access flow question

Specialties Urology

Published

Can anyone tell me if there is a correlation between a lower access flow (done on 2008K machine) and elevated arterial pressure. IE if the second access flow was taken, within a week, and it dropped, could that reading be due to a poor stick where the needle was pressing on the vessel thereby making the AP go from normal of around 180 190 to 240's? Had someone ask me and I do not know. Am not a dialysis nurse. Thanks.

shame shame...........

There is something grossly wrong with our healthcare system when individuals do not understand who it is providing care and who needs the education in order to do so. I did not know they took away the retirement, but then, I would have no reason to know that.. However, I always thought profit sharing would be good, but I guess it depends how many shares they give staff.. afterall, 1.5 billion profit is alot of shares. Might I ask what part of the country you are in.. west? east?............

I will share a story with you that happened at one of the FMC units. One day there were two visitors. One was a male, apparently, according to staff, he was the VP. Then the District Manager who is not a nurse, but has a masters in business, etc. was visiting the unit. They toured and walked through the unit, walking by each and every patient. Now, did they stop and introduce themself? NO NO and NO> To me this is the most insulting thing and if I were a patient I would have felt that I was a piece of meat being looked at and observed. My goodness, how is a patient suppose to feel when one walks by, in a close proximity and does not say hi,, I am so and so.............SHAME on FMC.............Oh, I might add the District Mgr is there once a month for some quality meeting and has she ever stopped to introduce herself,,,, NO NO and NO.......to me this is disgusting. Patients are suppose to be part of the 'family' what a joke............let alone at some facilities they are not even part of their own treatment team. This is what separates patients and makes them feel distanced. The dialysis culture is certainly unique unto itself.

It certainly is.. If I weren't making some good money and didn't love this patient population so much I'd get out.. It's the patient's that make my day ..

One cost effective thing many units/nephrologist have started .. to save money as these patients now have to be seen 4 times a month for Medicare reimbursement is to hire NP's.. I love them ..Are they perfect ..NO but they are so much more interested in the patient's well being. They are NURSES.. They come at this from a nursing perspective not a doctor perspective. I think they will be a boon to the clinic's bottom line as well as the nurses..

When this country wakes up and realizes that patient's don't come to a clinic or hospital for doctoring, the great food, or soft bed it will be a great day in the history of nursing.. People come to a dialysis unit or hospital for NURSING CARE... They don't come there for doctoring.. It is the NURSES and TECHS in dialysis who take the day to day care of these people.. It is they who deserve and should demand decent compensation.

Because unfortunately, it really does come down to money.. You are never gonna get superior staff without superior compensation.

Specializes in Hemodialysis, Home Health.
It certainly is.. If I weren't making some good money and didn't love this patient population so much I'd get out.. It's the patient's that make my day ..

One cost effective thing many units/nephrologist have started .. to save money as these patients now have to be seen 4 times a month for Medicare reimbursement is to hire NP's.. I love them ..Are they perfect ..NO but they are so much more interested in the patient's well being. They are NURSES.. They come at this from a nursing perspective not a doctor perspective. I think they will be a boon to the clinic's bottom line as well as the nurses..

When this country wakes up and realizes that patient's don't come to a clinic or hospital for doctoring, the great food, or soft bed it will be a great day in the history of nursing.. People come to a dialysis unit or hospital for NURSING CARE... They don't come there for doctoring.. It is the NURSES and TECHS in dialysis who take the day to day care of these people.. It is they who deserve and should demand decent compensation.

Because unfortunately, it really does come down to money.. You are never gonna get superior staff without superior compensation.

I agree, RRN !

I 'm not making near what you're making simply because of location.. I know I could cross the line from my state to yours and increase my pay right off teh bat. We, too, have a superb NP who stops in weekly and she is wonderful. (I noticed your NP thread.. good for you !)

And yes.. it really IS our patients who make our day.. and we theirs. They really miss us when we're gone a day or two, or on vacation. We always carry on with them, and truly they are "family" to us... even the few "grouchy" ones.. :chuckle we even go on to THEM abouit their grouchiness and get them laughing about it.

As to imperial's comments... I can SO relate to what you said about the "visit".

While our regional mgr. has never "toured" the facility, she has, on occasion walked on the floor or into the lab, but again, never stopping to introduce herself to patients(or to say hello to us).

