximetry. Monitor HR and BP. {phrologists immediately and Respiratory Therapy. sary, assemble and use manual resuscitation bag with high flow oxygen to maintainHemodialysis Unit | NuRHDU-04 Title: Discharge criteria for hemodialy'sis patients from dialysis unit following treatment DPP | Apoties All Hemodialysis Staff 1.0. Purpose: LA. Toest 3.0, Poliey Stater 3.22. Medical after ish criteria for safe discharge of hemodialysis patients from the dialysis unit, nt: istered nurses are responsible for the individual patient assessment prior to the patient's post-treatment, yuthorization for discharge is required where the patient does not meet discharge criteria, ent. 4.0, Procedure: 4a, The pati 4d. 41.2. 413. 42.1. 42.2, 423. 42.4, 425. 434. 432. 44. 442. 443. 444. 42. Ifthe paient is hospitalized, the unit receiving the patient must be advised of: 4.3, When pitient does not meet discharge criteria, the dialysis nurse will: 44, Ifa patidpt leaves the unit against medical advice (AMA): nit leaving the unit must meet the Following discharge criteria: fascular access hemostasis is achieved. lood pressure, pulse rate, respiration, temperature and weight readings are within .cceptable post dialysis range for the individual patient. No major inter or intradialytic problems which persist after discontinuation of dialysis. [Any changes in physician’s orders. sessment of vital signs, including fluid removal and relationship to dry weight. ‘ourse of dialysis treatment, fedications given during treatment. agnostic tests performed, (otify the Nephrologist with relevant information. fovide complete documentation to the receiving unit if admission is needed, (oti the nephrologist on duty “all the social worker to convince the patient to stay. 4 the patient sign AMA consent if the patient insist to leave against medical advice. Jocument on the appropriate form. 5.0. Attachments: 6.0. References: 6. http://g0g,eViaeDAka Ea DI Hemodialysis Unit NUR-HDU-05 Reverse osmosis plant normal operation PP | Applies All hemodialysis & maintenance staff 10. Purpose: 1 plant To be normal To desqfibe guidelines & procedures to implement for normal operations of Reverse Osmosis vare of the daily checklist needed to be implemented in order to maintain R.O, plant perating system. 20. Definitions: 2A. Valves 2.2. Normal positio 23, Normal conti 24. Condus measui product| 25. TDS ( 05-0. 2.6. Tempe! The te 2.7, Empty 300 lit ra the R.O, Plant Control Plan. Value is taken from a sensor mounted on the R.O. Il labeled valves and their normal operating conditions/ positions are indicated labeled. Position is the position of valves during normal operating conditions. These normal ‘are labeled in the valves, Reading is the nominal indication in the gauges that operates normal operating 1s. These normal readings are marked in the gauge. ivity (EC) is a water quality designation with jis (microsiemens) as its units of fnent. The high conductivity alarm is set at SOs as read in the conductivity meter ine to the product tank. tal Dissolved Solids) is almost synonymous but not the same as conductivity. TDS is, lof conductivity. ture is the temperature (°C) taken from the temperature gauge on the loop supply line. rature gauge Was calibrated to set off alarm at a temperature reading higher than 35°C. the condition in the produet tank when the water level reaches a low level setting of (cemaining quantity) as measured by a float switch inside the tank. 30. Policy State 3.1. HDU PI 3.LL. 312, 3.1.3. Ipform the Nephrologist and Safety Officer of any abnormalities in R.O. plant operation 34. 3.1.5. Ihform immediate! 3.1.6. BAT. BA. 319. 3.1.10. Iinplement personal hygiene and proper hand washing nt: 31 Operator shall insure that R.O. plant operations standards and guidelines are enforced. lomply with R.O. plant policies and procedures. !omply with the implement of R.O. water tank disinfection guidelines and procedure the HDU Nurse / Nephrologist of any alarm activation. lever leave the plant room unattended while loop sanitation procedures are being| plemented. insure correct temperature, pressure and TDS as required are maintained and HDU lurse/ Nephrologist informed accordingly. insure that the R.O. member cleaning standards and guidelines are enforced. {cep record of R.O, plant operations and water testing. a ‘NiRNDLE raat]Og Hemodialysis Unit NUR-HDU-05 Baia Reverse osmosis plant normal operation DPP | applies All hemodialysis & maintenance staff Bd. EMD FI 321. low hospital policy regarding reporting illness. gineer: ingineer shall be the responsible for all remedial actions necessary to be implemented to um the R.O. plants to normal operating conditions. 4k. 3.22. Safety officer and nephrologist shall be informed chemical disinfection is required to be plemented. 3.2.3. Safety officer should be informed of any alarm activation. He will supervise remedial tion to be implemented 3.24. HMD engineer will ensure proper installation of new membrane; R.O. equipment and ured control parameters are met. 3.3. Hemodiflysis Nurse: 3.3.1. Bbtient well-being should be paramount for the HDU nurses. 3.3.2. Ih case any alarm cannot be rectified and the system cannot be put back into normal eration, the HDU nurse should be informed immediately by the HDU plant operator / ety Engineer. 333. The HDU Nurse should confirm that the 82°C (min) temperature is maintained for 2 urs during loop sanitation process. 3.3.4. The HDU nurse should confirm that the 35°C or less temperature of the loop water is Jaintained before staring any treatment procedure. 34. Nephroljgist shall: 3.4.1. ave the final decision on water chemical disinfection if and when it should be scheduled sd implemented. 3.4.2. He informed and he shall make the decision as to be course of action to be implemented if ay alarm cannot be rectified 3.43. pnfirm that the 82°C (min) temperature is maintained for 2 hours during loop sanitation Phocess. 3.44. Hp informed and shall make the final decision as to be course of action to be implemented iffever any stage of the loop sanitation procedure cannot be fully complete. 3.4. Hp informed of any abnormalities in R.O. plant operation 3.4.6, Make regular review of daily R.O. performance checks. 3.4.7, Hyaluate all sampling results and make recommendations appropriate actions as essary |. Procedun 4.1, Daily Oerations Checklist: five alam 1eck for any alarm in the control panel, If any, report to Safety Engineer and rectify the [trae bona] om Fait 1Pie baa DPP Hemodialysis Unit NUR-HDU-05 Reverse osmosis plant normal operation Applies {b: All hemodialysis & maintenance staff 412, 413. 414, 415. 416, 417. 418. 41.9. 4.1.10. 4d. 412. 4.1.13. insure the product tank and raw water tank are fall. No indication of “Tank Empty.” insure all values are in their normal operating position. insure all gauges are indicating their normal readings. sure all control switches are in the ON position. Only one R.O. switch should be Wveryday to be changed alternately daily. sure the selector switch is in the AUTO position, jnsure circulation pump (1 or 2) is running, Pressure gauge # 4 indicated the correct fading (2.8.3.0). insure temperature gauge # 1 is reading less than 35°C. lest water from any of the treatment room outlets for TDS, PH, EC, temperature and total ‘fee Chlorine. Log your readings. trols TDS] PH_ [Conductivity Temperature | Total Chlorine [Free Chlorine] Chloramine <10 [675 | <35 35°C 0 o | o ye HDU water is READY for dialysis treatment. the water analysis failed in any of the above control limits, inform the HDU Head lurse and Nephrologist NOT to initiate dialysis treatment, Inform Safety Engineer and itiate troubleshooting to put back the water within contol limits, th water analysis is within the above control limits of item 7, inform HDU Head Nurse ery time the R.O. plant is running, conduct water analysis according to the log sheet vided. Log your readings. Inform Safety Engineer in case of abnormal readings. ‘Waring: In case of High TDS Alarm, manually shut OFF running R.O. Plant if it did 1 automatically shut down, Let the circulating pumps remain operational. Inform essary remedial actions. 50, Attachments: None 60. References: 6A. hpi 6.2. hntpi/ledb.2l/VGKmES aap ff —__Resios DnST SRD Tas 1be DPP | Applies Hemodialysis Unit NUR-HDU-05 Reverse osmosis plant normal operation Alll hemodialysis & maintenance staff 1.0. Purpose: LL. To des plant. be guidelines & procedures to implement for normal operations of Reverse Osmosis 12. To be normal vare of the daily checklist needed to be implemented in order to maintain R.O. plant jperating system, 20. ions: 2A. Valves 2.2, Normal positio 23, Normal condi 24, Conduc ‘measur ‘mount product| 25. TDS ( 05-0. 2.6, Temper The te 2.7, Empty 500 it labeled valves and their normal operating conditions! positions are indicated labeled. Position is the position of valves during normal operating conditions, These normal are labeled in the valves, Reading is the nominal indication in the gauges that operates normal operating These normal readings are marked in the gauge. ivity (EC) is a water quality designation with us (microsiemens) as its units of ent, The high conductivity alarm is set at SOus as read in the conductivity meter in the R.O. Plant Control Plan. Value is taken from a sensor mounted on the R.O. ine to the product tank ital Dissolved Solids) is almost synonymous but not the same as conductivity. TDS is lof conductivity. ture is the temperature (°C) taken from the temperature gauge on the loop supply line. srature gauge was calibrated to set off alarm at a temperature reading higher than 35°C. Js the condition in the product tank when the water level reaches a low level setting of (remaining quantity) as measured by a float switch inside the tank, Policy States 3.1, HDUPI Bad. 312. 313. 34, 315. 3.6. mt: t Operator shall: insure that R.O. plant operations standards and guidelines are enforced ‘omply with R.O. plant policies and procedures. iform the Nephrologist and Safety Officer of any abnormalities in R.O. plant operation. lomply with the implement of R.O. water tank disinfection guidelines and procedure. form immediately the HDU Nurse / Nephrologist of any alarm activation, fever leave the plant room unattended while loop sanitation procedures are being ifplemented, 3.7. 