When she comes down every month for CQI meetings, she avoids staff like the plague. The only person she talks with is out DON as this is the one she directly communicates with. But she'll never come out to talk with us, say hello, ask for input or how we're doing, do we need anything.. nothing. It's like we don't exsist. She has a business degree, has never been a nurse, knew ZIP about dilaysis when she started a few years ago. And yet she calls the shots on the daily running of I don't know how many facilities.

This is truly one of my pet peeves.. these regional/district mgrs. make it so obvious they don't have a clue, and that all they are there for is to ensure the clininc is cutting costs down to bare bones.

Really makes the staff feel like crap when htese folks won't even acknowlege us when they are present in our facility.. no hellos, NADA. :angryfire

I agree with you Jnette and RRN 100% and MORE>

If staff feel this way when the uppers don't acknowledge them, you can imagine how patients feel. I have heard the expression 'cash cows' and I might, now be understanding more where this expression originates. District people and upper level people visiting the unit, looking at patients as if they were cows delivering milk that would make them money. If that makes sense.

As a lifelong patient advocate, working iwth various levels of patients and various areas of delivery of care, I am totallyl appalled at what I am seeing. It is no wonder why the good staff leave and the bad stay.

It is interesting to me that when a patient starts dialysis, and, I know, specifically with FMC, staff state to patient they will become part of a family as this is a lifelong process. OK> so when the grandparents (upper levels) visit, they don't speak.. oh, dear me... what a dysfuntional family this is.

Patients as it is have an emotional component that no one can understand unless they are in their shoes. We can emphasize and be compassionate, but never understand whta it really feels like. The other day I had the opportunity to speak with a dialysis patient, a retired physician. She has been on dialysis for 5 years, elderly. She still verbalizes how difficult it is to sit for 3 hours and come to dialysis 3x a week. She reviewed the process of getting ready for each trip to the center, gettingthere, etc etc. My heart goes out to patients ............and, staff, especially those, as yourselves, who are dedicated. I realize more and more how difficult it is to be a staff, a good one. There is also so much propaganda brought down from the top. So, unless staff continually educate themselves, they can only get what the corpos give them. In researching some information recently for a family, I found the staff giving totally wrong information about something. But this is what the staff were told by the manager and what they were taught.

Whoever posted FMC does 4 weeks t raining made me realize it is not wonder mistakes are made... esp for those with no medical backgrounds.

p.s. I enjoy communicating with you all and sorry if, at first, I came across the wrong way.. Hvae a great day.... :balloons:

Specializes in Hemodialysis, Home Health.

It is sad and frustrating, imperial.

FMC provides 4-6 weeks training depending on your medical back ground... HOWEVER... that does not mean they are set loose on the floor without further trng. and supervision !

From there they continue a 6 mo orientation with supervision and a preceptor, and at this time, they do not access caths, either. After they have accomplished all the orientation for teh basics, they then are further trained/precepted in accessing caths.

I feel comfortable with the training, myself. I don't see an issue there. There is ALWAYS someone there to back you up and answer questions.. be it EDW, or whatever. We all know to ASK if there is anything we are not sure of, and new staff always has at least one or two experienced staff working with them.

Again, this works in MY facility, because I do feel we have caring, competent, and cooperating staffmembers.. no one there risks anything or would go it alone without asking if there were any doubt, confusion, or questions unanswered.

How it works in some of the really BIG facilities is something I have no experience with.. and honestly don't care to. I have heard stories that bother me... and I would never want to work in one of these "assembly line" facilities. Not good for patients, not good for staff. The staff turnover is tremendous there from what I hear.

It is sad and frustrating, imperial.

FMC provides 4-6 weeks training depending on your medical back ground... HOWEVER... that does not mean they are set loose on the floor without further trng. and supervision !

From there they continue a 6 mo orientation with supervision and a preceptor, and at this time, they do not access caths, either. After they have accomplished all the orientation for teh basics, they then are further trained/precepted in accessing caths.

I feel comfortable with the training, myself. I don't see an issue there. There is ALWAYS someone there to back you up and answer questions.. be it EDW, or whatever. We all know to ASK if there is anything we are not sure of, and new staff always has at least one or two experienced staff working with them.

Again, this works in MY facility, because I do feel we have caring, competent, and cooperating staffmembers.. no one there risks anything or would go it alone without asking if there were any doubt, confusion, or questions unanswered.