38. 319. 3.10. insure correct temperature, pressure and TDS as required are maintained and HDU urse/ Nephrologist informed accordingly. insure that the R.O. member cleaning standards and guidelines are enforced, {eep record of R.O. plant operations and water testing. yplement personal hygiene and proper hand washing. Bain eR ——T SRD Tere]~—) [ele] Hemodialysis Unit NUR-HDU-05 Fa Reverse osmosis plant normal operation DPP | Applies All hemodialysis & maintenance staff BAI. lollow hospital policy regarding reporting illness. 3.2, EMD Ehigineer: 324. 322, 323, 324. ingineer shall be the responsible for all remedial actions necessary to be implemented to tum the R.O. plants to normal operating conditions. afety officer and nephrologist shall be informed chemical disinfection is required to be ;plemented. afety officer should be informed of any alarm activation, He will supervise remedial tion to be implemented [MD engineer will ensure proper installation of new membrane; R.O. equipment and -quired control parameters are met. 3.3, Hemodiflysis Nurse: 331. 332. 333. 334. tient well-being should be paramount for the HDU nurses. case any alarm cannot be rectified and the system eannot be put back into normal eration, the HDU nurse should be informed immediately by the HDU plant operator / fety Engineer. 1¢ HDU Nurse should confirm that the 82°C (min) temperature is maintained for 2 urs during loop sanitation proces. 1e HDU nurse should confirm that the 35°C or less temperature of the loop water is aintained before staring any treatment procedure 3.4, Nephrolbgist shall: 34d. 342. 343. 344. 345. 34.6. 347. we the final decision on water chemical disinfection if and when it should be scheduled 1d implemented. informed and he shall make the decision as to be course of action to be implemented if alarm cannot be rectified, lonfirm that the 82°C (min) temperature is maintained for 2 hours during loop sanitation rocess. Je informed and shall make the final decision as to be course of action to be implemented. ‘ever any stage of the loop sanitation procedure cannot be fully complete informed of any abnormalities in R.O. plant operation, fake regular review of daily R.O. performance checks. Wvaluate all sampling results and make recommendations appropriate actions as scessary. 4.0. Procedure: 4.1, Daily Operations Checklist 4.1.1. @heck for any alarm in the control panel. If any, report to Safety Engineer and rectify the fhilure alarm. (tit emes nics ——[___ Rees raat —] SEs TairaHemodialysis Unit NUR-HDU-05 Title: Reverse osmosis plant normal operation DPP | Applies fo: AU hemodialysis & maintenance staff 4.1.2. Ensure the product tank and raw water tank are full. No indication of “Tank Empty.” 4.1.3. Ensure all values are in their normal operating position, 4.14. Ensure all gauges are indicating their normal readings. 4.15. Hnsure all control switches are in the ON position. Only one R.O. switch should be etyday to be changed alternately daly. 4.1.6. Rnsure the selector switch isin the AUTO position. 4.1.7. Hosure circulation pump (1 or 2) is running. Pressure gauge # 4 indicated the correct ing (2.8-3.0). 4.1.8. Rnsure temperature gauge # 1 is reading less than 35°C. 4.1.9. Test water from any ofthe treatment room outlets for TDS, PH, EC, temperature and total r Chlorine. Log your readings. 4.1.10, Gontrols: TDS] _PH_ [Conductivity | Temperature | Total Chlorine [Free Chlorine | Chloramine <0 [6-75 | <35 35°C 0 0 0 4.1.11. If the water analysis is within the above control limits of item 7, inform HDU Head Nurse ye HDU water is READY for dialysis treatment, 4.1.12. If the water analysis failed in any of the above control limits, inform the HDU Head jurse and Nephrologist NOT to initiate dialysis treatment. Inform Safety Engineer and jtiate troubleshooting to put back the water within control limits 4.1.13. Bvery time the R.O. plant is running, conduct water analysis according to the log sheet fovided. Log your readings. Inform Safety Engineer in case of abnormal readings. ‘Waring: In case of High TDS Alarm, manually shut OFF running R.O. Plant if it did automatically shut down, Let the circulating pumps remain operational. Inform -cessary remedial actions. 50, Attachments:None 6.0. References: 6.1, http/edp.el/UQ0917 6.2. http://edb.s/VGhHemodialysis Unit | wur-HDu-08 Equipment-Maintenanee, Repair and Failure DPP | Applies All Hemodialysis Staff & Bio-Med Staff = 1.0. Purpose: 1.1. To estatfish safe and efficient techniques for setting up operation of Gambro hemodialysis, machine} and portable reverse osmosis machines for hemodialysis treatments. 2.0, Definitions: 2.1. Water chemical use in he 22. Gambr ultrailey excess ater fom the patient's blood through a semipermeable membrane by a process of 'reatment System is a water purification system which removes unwanted pollutants, and microbes from tap water, making it pure enough to meet AAMI standards for safe fnodialysis treatments. AK 96 and NIKKISO is hemodialysis machine which removes waste products and. tion, negative pressure, and osmotic pressure gradients. 23. Gambr making RO is a portable reverse osmosis water purification machine which purifies tap water, safe to use in hemodialysis. 3.1, All Ganfbro hemodialysis machines will be disinfected by heat and acid power (clean cart) between pach patient use. 3.2. Patient hose Hepatitis status is unknown will be hemodialyzed on the negative machines and will be chemical disinfected once and cleaned carefully before use on any patient. 3.3. Hepatitis) C patients will be hemodialyzed on designated machines (marked with red tape) reserved|pxclusively for Hepatitis C patients. 34, The Gangbro for NIKISSO contract engineer and HAH Bio-medical engineers will work together to coordihate and perform maintenance and repairs of Gambro hemodialysis machines, NIKKISO hemodialysis machines & Gambro RO portable reverse osmosis water purification machines. 4.0. Procedure: 41. The staffnurse shall: 4.1.1. Gpmplete visual checks of the HDU area and machines. 4.12. Ifhmediately inform Biomedical Engineer of any equipment that fails & or needs repair. 4.13. Hills-up "Medical Equipment Maintenance Work Request” form. 4.1.4, Gpntact the hospital Biomedical Engineer regarding all equipment needing identification smber, preventive maintenance, and\or repairs. 5.0. Attachments:|None 6.0. References: 6.1. Gambro Manual 6.2. HAH Policies & Procedures [eee bana Soca are mlD Hemodialysis Unit NUR-HDU-07 DY ee: R.O. Membrane Chemical Cleaning PP Apolis R.O. Operator 1.0. Purpose: LA. To descr 1.2. To bea ‘membr ‘the guidelines and procedures in case R,O. membrane cleaning is necessary. of the procedure to be implemented in case chemical cleaning of the permeator! is required. 20. Definitions: 21. R.O.M 2.2. Cleaninj permeaté brane is the permeator itself. is the process of chemical cleaning of the permeator / membrane as prescribed by the ‘manufacturer / supplies 30, Poliey Statembnt: 3.1. HDU plat operator shall 3d. 3. 3.2. Nephrol insure that these standards and guidelines are enforced and complied with, insure proper installation of new membranes & control parameters are met, ist shall be informed of any abnormalities in R.O. plant operations. 4.0. Procedure: 4.1, In the inibrest of safety of the patients of hemodialysis, if ever a membrane is fouled up, when TDS in manufac possible 42, Since m condition frase > 75% it has to be replaced with a new membrane. R.O. plant suppliers / or any provided suppliers will supply approved replacement membrane the soonest i put back the defective R.O. unit to normal operations. brane chemical cleaning cannot assure return of membrane to normal operating it is practical & recommended to replace fouled out membranes with new membrane. 43. Itis requffed to conduct PH, TDS and Chlore chemical tests of product water of newly installed membranks. 44, Record al 48. Record a 4.6. Divert to 4.7. Obtain s operating parameters before shutdown for membrane replacement. operating parameters after membrane replacement. rain product water of new membrane for 1 hour. ple of product water of new membrane for bacteria and chemical tests. 48. Change eftridge filter before & after membrane replacement & initial flushing of 1 hour. 49. Introduc the product water of the new membrane to the product tank only when water sample tests resulfs are good and normal control parameters are met. 4.10.R.O. plang operator will do chemical cleaning of membrane using Citric Acid 50%. 50, Attachments: fone 60. References: 6.1. http://go4.gVubtudha I NNO PaoDPP | Applies Hemodialysis Unit NUR-HDU-08 2 Title: R.O. water tanks disinfection R.O. Operator 20. Purpose: i L To dese' Tobea Definitions: Water microbi lare of the procedure for tanks eleaning and disinfection, nks are the raw water tank and product tank. Disinfedtion is the set of actions implemented in order to clean the tanks to eliminate and prevent ‘growth in the tanks. =e 3.1, HDU Pldnt operator shall ensure that the above guidelines are enforced. t operator shall comply with the mentioned procedures and shall follow standards as Jo inthis policy. ogist should be informed if chemical disinfection is required to be implemented, 1rologists will have the final decision on when chemical disinfection should be schedule and implfmented 3s lysis water is not suitable for human consumption, 4.0. Procedure: 4.1. Raw Wafer Tanks: 4.1.1. {Phemical disinfection / cleaning to be done at least bi-annually (every 6 months) or as -quired when there is presence of algae growth or microbial growth as detected through vater samples from the tank. 4.12, The tank should be cleaned and flushes thoroughly with fresh water in order to remove Igae growth or loose debris that might have been accumulated during system operation. 4.13. (Phlorine should be added to the empty tank in the form of sodium hypochlorite in order attain oF increase the level of free. Chlorine to at least 50 ppm. For this 1000 liter ks should then be filled to the optimum level with portable drinking water. 4.14. nce the required dosing of chlorine has been added, check for chlorine content using Hhloroscope. 4.15. fer checking the correct high chlorine content, it should be left for 24 hours to insure fectiveness of disinfection, 4.1.6. the end of 24 hours period, drain the tank, wash and flush the tank with fresh clean ater. 4.1.7. Takes bacteriology sample downstream of the tank for total bacterial count, Total jacterial count results of the other samples should meet AAMI standards. 4.1.8, Repeat chemical disinfection procedures if total bacterial count failed to comply with \AMI standards.423. 42.4, Ae Hemodialysis Unit NUR-HDU-08 FD te] 0. water tanks aisinteeion DPP | Applies fo: R.0. Operator 42. Product Water Tank: 4.2.1, [Chemical disinfection if necessary for the production of plants and loop shall be done ‘ith 50 ppm free chlorine for 24 hours circulation. Confirm concentration of 50 ppm. 4.2.2, is chlorine should be detected in the outlets after draining, flushing and triple rinsing. fill the tank with fresh product water fake samples from the outlets for total bacteria count analysis, total bacteria counts aff a mee NAM sa as. fe cepeat disinfection procedures if total bacteria count failed to comply with AMI andards, ‘Chemical disinfection / cleaning of the product tank to be done only as a lubstitute when the Loop Sanitization Procedure cannot be implemented. 5.0. Attachments: fone 6.0, References: Ga. htt VILCAHHemodialysis Unit NUR-HDU-09 Pe Bia = ‘Transporting patients to and from hemodialysis unit DPP | applies All Hemodialysis staff nurses 1.0. Purpose: Lal. To retu 1.2. Toensuf the patient to his/her toom in stable condition proper and safe transport of patient. 2.0. Definitions: ne 30, Pe 3.1. Patients accomps 3.2. The pati 3.3. Patients| nurse if Stater nt: all be brought to the dialysis room via wheelchair, bed, stretcher with the iment of the ward nurse. ints chart shall accompany him/her. shall be returned to his/her room in stable condition. Patient must be accompanied by the turning by wheelchair or by bed. 4.0.Procedure: 4.1, Transfer 4d. 413. 414. 41.8. 4.2, Transfer 421, 422. 423. 424. ing patient from Nursing Unit Jdentify patient by asking his complete name and compare with patient patient's ID band hnd record number at patient's file. xxplain the procedure to the patient. ssist patient to wheelchair or transfer patient to wheelchair or bed indorse patient to dialysis unit, Jocument at the nurse’s note: 41.5.1. Vital signs 4.1.5.2. Patient's condition before transfer 4.1.53. Special onder (ic. Blood Transfusion) ing patient back to Nursing Unit ssist patient to bed. Allow patient assume comfortable position. ‘ake vital signs. {eview patient's file for doctor's order and nursing assessment post HD treatment ssessment shall include the following: 12.4.1. General condition of the patient: Both needle sites are clotted and dressed, Blood pressure Pulse Ce ‘Temperature 2.4.8. Any laboratories that were drawn post treatment and if they were sent to the lab. 4.2.4.6. Any orders on the patient’s chart c Der Appr ta[ele] Hemodialysis Unit _NuRHDU-09 FEMI | trererin er ant ton ncaa a DPP | Applies All Hemodialysis staff nurses l.2.4.7. Patient's tolerance to procedure 4.2.4.8. Fluid loss and weight loss 4.2.5. |Document in the Nurse’s Note. 1.2.5.1. Time sent and receive for dialysis 1.2.5.2. Patient's condition on admission 12.53. Vital sens 50, Attachments None 6.0, References: G4. Ministry) Health Policies and Procedures 6.2, JCIA Stdndards for Hospital 4th edition: Te es PanePiel Bi Hemodialysis Unit NUR-HDU-10 assessment of machine DPP | Applies 1.0. Purpose: Ll Toa 12. To 13. Toad 14, Tom 15. Topi yure the readiness of the machine. 1 the blood and dialysate compartment of the dialyzer. {aerate the blood lines and the blood compartment of the dialyzer. jimize the residual ethylene oxide used. vent clotting. 20, 16. nae leakage (factory defect) |. Definition 2A, Pre-dial fitness 2.2. Extra sis assessment of the machine is the preparation of the machine to determine its Fuse and safety to avoid unnecessary breakdown during the procedure. rporeal Blood Circuit: The blood lines used in treatment inside the dialyzer. 3.0. Policy Statem| mnt: 31. Nikkiso |PB-05 and Gambro Ak96 HD Machine should be prepared according to its operating instructigfns manual 3.2. Preparatjpn and priming should be carried out under strict surgical aseptic technique, 3.3. Preparatjpn of machine, assembling of lines, dialyzer, and priming should be carried out thirty minutes prior to initiation of HD treatment. 4.0. Procedure: 4, Start Up)Procedure 41:1, Water & Water Supply 4.12. [Confirm that the water treatment system is opened for the machine and the machine plug [connected in the socket properly. Press the power “on / off” key lights 4.1.3. [Pialysis start key flashes, if the machine has completed its rinsing procedure. Wait for he test alarm to g0 off, 4.2 Position)pf Safety Elements 42.1. et the single needle dialysis pointer to OFF position, 4.22. Position the UF minimum limit to “O” and maximum to 20 mmHg. 423. PPialysate flows switch to ON position. 424, Bet the fluid sample to OFF position 428. Check the “adjust concentrate” pointer is at 1:34 position. 42.6, Have the ultrafiltration rate mieror in “0000” position and the ultrafiltration rate at inter at “O” level, OCTET SORNBC- PageHemodialysis Unit NUR-HDU-10 Bo Title: Pre dialysis assessment of machine DPP | applies jo: Atl Hemodialysis staff nurses 43: Dialysalp Startup Procedure 43.1. [Select the suitable composition of the dialysate according to the needs of the cient. 4.3.2, |lnsert the pre plus which i 43.3. |Reconfirm that the connectors fit properly. ‘the Rinse - Hot Rinsing socket to the concentrate canister. 43.4. [Press the “dialysate start” key for the machine to suck the dialysate 43.5. [Wait for the conductivity and temperature to reach the normal range. 423.6. {Conductivity range: 13.5 msfem - 14,5 msfem 43.7. Temperature range : 35.0€ - 38.0C 4.4. Priming)pf the extracorporeal blood circuit 44.1. [Place the clients’ arterial Line which is proximal to the IV port in the clean canister. 44.2. [Connect the Isotonic Normal Saline (0.9% NaCl) 500 ml to the IV priming port of the arterial blood line. 4.43. [Prime the client’s arterial line by gravity, clamp it and hook it on the IV pole, 4.44, [Put on the “Prime” key and it lights. 4.4.8. [Press the “override” button and it lights. 4.4.6. [Switch on the blood pump and the bump at = 100 ml/mis 4.4.7. [Prime the heparin line and affix heparin syringe. 4.4.8, [Pre-select the delivery rate of the heparin pump per hour. 44.9. [Discard the first 800 ml of priming fluid and the remaining 200 ml should be re- birculated through the lines and the dialyzer by interconnecting the artery and the venous th the sterile connector provided in the lines. ulate the fluid as above mentioned until the patient is about to be connected to he machine. to prime the remaining port. 44.10, 4.4.11. [Re-prime the lines and the dialyzer, ithe patient isnot connected within 30minutes of riming. 44.12. [Ensure that complete de-aeration of the lines and dialysis is earried out 4.4.13. |(Check that connector and caps are intact and arranged in onder. 44.14. [Place the whole system in the dialysis process by keeping the IV line opened, UFR at 0” ml/min, with the blood pump running at the rate of 2 $0 ml/min, till the patient is connected. 5.0. Attachments: None 6.0, References: 6A, holga gL LLvhpog ie Hemodialysis Unit NUR-HDU-11 Title: Dialysis Patient Education DPP | Applies fo: Au Hemodialysis staff nurses 1.0, Purpose: 1. To ere knowledge of the patient's illness and treatment needs 1.2. To learn|skill and behavior necessary to improve or restore function 1.3. To assists patient/family to identify the dietary restriction requirements for his condition. 2.0. Definitions: 2.1. Patient Education is 2.1. [The provision of appropriate education and training to patient and/or the family 2.1.2. |A therapeutic relationship between patients / family and members of the healtheare vers that focus on the patient's specific needs. 3.0. Poliey Statembnt: 3.1. The patifnt and/or, when appropriate, his or her family are provided with appropriate education and traifing to increase knowledge of the patient's illness a needs and to learn skills and bbchaviog that promote necessary and improve function. 3.2. ‘The Dialysis Services RN will review and reinforee the dietary requirements for each dialysis patient. 4.0. Procedure: 4.1. Upon admission, the assigned nurse will begin the nursing process for patient education as follows: 4.1.1. |hssess leaming needs and learning capabilities of patient. 4.12. [Establish teaching plan based on goals and objectives of patient education for the individual. 4.13. implement the teaching plan. 4.14, [Evaluate learer’s response, 42. Upon adpnission, the staff nurse will orient the patient to the environment physical patient rights and resp4fnsibilities, hospital staff, safety issues and other pertinent issues 43. Teaching will be initiated when the patient's condition permits. Teaching will be modifies as needed, tp meet individual needs, ic. language barrier, physical limitations. 44, The family and / or significant others will be included in patient education as frequently as possible fvhen appropriate 45, Educatioh will include information, as necessary about patient responsibilities in his / her own. ‘ease, inchuding but not limited to responsibilities for: 4.5.1. Providing information 4.52. Asking questions and obtaining information about his / her eare. 453. Following instructionsHemodialysis Unit NUR-HOU-11 Bian Dialysis Patient Education DPP | aopiies All Hemodialysis staff nurses SA, 45.5. 4.6. Relevan| ecepting the consequences of not following care and/or treatment. [Following rules and regulations regarding care and conduct. ts physician) including a discharge instruction written materials (approved by pat sheet will be given to the patient by the assigned nurse 4. 48. Safe ani Safe an 49. Potential 4.10, Instruct 4.13. List of 4.3.1, leffective use of medication leflective use of medical equipment. drug-food interactions and counseling on medical diets. mis about any follow-up care and how to obtain care, jon provided to the patient family at the time of discharge is provided to the individual zation providing continuing care of the patient. tation: lealth teaching provided atient’s understanding, eral dietary requirements for a dialysis patient: ‘ow protein - protein should come from meat and poultry 4.132, |Monitor potassium intake - potassium is found in salt substance, some fruits and regetables, milk, chocolate and nuts.” 4.13.3. |Pluid restrictions as prescribed, 4134. [e soditum (24-40 g/day). 4.13.5. |High carbohydrate 4.13.6, [Limit foods such as milk, cheese, nuts, dried beans, soft drinks. These foods contain Jhosphorus which causes calcium to be pulled from the bones. 4.13.7. [Dietary requirements for patients on peritoneal dialysis may differ slighty. 4.13.8. [Follow nephrologists’ orders for patient diet, 5.0, Attachments:|None 6.0. References: 6.1. hitp://gop.zl/6ebk80Hemodialysis Uni [alc] _NURHDU-12 Bo Title: Vascular Access DPP | appiies All Hemodialysis staff 1.0. Purpose: LA. To provi 1.2. Todete 13, Torule To provi 2.0, Definitions: 2a. Arteri together| syntheti 23. Hemodi Purpose 24. Bruit 25. Thrill: 2.6. Tempo femoral undergo’ Kidney le information on vascular accesses used for hemodialysis ne patency of the AV fistula / graft prior to hemodialysis treatment. signs of infection. fea catheter insertion site that remains infection free. yenous fistula (AVE): A minor surgical procedures that connect the artery and vein inder the skin for long term dialysis treatment. ‘enous graft (AVG): A minor surgical procedure that uses autograft or xenograftor a tube grafted onto the artery and vein under the skin for long term dialysis treatment ysis catheter (PermCath, hemo cath): A short term, or tunneled CVC used for the dialysis’ apheresis. ‘The sound heard when auscultating the fistula (should have constant whooshing sound) Ihe “buzzing” feel of the access, felt the best over the anastomosis of the artery to the vein (usifilly near the scar from the surgery). wry Vascular Access: Catheter introduced into a large vein (jugular, subclavian, nto the superior vena cava or right atrium to serve as dialysis access for patients 1g dialysis treatment on a temporary basis. It is usually indicated for patient with Acute failure or during the three (3) postoperative periods after placement on an AVF or AVG, 3.0, Policy Statem| 34. The dial initiation Do not 33. It is st removal. needed. 3.4, For dresfing change, site nts sis nurse will assess the patient's AV fistula/ graft and affected extremity before the lof dialysis. 3 dialysis if bruit and/or thrill is not present. tly jplemented that no visitors are allowed during access cannulation & needle be cleaned and a transparent dressing applied once per week or as 4.0, Procedure: 4. Care of| 41d. 4.12. 413. ‘tablished Accesses (AVF/ Gratt) ralpate for thrill and quscultate for bruit. If no thrll/ bruit, notify the Nephrologist 1ediately. Do not start dialysis. 10 not allow B.P.’s, venipunctures or name bands on access arm, sessment of Patient on Hemodialysis (NUR-HDU-02). [fee Da NORD Fao 1Hemodialysis Unit NUR-HDU-12 Title: Vascular Access taf Applies {p: All Hemodialys 42. 43. Hemodjalysis CVC (PermCath) 4.2. [Inspect catheter and site, Ensure clamps are closed. Dressing|change: 43.1. || Identify patient. Check ID wrist band, ask patient name, number, 43.2. |) Wash hands and dry 433. |) Ready necessary equipment 434. |) Puton gloves 435. || Remove old dressing and discard 43.6. || Discard gloves 43.7. || Observe exit site for signs of inflammation 43.8, | Observe that suture is intact 439. || Paton sterile gloves and tally with record 4.3.10. || With Betadine swabs make a circular motion from catheter exit site outward, swab an area covering a 3-inch diameter circle and allow to air dry, 43.11.|) Apply transparent dressing 43.12.|| Apply label to dressing indicating date of dressing change, nurse name and “HEMODIALYSIS ACCESS- DO NOT REMOVE”, 4.3.13. || Chart dressing change and observations. 5.0. Attachments: None 6.0. References: GA. 62. btp:l/eob.t/wntQub JCIA Stdhdards for Hospitals, 5" ed. 2014: COP.3 ME.2@ Tite: Hemodialysis Unit NUR-HDU-13 Power Failure in Hemodialysis Unit DPP | Applies fo: AU Hemodialysis staff nurses: 1.0. Purpose: 1.1. To minifnize disruption of patient care and prevent untoward events during power interruption at Hemodiflysis equipment. 2.0. Definitions: None 30. Policy Statement: 3.1. All stafilmust know how to manage power failure in the unit to maintain the safety and comfort of the pafient. 4.0, Procedure: 4.1. Machidle should always be plugged into a source that will ensure automatic transfer to emerg 42. Inthe 421. 42. 423. 424, 43, Matter 43d. 432. 433. 434, 438. 43, 43.101 43.11 43.12! 43.131 cy power ifnecessary. ent of a power failure: The hospital emengency generator will take over. All machine plugs will be moved to the emergency (red) outlets. The emergency generator will power auxiliary lighting, Always have a flash light available. In the event that power is not restored, the blood pump will be hand cracked by the Dialysis Nurse. 15 minutes the power is not restored, dialysis will be terminated: Shut the machine off stop the “Loss of Power Alarm” from buzzing Unlock the foam trap detector and remove the venous line from the line clamp, Clamp the arterial patient access and the arterial blood line. Separate the arterial access and the arterial blood line. Hand crank the blood pump a few turns to build up some negative pressure in the arterial line, To hand crank the blood pump, insert the hand crack in the center. of the blood pump rotors. Remove clamp from the arterial blood line. When air has reached the infusion line, clamp the arterial blood line before the infusion line Open saline line. Continue to hand crank the blood pump, returning the blood slowly and evenly. Monitor the drip chambers carefully as all the alarms are deactivated, Infuse approximately 200 ml saline until all blood is returned to the patient, Clamp the venous blood line and the patient venous access. Separate the venous patient access and the venous blood lineHemodialysis Unit NUR-HDU-13 Title: Power Failure in Hemodialysis Unit DPP. | Applies {o: All Hemodialysis staff nurses 43.14]| Complete the treatment on the usual fashion. Document procedure and notify the nephrologists of early discontinuation of treatment. 43.15]| Complete Occurrence Variance Report. 50, Attachments: one 6A. 6.0. References: Hussein -Ali Hospital Policies & Procedures [Rete Dan SECT Peo aBe Bo Title: DPP | Applies Hemodialysis Unit NUR-HDU-14 Dialysis Services Scope of service All Hemodialysis Staff 10. Purpose: Ll. To provi timely management of patient for dialysis. 20. Definitions: me 30. Policy Statement: 31. Dialysis’ dialysis m 3.2. Cancell treatm Service is available on a 24-hour per daily basis. Trained Dialysis Nurse provides jrsing care on a one to one basis. ion of treatment must be received no later than one (1) hour before reporting time for 40, Procedure: 41. Obtain st 4.2. Patient 4.3. Samples} edule dialysis treatment. re unit obtain nephrologists orders. f water are collected by the Dialysis services each month, 44. Scheduld|reatment with the Dialysis unit. 4.5. Dialysis Wurse / Charge Nurse ofthe unit will take pertinent information and schedule dialysis. 45.1. Patient's name 45.2. Ward /Room Number 4.6. Dialysis hnit will confirm the name of the patient, date and time of the treatment to the patient care unit 5.0. Attachments: None 6.0. References: 6.1, Hussein Al-Ali Hospital Policies & ProceduresHemodialysis Unit _NUR-HDU-15 Be Baa Infection Control in Hemodialysis DPP | Applies : All Hemodialysis Staff 1.0. Purpose: 11. To provipie the guidelines needed for the prevention of infection transmission among chronic dialysis patients. These guidelines include recommendations for the management of equipment, ‘water supply, sereening, monitoring of patients and HCWs and other related activities. 1.2. To provifle guideline related to precautionary measures / action to be taken to avoid occurrence of | Js @ process that replaces the normal function of the kidney by removing toxins and ids from the bloodstream, lysis (HD) is a process that involves circulating the patient’s blood outside of the body in entracorporeal circuit (ECC), where it is separated from dialysis fluid by an artificial jeable membrane, ion is the process of complete destruction of all forms of microbial life (bacteria, fungi, id viruses) by chemical or physical processes (e.g, steam under pressure, dry heat, ne oxide gas, liquid chemicals). Cultures are obtained from body fluids to isolate the junknown fever and to identify the microorganism causing signs of clinical infection. 20. Definition 2. Dialysis excess fl 22. Hemodi through semi-pe 23. Steriliza spores, ethylene souree of 3.0. Policy Statem| Bal. All pers selected 3.2. Patients of a be immediately reported to the Infection Control Practitioner who in tum will int: 1 will follow strict Standard Precautions on all patients at all times. Barriers will be sed on the likelihood of exposure. jiring isolation shall be served in a designated room with specialized nursing care, jon techniques as outlined by Centers for Disease Control and Prevention, All 1 regarding isolation requirements and techniques. 4.11. is complications Dialysis ~ In general, the hemodialysis system consists of a water supply, a system for xing water and concentrated dialysis fluid and a machine to pump the dialysis fluid through the artificial kidney. This aqueous environment provides a good growth jmedium that can result in the massive accumulation of Gram-negative bacteria, w an have direct and indirect infectious complications for patients such as septicemia and ls pyrogenic reaction to bacterial endotoxins. Hat Non-tuberculous mycobacteria, which have the capability of multiplying in aqueous environments, can cause some infectious complications for dialysis patients, 1.1.2. The process of hemodialysis requires vascular access for prolonged periods; hence, these patients are at high risk for vascular access infection. Hat. ‘Such_an_ infection is usually caused by S. aureus, coagulase-neg[Hemodialysis Unit urnouts | BEI te | toetn conra DPP | Apotiesb: an Hemodialysis Statt Hemodialysis “laphylocoesl, Gram-negative bacill, non-staphylovoceal gram-positive cocci (Gncluding enterococci), or fungi 4.1.1.4, Bacterial infections, especially those involving vascular access, are considered, the most frequent infectious complications of hemodialysis and the most common cause of morbidity and mortality among patients undergoing hemodialysis. 4.2. Water supply 4.2.1, | Dialysis centers use water from the public supply, which despite being chlorinated, is usually contaminated with bacteria (e.g, Gram-negative bacteria, non-tuberculous mycobacteria and certain types of blue-green algae). Endotoxins produced by Gram negative bacteria may reach levels high enough to produce pyrogenic reaction in patient undergoing dialysis. 4.2.2. || Water treatment system 4.2.2.1, Water used for the production of dialysis fluid must be treated adequately by reverse osmosis (RO) fo remove chemical contaminants. It should be also filtered to prevent bacterial contamination. Used filters should be frequently tand regularly changed and/or disinfected according to the manufacturer's instructions. 423. | Distribution system 142.31. This system delivers dialysis fluids to each dialysis machine and consists of plastic pipes and appurtenances. This distribution system plays a role in microbial contamination because pipes that are larger diameter and longer than necessary are frequently used to control the required fluid flow. This, scenario inereases both the total volume and the wetted surface area of the system and decreases the fluid velocity, which allows Gram-negative bacteria to multiply rapidly and colonize the’ wetted surfaces of the pipes. Such colonization leads to the formation of biofilms, which are usually difficult to remove or disinfect 142.32. To ensure adequate disinfection of the distribution system, the system should be routinely disinfected at least weekly. Furthermore, the system should be designed in a way that facilitates adequate disinfection and prevents fluids from being trapped and serving as a reservoir for bacteria. Use of an ultra- filter at the outlet of the storage tank of the distribution system is recommended. Regular monitoring of the system 424.1. Standard microbial assay methods to test for waterbome microorganisms should be performed at least monthly and after disinfection of the system or after maintenance work. Tests should be repeated if counts are elevated [i.e., more than 200 colony, forming units per milliliter (CFU/ml). There should be written procedures regarding water monitoring and a plan of action if excessive contamination is found. {+— Dis pred Mics [Revo De ea OTT SORT Fata 1Hemodialysis Unit NUR-HDU-15 Title: Infection Control in Hemodialysis Applies 43. Disinfé 431. 433. 44, 442. 443. 44.4. 44.5. 4.4.6, 48. Record 4S. 45. 48. tion of the dialysis system: ‘The purpose of the disinfection procedures for the dialysis system is not only to Prevent the multiplication of waterbome bacteria to a significant level but also to Eliminate blood bome viruses. ‘The routine disinfection of isolated components of a dialysis system is usually inadequate, and consequently, the complete dialysis system (water treatment system, distribution system and dialysis machine) should be considered during the disinfection procedures. For single-pass machines, the disinfection process should be performed at the beginning and end of the shifl. Disinfection processes should be performed after leach use for batch recirculating machines. ‘The rinse water, which usually contains some Gram-negative bacteria, should not be [permitted to stand overnight; otherwise, the water will contain significant microbial ‘contamination and nullify the disinfection procedure. Different types of disinfectants, lare used for the purpose of disinfecting dialysis systems. The manufacturer's instructions should be followed for both the machines and the disinfectants. Dialysis facility | At least one separate room for dialyzing patients with positive HBsAg, ‘Adequate storage rooms for clean and sterile supplies, |A designated room for disinfection of portable dialysis equipment |A dirty (soiled) utility room with a sluice for disposal of blood or body fluid. Handwashing sinks must be close to the nurse station and patient treatment areas. One Ihandwashing sink for every four (4) dialysis chars |Aleohol hand rub in a wall-mounted dispenser or tabletop pump bottles should be available for hand hygiene. keeping |A properly kept recording system is essential in the dialysis unit for better Surveillance land follow-up purposes The patient records in the dialysis unit should include the following: |4.5.2.1. Lot number of all blood and blood products used, |4.5.2.2. Name or number and location of the machine used for each dialysis session. |45.2.3. Names of staf members assigned for the patient during each dialysis session, |45.2.4. Any mishaps, including dialysis machine malfunction and blood Leaks. 4.5.2.5. A log for all injury. |A log forall hepatitis serology results for patients, idents sustained by patients and staff, such as Needle stickIRR Tc Oo Hemodialysis U NUR-HDU-15 le: Infection Control in Hemodialysis DPP. | Applies jp: Au Hemodialysis Stat Houseleeping 4.6.1. | Dialysis units are considered high-risk areas due to the nature of the Procedures [performed and the immune status of the patients; thus, housekeeping should serve two asks: removal of soil and waste to prevent the accumulation of infectious material and ‘maintaining a clean environment for better patient care. 4.6.2, |Special training should be given to housekeeping personnel working in Dialysis unit 4.63. | The patient care area should be utilized efficiently by arranging the required items, discarding the unneeded ones and removing excess tubes and wires on the floor. 4.64. |All personnel should wear gloves and gowns during work and when handling ‘contaminated items, 4.65. | Chairs and beds should be cleaned and disinfeeted with hospital-approved disinfectants between patients. 4.6.6. Separate cleaning tools should be used for cleaning the area designated for patients with [bloodborne diseases. Linens should be used on chairs and beds and should be changed after each patient 4.6.8, ||Chairs and beds should be cleaned with hospital-approved disinfectant after Each use. 4.6. Soiled linens and other laundry items should be placed in water-soluble bags before sending to the laundry, 4.6.10,|Or soiled linen should be collected in such a way as to keep the heavily soiled portion |contained in the center by folding or rolling the soiled part. 4.7. Waste thanagement: 4.7.1. [Disposable items should be placed in strong leak-proof bags; double bagging is only necessary when contamination ofthe outer surface occurs. 4.72 [Disposable used needles and sharp items should be discarded in hospital-approved [puncture-proof sharps containers. 4.73, |All used disposable items should be discarded according to the waste Management policy 4.8, _ Infectidn control practices in the dialysis unit: 4.8.1, |nfection control recommendations for the prevention of hospital-acquired infections in hemodialysis patients: 4.8.2. ||Use Standard Precautions for all patients, regardless of their known or Presumed infectious status. 428.3. |[Hand Hygiene '48.3.1. Before and after handling dialysis machineHemodialysis Unit NUR-HDU-15 Title Infection Control in Hemodialysis Applies {p: Al Hemodialysis Staff 48.3.2. Before and alter performing non-invasive teck '4.8.3.3. Before performing any invasive procedure such as inserting a circulatory access or CV lines |4.8.3.4. Before and after connecting the patient to the dialysis machine through the AN fistula 14.8.5. Before donning gloves and after removal of gloves After leaving a particular patient's dialysis station and before dealing with another patient's station 484. ||Gloves 1484.1. Use non-sterile disposable gloves when performing non-invasive procedures or when cleaning or disinfecting instruments or the environment, including the dialysis machine. 14.8.4.2. Use sterile gloves when performing invasive procedures or connecting the patient to the dialysis machine 4.8.5, |[Personal protective equipment (PPE) 14.8.1. Personnel should always wear protective equipment (fluid-resistant gown, mask, and eyewear) to prevent exposure to blood in the event that there is, rupture of the hemodialyzer membrane and/or a disconnection or rupture of tubing. 1488.2. Water-proof aprons or gowns should be worn if the nurse is located within the patient station providing any service. 4853. It is advisable for staff to wear protective eyeglasses and surgical masks during procedures in which splashing of blood is anticipated. 148.54. Staff should change gowns between patients, and the gowns should be discarded at the end of the day. 48.5.5. Staff should not drink, eat or smoke in the dialysis treatment area. 1485.6. Crowding of patients and staff should be avoided; give enough space for the easy movement of staff, placement of equipment and cleaning of the environment. 4.9. Bloodbpme viral infections 49.1. jn the dialysis unit, both patients and staff are at high risk of acquiring bloodborne viral infections. Viral hepatitis is a major complication of hemodialysis, and several agents such as Hepatitis B, C, and D are involved. Recent studies have proven that HIV is significantly less efficiently transmitted than Hepatitis B virus. 4.9.2. |Hepatitis B (HBV) infection 4.9.2.1. Mode of Transmission of Hepatitis B 49.2.2. Chronically infected patients are the primary source of transmission. HBV is considered to be a resistant virus, is relatively stable in the environment, and remains viable for at least seven days on environmental surfaces at room (ppt [ees be [TE I Tes 1Hemodialysis Unit NUR-HDU-15 Infection Control in Hemodialysis DPP | Applies All Hemodialysis Staff 493. 494. 4.10. Mana; 4.1041, 4.10.21 4.10.31 4.104% 4.10.53 4.10.6, 4.10.7. 4.10. Temperature Dialysis staff members may acquire the infection by 14.9.3.1. Accidental needle puncture through intact skin, 149.32. Infected plasma, serum or contaminated environmental surfaces through breaks in the skin such as abrasions, cuts, or scratches. '4.9.33. Introduction of infected serum or plasma into mucosal membranes (e.g, the splashing of blood onto the mouth or eyes). Dialysis patients may become infected through the following means 49.4.1. Internally through contaminated dialysis equipment (e.g., venous Pressure gauges, isolators or filters). 49.4.2. Extemally through contaminated dialysis machines, including their surfaces, control knobs or intravenous poles. 4.9.4.3. Improperly prepped or contaminated injection site, 49.44, Through breaks in the skin or mucous membranes. 49.45, Contaminated items & surfaces such as clamps, scissors, telephones or walls 49.46, Improper handling of multiple-dose medication viels & intravenous solutions. 49.4.7. ‘The dialysis staff (contaminated hands, gloves and other objects) rment of Hepatitis B virus-positive patients Isolate HBsAg-positive patients in a designated or separate room for Treatment with dedicated machines, equipment, instruments, supplies, and medications, These equipment and supplies must not be used on HBV-susceptible patients. ‘These patients should be end or comer of the unit). jalyzed at a station away from adjacent stations (e.g., at the HCWs cating for HBsAg-positive patients should not care for susceptible patients at the same time, including during the period when dialysis is terminated for one patient ‘and initiated for another. HCWs should not attend to both HBsAg-posi during the same shift and HBV-susceptible Patients Machines used on an HBsAg-positive patient must be disinfected using manufacturer's recommendations & should not be included in the dialyzer reuse program, Extemal surfaces should be cleaned using hospital-approved disinfectant. A specific dialysis machine, bed, chair, and supply tray (including tourniquet, antiseptics and blood pressure cuff) should be assigned for each patient. Disposable, single-use extemal venous and extemal pressure _ transducer filters/protectors should be used once for each patient and discarded. These items should not_be reprocessed or reused. Non-disposable items such as_clamps and De pr isHemodialysis Unit NUR-HDU-15 4.10.1 4.11. HBsA; 41d 4.11.2, 4113. 4114 4.1.5) 4.12, HCV 421 4.12.2 “iq 4.10.12, Title: Infection Control in Hem Applies {p: All Hemodialysis Staff seissors should be appropriately cleaned and dish another patient, 4.10.9] When multiple-dose medication vials are used, doses should be prepared And labeled in a clean area away from the dialysis stations and should be Delivered separately to cach patient 4.10.14, Do not use common medication carts to deliver medications to patients. Trays should bbe used to deliver medications to individual patients. These trays must be cleaned and disinfected between patients, | Patients should not share food or utensils with other patients or staf. HCWs should change PPE and perform hand hygiene between patients seroconversion Report HBsAg-pos law or regulation, five seroconversion to the local health department as required by When a seroconversion occurs, review all patients’ routine laboratory test Results to identify additional cases. Investigate potential sources for infection to determine whether Transmission may have occurred within the dialysis unit. Review newly infected patients’ recent medical history (e.g., blood transfusion, hospitalization) and history of high-tisk behavior (e.g., hypodermic drug use, sexual activity) as well as the unit practices and procedures. In patients newly infected with HBV, HBsAg is often the only serologic Marker detected; repeat HBsAg testing and test for anti-HIBe (including anti-HB¢ IgM) 1 to 2 months later. Six months later, repeat HBsAg testing and test for anti-HBs to determine clinical outcome and the need for counseling, medical evaluation, and ‘vaccination of the patient’s contacts. Patients who become HBsAg-negative are no longer infectious and can be removed from isolation. fections Mode of transmission 4.12. HCV is most efficiently transmitted by percutaneous exposure t infectious blood. A chronically infected person is central to transmission, which occurs because of inadequate infection control practices and cross- contamination among patients. Screening 4.12.21. Screening of patients for HCV should be performed upon admission to determine the prevalence of the virus in the hemodialysis unit. 4.12.2.2. Sereening for ALT and anti-HCV should be carried out upon admission, with anti- HCV-negative patients sereened monthly for ALT and semi- annually for anti-HCV. Management of HCV infectionOia Hemodialysis Unit NUR-HDU-15 Be Title: Infection Control in Hemodialysis DPP Applies fo: Atl Hemodialysis Statt “123.1. HCV transmission within the dialysis environment can be prevented by strict adherence to the infection control precautions recommended for all hemodialysis patients 4.123.2. Although the isolation of HCV-infected patients is not recommended, routine testing for ALT and anti-HCV is important for monitoring transmission within centers and ensuring that appropriate precautions are being properly and consistently used. 4.1233. HCV-positive persons should be evaluated (by consultation or referral, if} appropriate) for the presence ot development of chronic liver disease according to current medical practice guidelines. 4.1234, HCV-positive patients should receive information conceming how they can prevent farther harm to their liver and prevent transmitting HCV to others 4.12.3.5. Persons with chronic liver disease should be vaccinated against hepatitis A, if susceptible. 4.12.4] HCV-negative patients 4,124.1. Monthly ALT testing will facilitate the timely detection of new infections And provide a pattern from which to determine when exposure or infection may have occurred. 4.12.42, In the absence of unexplained ALT elevation, testing for anti-HCV every 6 months should be sufficient to monitor the occurrence of new HCV infections 4.12.4.3. If unexplained ALT elevation is observed in patients who are anti-HCV negative, repeated anti-HCV testing is warranted. If unexplained ALT elevation persists in patients who repeatedly test anti-HCV negative, testing for HCV RNA should be considered. 4.12.54] Anti-HCV seroconversion 4.12.5.1. Report anti-HCV-positive seroconversion to the local health department As required by law or regulation. 4.12.5.2. When a seroconversion occurs, review all other patients’ routine laboratory test results to identify additional cases 4.12... Perform additional testing as indicated later inthis section, 4.12.54. Investigate potential sources for infection to determine if transmission may have occurred within the dialysis unit; review newly infected patients’ recent medical history (¢.g., blood transfusion, hospitalization) and history of high-risk behavior (¢.g., hypodermic drug use, sexual activity) as well as unit practices and procedures. 4.12.6) If patients) seroconvert from anti-HCV-negative to anti-HCV-positive during a 6- month period, frequent monitoring (every 1 to 3 months) of all patients may be Ba pred Mcoe Hemodialysis Unit NUR-HDU-15 x Infection Control in Hemodialysis, DPP | Applies All Hemodialysis Staff 412.7 4.124 4.13, Hemot 43.1. 4.13.2. 4.14, Patient 441 4.15. Educa] 415.1 Indicated for a limited time to detect additional infections, If no additional eases are identified, semi-annval testing can be resumed, Hepatitis D infections 4.12.71. Delta Hepatitis is caused by hepatitis delta virus (HDV), which causes infection only along with active HBV infections either as a co-infection ‘or superinfection. 4.12.72, Sereening 4.12.7.2.1. Routine testing of hemodialysis patients isnot recommended. 4.12. Prevention of HBV transmission will reduce the risk of HDV infection in HBV susceptible patients, Management of HDV infection 4.12.8.1. Patients known to be infected with HDV should be isolated from all other Dialysis patients, including HBV-positive patients, and should receive dialysis on dedicated machines. 4.12.82, Routine screening for HDV is only indicated if there is a patient who is known to be infected with HDV alysis staff members Routine testing of staff members is not recommended for HBV except when required to document response to HBV vaccination. In addition, routine testing of staff for HCV, HDV, or HIV is not recommended. jonitoring ‘The patient's temperature should be monitored before and after dialysis to detect Barly signs of a pyrogenic reaction. Any fever (> 37.8°C) or rigors should be investigated by: 4.14.11. Clinical assessment of the patient to rule out other eauses of fever (e.. pneumonia). 4.14.1.2. Culturing of blood samples, 4.14.1.3, Culturing of other body fluids or secretions if suspected to be the source of infection. 4.14.1.4, Culturing of the dialysate (on the downstream side) using quantitative and Qualitative bacteriologie assays. A continuous educational program regarding infection control should be instituted In dialysis units for patients and staff, The program should highlight the following | Da pred icOe Hemodialysis Unit | NuR-HDU-15 x (EE Infection Control in Hemodialysis DPP | applies |p: Al Hemodialysis Statt pons 4.13.2]) Nursing Education 4.1821. ‘The most common pathogens causing infections in dialysis patients. 4,182.2. Principles and practices of infection contol (aseptic technique, hand hygiene and. standard precautions) to prevent the tansmission of microorganisms both in the dialysis unit and at home 4.183]| Patient Education 4,183.1. Patients should be instructed to keep the access site clean and dry at all times, The importance of personal hygiene and its possible relation to access site infections should be emphasized. Patients should be instructed about the proper way to care forthe access site and to recognize and report any signs and symptoms of infection immediately. These signs include fever, chills, pain, and redness or drainage around the access site 4.184) Infection Control Surveillance in Hemodialysis 4184.1, Sterilization of Equipment 4.15.4.1.1, All equipment is terminally cleaned alter every treatment, 4.154.1.2. It is monitored each month with cultures for bacterial contamination. 4154.13. If any machine culture is positive for bacterial contamination with a colony Count greater than 2000 per mi, itis taken out of use, decontaminated and re-cultured. 4.15.4.14. The dialysis machine shall be with bleach after each use. A hospital approved disinfectant is used to decontaminate the machine after any blood contamination or hepatitis positive patient use, 4.15.4.1.8. All disposable supplies used during dialysis treatment are considered contaminated materials. There shall be a written procedure on sterilization of equipment, Hemodialysis filters: there will be nore processing and reuse of hemodialysis filters. 454. All recommended control measures for hepatitis B surface antigen (HBsAg) positive patients. 4.15, Cultures AAS. 1. Cultures will be obtained from dialysis eatheters, fistulas, of grafts for any sign of infection 4.15.4,2.2, Cultures shall be obtained from the water and dialysate on a De pred Nc Titi oe nara | NORIDUS I Pewa i Applies Hemodialysis Unit NUR-HDU-15 Infection Control in Hemodialysis All Hemodialysis Staff ‘monthly basis. 4.15.4.2.3. The Dialysis Services nurses are not permitted to eat, drink, smoke or put on makeup while performing dialysis treatments, 4.15.43. When doing dialysis AAS, ‘The nurses shall wear protective gown, goggles (if applicable), mask and gloves. These are removed before leaving the room. It is acceptable to wear individual lab ‘coats provided a change is made if the coat is contaminated blood. 4.15.43.2. Strict hand-washing technique is observe between and after all patient eontacts, 4.15.43. All blood contaminated trash from the dialysis shall be bagged in yellow plastic bags and handled as biohazard waste 4.158.434. All line handled as contaminated and is placed in “appropriate bags which are closed to removal from the unit 415.435. The Dialysis Services Clinical Coordinator will be a consultative member of the Infection Control Committee and is responsible for maintaining infection control standards during dialysis treatment, 5.0, AttachmentsjNone 6.0, References: 6.1. Alter MJ, Tokars J, Arduro M, Favero MS, and Bland LA. (2004). Nosocomial infections associfted with hemodialysis. In Mayhall CG (Ed,): Hospital Epidemiology and Infection Contre (pp. 1139-1173). Baltimore: Williams & Willkins, 6.2. Assocition for Professionals in Infection Control (APIC) and Epidemiology, Inc. (2008). ‘Chaptdf 48: Dialysis. In APIC Text of infection control and epidemiology (3rd ed.) 6.3. Center for Disease Control and Prevention (CDC). Hepatitis: Control measures for hepatitis B in dialfsis centers, Viral Hepatitis Investigations and Control Series, November 1997, 64. Center for Disease Control and Prevention (CDC). Recommendations of the Advisory Commttee on Immunization Practices (ACIP): Use of vaccines and immune globulins in persor 65. Cent infect 6.6._Sulowkz W. Radziszewski A, Chowaniee E, HCV infection in dialysis patients. Hemodialysis. with altered immunocompetence. MMWR, April 1993/42 (RR-04). for Disease Control and Prevention, Recommendations for preventing transmission of ins among chronic hemodialysis patients. MMWR, April 2001/50 No. RR-S). c [are Bane TERT I Pax 1Hemodialysis Unit NUR-HDU-15 Title: Infection Control in Hemodialysis DPP. Applies fo: | All Hemodi: is Stat Tt, 207-286-295. 6.7. Gulf Choperation Council — Center for Infection ControlT porreeres are Aa Hemodialysis Unit HDU.6 ig Title: ‘Anticoagulation Therapy / Heparin Free DPP | Applies fo: Doctors, Nurses,. Allied Medical Personnel SSeS Ci sce eee SSCL LSE CS-E LEE ESS GSE SEE EEE CHEESE SEES EEE 4.0. Purpose: 1.1. Anticoagulation therapy is required during hemodialysis to prevent the patient's blood from clotting ifthe dialyzer. It is administered by one of the following methods: 1.1-1]) Routine systemic of low dose heparin. 1.1.2|| No heparin dialysis may also be ordered. 1.13]| To provide a safe heparin free hemodialysis in those patients who are unable to have heparin, s0 as to minimize the risk of clotting in the extra-corporeal 2.0. Definitions: 2.1 Anticodgulation therapy - is the administration of medications to prevent patient's blood from clotting inside dialyer for patient’s undergoing dialysis treatment. Heparin is routinely used. Clotting is defined as follows: Minimal - sifall amount of fibrin in the drip chambers and / or occlusion of <10% of the dialyzer fibers Moderate - sfpall amount of clotting inthe drip chambers and / or occlusion of 10-50% of the dialyzer chamber. Large- modefate to large amount of clotting in the drip chamber and / or occlusion of >50% of the dialyzer fibers. 3.0.Policy Statement: treatments. 3.2. Post dperatively and according to patient's condition, hemodialysis patients have heparin free dialytis until this order is changed by the surgeon or the nephrologists, 3.3. Hepafinization will be performed by a registered nurse who has received training in hemodialfsis 3.4, Low dpse Heparinization or no heparin is used when the patient is at risk and /or if the clotting tifnes are prolonged, Le. active bleeding, pre-or post-surgery or pericarditis. 3.5. The Idjw dose method may also be used routinely. 3.6. _Depeltding upon assessment, for systemic heparinization, the heparin loading doses will routinely nay be 0-2000 U. The heparin pump will be set at 0 - 2000 U per hour. 3.7. During hemodialysis, the patient is to be routinely assessed for signs of bleeding, 3.8, The dlplyzer may be flushed with 50 - 100 mi of normal saline every 15 - 30 minutes. PRN, to visualize the drip chambers and dialyzer for clotting 3.9. _ The hbparin dose is to be adjusted based in the visualization of clotting in the drip chambers / dialyzer} 3.10. IF no minimal clotting is evident, heparin delivery is to be discontinued one hour prior to the ‘completigh of the hemodialysis treatment.ha Hemodialysis Unit HDU.16 Free x |e eee DPP | Applies fo: Doctors, Nurses,. Allied Medical Personnel the hemodialysis treatment, the dialyzer and drip chambers will be visualized for f clotting. If no fibrin/clotting is evident, the heparin dose may need to be decreased ft hemodialysis treatment. If moderate to large amount of clotting is evident, the se may need to be increased in the next treatment. illness in addition to various antibiotics, phenothiazides and anti-inflammatory agents {the anticoagulant effect of heparin, 4.0.Procedure: 4 \dentfy phtient by asking his name and check ID wrist band, and patient’ file. 4.2.Assess lal} works and patient for risk of bleeding 4.3.Wash hans. Water less skin cleanser is acceptable if hands are not visibly solled 4.4, Put on gloves 4.5.Routine Systemic Assemble equipment's Swab injection port on 1000m! 0.9 Saline prime. Allow to dry. Prime and re-circulate with heparinized saline. At beginning of hemodialysis, administer $00 - 2000 U of heparin Turn the heparin pump ON to 1000 - 1500 U of heparin / hour Flush the dialyzer with 50 -100 ml of normal saline every 30 minutes and PRN.Totaly ‘occlude the arterial blood flow while flushing 4.5.7 Calculate into the TMP the volume used for flushing 4.5.81 Discontinue the heparin 30 minutes to thour prior to the completion of dialysis Assess the drip chambers and dialyzer for clotting at the completion of the dialysis Treatment. 46. Low Dose Method Assess the lab work and patient for risk of bleeding. {At beginning of hemodialysis, administer 0 -1000 of heparin. Turn the heparin pump ON to 500 - 1000 U of heparin/hour Flush the dialyzer wit 50 - 100 ml of normal saline, PRN. Adjust the heparin infusion accordingly. Totally occlude the arterial blood flow while flushing, Calculate into the TMP the volume used for flushing, Discontinue heparin 30 minutes to 1 hour before dialysis is completed as indicated. ‘Assess the drip chambers and dialyzer for clotting at the completion of the dialysis treatment 47. ‘No heparin ‘Assess the lab work and patient for risk of bleeding. 4,7.2| Do not give a loading dose of heparin and do not turn the heparin pump on. 4.7.3] Flush the dialyzer with SO - 100 ml normal saline within the first 15 minutes of the initiation of dialysis and every 15 - 30 minutes thereafter as needed. Totally occlude the arterial blood flow while flushing, Calculate into the TMP the volume used for flushing.oe Hemodialysis Unit NUR-HDU-17 1.2. To reauc Bg Title: Electrical Safety in Hemodialysis Unit DPP. | Applies fo: Atl Hemodialysis staff 1.0, Purpose: 4A To roof ‘a safe environment for the patent, families and staff while in Hemodialysis Unit, electrical hazards that may occur during operation of equipment, 2A. 2.0, Definitions: None 3A, 32. 30. Poliey Stater |. Hemodial times. 2. The Cent power s 3.3. staff wf is Unit equipment deemed essential will be plugged into the red emergency power outlets at all | Reverse Osmosis Water System equipment is connected to the emergency power back-up be oriented to the locations of shut-of valves for oxygen and pressure line. 4.0, Procedure: 4A. The Stat 42.3) Jurse shall: Practice in accordance with the guidelines outined in this policy Shares the responsibilty for completing dally’ weekiy/ monthly checks ensuring all equipment is electrically safe and operational. Familarizes self with the battery back-up of all equipments used, Reports immediately all unsafe conditions (hazards), injuries or illnesses to immediate supervisor. cal Engineer shall Performs Preventive Maintenance checks on all medical equipment. ‘Trouble shoots and repairs all faulty equipment Approves new equipment for safety before use on patients. 5.0. Atta 5A ychments Standar for Electrical Safety 6.0, Refer 6A. 62. srences: hutp://edp.eVvmtQvb ek sae Hospitals, 5" ed. 2014: COP.3 ME.2Pi Hemodialysis Unit NUR-HDU-12 Ba Unit DPP | Apoiies 110. Stan 1 fy ‘Attachment 5.1 ndards for Elec foty in ar |. Biomedical Engineering will carry out Preventive Maintenance (PM) on all electrical equipment in the Hemodialysis Unitas scheduled 2. Only equipment certified and labeled by Biomedical with current PM tags can be used in the unit . Ifthe PM tags has expired, the equipment must be replaced as soon as possible and ‘Biomedical Engineering is contacted to complete routine PM. Electrical equipment should not be operated with wet hands or if the operator is standing on a wet surface, Is. Equipment must be stored in a clean ary space. Equipment with frayed leads of wires or with broken casing must be removed from the ‘unt and sent to Biomedical Engineering for repair and inspection, C02 fire extinguishers willbe avaliable in the unt at all mes. 3: Equipment deemed essential and placed on RED emergency outlets all the time: Hemodialysis Machine 1.8.2, Portable Reverse Osmosis Water Purification Machines, 1.8.3. Defibrillator lo. in the event of emergency power failure: 41.9.1. The machine has a back-up power. 1.9.2. Ifregular power outlets ae functioning, equipment may be switch to the regular power outiets to complete treatments 4.9.3. Allpatients HD treatments should be immediately terminated, rinses back {and blood returned to patients and disconnected from HD machines. 4.9.4, All patients’ fistula needles and central ines should be flushed with Normal Saline, clamped, capped off, and secured in place with tape. 4.9.5. Central line hubs willbe installed with Heparin 5,000 unis! mi, volume ‘documented on the outside of each hu, Fistula needies will be removed when situation is safe to do so. ‘A muttdisipiinary assessment ofthe current situation is to be done to determine if the procedure can safely proceed. Dain NTfol a Title: Hemodialysis Unit NUR-HDU-18 Hemodialysis Water Quality Monitoring DPP | appliesjo: Ail Hemodialysis staff 1.0. Purpose: LL. To defipe the policy, procedures and reporting requirements for the bacteriological and chemical testing afid monitoring program of water used by the Hemodialysis unit. 2.0. Definitions: 241. None 3.0. Policy Statement: 3.1. This polidy must always be ullizes under normal circumstances, All recorded results are to be documented ‘and comfjunicated to all associated departments as specified 3.2. Under erpergeney conditions in the event ofa substandard result, the Hemodialysis Department Head must 'be note immediately by telephone in order to take appropriate actions 4.0. Procedu 4.1. The poift of reference or guideline for the general procedure is the AAMI standards, 42. The U /M Department will be responsible for operating the treatment plants and the pipping to the User po}nts in 2 manner that conforms to the guidelines. The Water Treatment Plant Foreman will censure {hat the water is checked as per the related standards operating procedures (SOPs) and reported In wrtig to the IP&C and the head of the concerned department. 43.40 nf, th Water Teste lant Foveran vl submit a sample of treated water to an approved facility determine the comprehensive AAMI chemical analysis as per the related U & M Department SOPs. 44, The IP&C will collect water samples from the hemodialysis water treatment plants (pre-reverse osmosis and pos reverse osmosis water outlets) when operating: ‘4.4.4, Once per month for endotoxin analysis for delivery to the chemistry Laboratory using the sampling containers provided (non-pyrogenic containers). 4.4. Once per month collected water samples for analysis in sterile sample containers which contain sodium thiosulphate to neutralize the chlorine in the water for delivery to the microbiology laboratory for analysis. Chlorine evels wil be noted for each sample at the time of collection. 4.8. .Afree chlorine residual of 0.3 mg/! will be maintained by the U&M Water Treatment Plant Foreman at al points | ‘the hemodialysis water system, While some variation in levels is unavoidable, the chlorine levels should not drop below 0.1 or rise above 0.5 mg/l Failure to achieve this would warrant immediate notifca Water 46. Collect from pt 46.1. ri 4.7. The Her ion to IP&C and the Hemodialysis Department Head. Corrective action will be taken by the featment Section, UBM. of water for testing, including chemistry endotoxin analysis and aerobic colony count analysis, and post-hemodialysis machines. Jater samples will be collected and delivered by trained Hemodialysis unit staff to the Lab for testing. Analysis and reporting wll follow as per related SOPs. 2. Hf colecing sat wil ena tt ony sre sale ‘containers appropriate for the tests are 1d, These samples have to be delivered to the appropriate laboratory as soan as possible. 4. Bacteriological testing - samples for aerobic colony count to be delivered to the Microbiology Laboratory. 2.2. Endotoxin level testing - samples ta be delivered to the Chemistry Laboratory. (dialysis Department Head, IP&C, and the laboratory staff will ensure that sampling procedures are appfopriate. P&C to ensure thatthe technique is appropriate and the results are vai coa Hemodialysis Unit NUR-HDU-12 Be Title Hemodialysis Water Quality Mo! DPP Appia: a temodiatysis stat ring “iB. Quality coftol for standards of sample collection willbe provided by IP&C through Inservice training. 43. All samp results will be ceported by departments who collected the samples to the Hemodialysis Depart Head nthe evento an abnormal result, the laboratory will immediately inform the irectors}pfthe hemodialysis unit, USM division, and IP&C. Representatives from IP&C, UM, Laboratory ‘and the Hemodialysis Unit will meet .When needed to ensure effective communication, review current activities|{and discuss any required changes / related issues. 4.10. Responsipility: All departments involved in providing, maintaining, testing, and using water for Hemodialysis are responsible for adhering to the provisions as stipulated. The Quality Management Departmint is responsible for monitoring compliance to the provisions ofthis policy. ‘4.104. P&C is responsible for conducting monthly water sampling; report the results; and, take corrective measures accordingly. IP&C serves as the reference point for training and consultations related to water quality standards. 4.10. U&M will maintain the reverse osmosis water treatment plants; do water sampling and testing; report the results; and, take corrective actions accordingly and as per their related ‘SOPs and guidelines, 4.10. Hemodialysis Unit staf wll conduct regular sampling from their unit and wherever the reverse osmosis outlets are; report the results; and, take perceptional actions toward patients accordingly, especially when abnormal results are reported. 4.108. Laboratory will receive the samples; analyze them; and, report results ina timely manner and as per related SOPs. 4.11, Sterliggtion of Equipment 4.11.4) All equipment is terminally leaned after every treatment. 4.11.2) itis monitored each month with cultures for bacterial contamination, 4.11.4| If any machine culture is positive for bacterial contamination with a colony count greater ‘than 2000 per mits taken out of use, decontaminated and re-cultured 4.11.4| The dialysis machine shall be with bleach after each use. A hospital approved disinfectant is used to decontaminate the machine after any blood contamination or hepatitis positive patient use, 4.11.4| All disposable supplies used during alysis treatment are considered contaminated materials. 4.414 There shall be a written procedure on sterilization of equipment. Hemodialysis filters: there will be no re-processing and reuse of hemodialysis fiers. All eecommended control measures for hepatitis B surface antigen (HBsAg) postive patients, 422. Cultures will obtained from dialysis catheters, fistulas, or grafts for any sign of infection. Cultures shall be obtained from the water and dialysate on a monthly basis The Dialysis Services nurses are not permitted to eat, drink, smoke or put on make up while performing dialysis treatments. 4.13. When Hoing dialysis. ‘4.13.4, The nurses shall wear protective gown, goggles (if applicable), mask and_gloves. These are removed before leaving the room. It is acceptable to wear individual lab coats provided a ‘change is made ifthe coat is contaminate with blood. 44,134. Strict hand-washing technique is observe between and after al patient contacts. 4.134, All blood contaminated trash from the dialysis shall be bagged in yellow plastic bags and handled as biohazard waste. 4.34, All line handled as contaminated and is placed in appropriate bags which are closed to removal from the unit. ‘4334. The Dialysis Services Clinical Coordinator will be a consutatve member of_the Inf Le SePe) Re Title: . 5, y eee eee Hemodialysis Unit __ NURHDU-t2 Hemodialysis Water Quali Monitoring DPP | amnies jo: All Hemodialysis staff Control Committee and Is responsible for maintaining infection control standards during dialysis treatment. 4. Attachments! ‘44, None References: 54. http slivmtQu 5.5. Association of the Advancement of Medical Instrumentation (AMI) Standards for Hemodialysis Water Supply. 56. aneca 57. Gulf co National Standards Insitute (ANSI) eration Counci-Center For Infection Control (6CC-CIC) ICM -X-02 Da pred Na SoC Fait 1Hemodialysis Unit Title: Management of Patient with Disequilibrium DPP | Applies; jo: All Hemodialysis Staff 1.0. Purpose: 1.1.To estabfsh standard way on how to manage patent with disequilibrium. 2.0, Definitions: 24. Disequi between other the brain tisfue occurs because urea dose not leave brain tissue and spinal fluid as rapidly as it does brium syndrome is due to the rapid or high volume shifts in water, pH and osmolality erebral tissue and blood. It is related to the use of rapid, efficient dialysis. Swelling of ly tissues. This cause water to enter the brain because solute or urea content is higher in {than itis in the rest of the body. 34. Follo post dial 3.0, Policy Staterjent: dialysi ‘blood pressure is low and shock symptoms are present, treat according to 4.0. Procedure: 4.1. Take vit 4.2. Observe] inrtabili 43. Utilized 444. On the s 43. Preventi 45.1. I signs for any mental status changes; such as headache, nausea and vomiting, restlessness and ; confusion, leizure precautions. cond day, weakness and dizziness on standing may develop. je measures: requent short dialysis when BUN is high Seizure precautions. equent monitoring of vital signs. patient is acutely or severely uremic. se shorter, more frequent dialysis treatments. se slower blood flow rate - 150 ml/minutes. se les efficient or small surface area dialyzer. jent/Treatment jest treatment is prevention during dialysis, i. decreasing the length of dialysis when mptoms appear. iscontinue ultrafiltration Fylenol may be given for headache, if ordered by physician, um may be given for restlessness, Dilantin for seizures, if ordered by physician, jympioms will usually clear 8 to 12 hours post dialysis 5.0. Attachments; INone 6.0, References: 6a. ht ViwntQvb 62. 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