How it works in some of the really BIG facilities is something I have no experience with.. and honestly don't care to. I have heard stories that bother me... and I would never want to work in one of these "assembly line" facilities. Not good for patients, not good for staff. The staff turnover is tremendous there from what I hear.

Where I am right now they just hired an RN who will take my place in six weeks when I am gone. SIX WEEKS and he's never done dialysis.. It's not just knowledge that he needs but some priority setting tools. He came from a cath lab.. ONE PATIENT at a time.. Sorry to any ICU nurse here but they may have lots of knowledge and wonderful competent nurses but they can't handle more than 2-3 patients.

In every unit I've worked in from Maine to Cali and back if you hire 3 you might retain 1.. FMC does all it's book learning in that first four weeks and then puts the nurse or tech in the unit and they get reality shock..

I certainly feel sorry for this guy who will be alone in a 24 station unit on a SAT.. I've been there and no one answers their phone i.e the other RN or CM on Sat so you truly are on your own.. He will have to make bi-carb because half the techs don't "know how to make it" And he will have to do all the water tests and difficult sticks. He told me he hasn't stuck a patient in years...OMG...

The techs in this unit "learn" cath access in orientation and dressing changes but as you say can't access a cath for the first 6 months so guess who puts on and takes off all the caths.. And guess which day has the most caths. Yes TTS... And the tech don't get re-train on cath access after 6 months so I gotta wonder how much they even remember...We have a couple who watch me do it so that's good...

Six more weeks and I move on ..Thank God.

If this were me and I was aware of such a severe problem that would put, obviously, patients lives in danger, I would report to the licensing department in that area for them to investigate. It is only when this is done that companies will get hit and something will be done. For us to just sit back (not inferring you are doing so) and know this injustice to patients is being done, makes us as guilty as the companies doing same. Again, mean no disrespect to you or sayiing that you are sitting back, to me just hearing this is outrageous and says that mistakes are inherently going to happen. Wrong dialysate? etc etcetc

btw, Jnette did you find out what contributing aspects/conditions can affect the access flow.. i.e. poor stick.. thanks.

Specializes in Hemodialysis, Home Health.

imperial..

not much time.. got in only a little while ago, and must get to bed.. gotta be up at 0300 to be at work at 0400 again in the morning.

OK..

If this patients access flow numbers were LOWER the second time, that is not a bad thing, but a GOOD thing !

We just did our monthly AF tests again today. The test gives you two numbers, then a final number for the actual test.

The first two should be as close to the patient's usual KECN as possible (their usual "clearance" number while dialyzing).

And this should always (or preferably) be

The first two AF #'s should reflect this, in other words, also be

The final AF# is the overall and most meaningful #, and it should be under 2000 .. if above that, then there is something going on in the access.

Hope that helps !

Going to bed now.

Oh ! And guess what? The "STATE" popped in on us today ! Moved right along after looking over our facility and us at work.. said she thought we were doing a superb job and saw no reason to waste any more of our time.

Jnette: CONGRATS for having good visit from State... great...

I think I understand some of what you wrote.. but not sure... It is interesting believe staff provided information that if number is lower than indicates problem possibly. When you have time, maybe you can explain a little more, it is confusing. I appreciate you taking time to give me this information. ... I really really appreciate it.. ALso,, wow... 4 AM?? geesh... Hope you get a good's night rest.

Specializes in Hemodialysis, Home Health.

Heh. yes.. 4 am. Our first patients go on at 0500, but we are there at 0400 to set up, prepare bicarb.. do all the water and machine tests and checks, etc, etc...

OK.. I'll try to explain.

During the course of tx., the patients' CLEARANCE (just how much is actually being removed of the toxins, urea, etc.) is always being monitored. This shows up on the screen at scheduled intervals. These numbers usually (and preferably) fall anywhere between 200-300. If they fall below 200, then they are not clearing as much as would be ideal.. and their "yellow" light would show (IF they have the "stoplights" installed on theior machines.)

Green = good clearance, yellow = clearance falling, check for needle placement, clotting dilayzer, or other possible scenarios. Red is always an alarm of one kind or another.

With the new AF testing, the first # given is along the same line as this. After the first test in "normal mode", a numeric value is given.

Then the "twister lines" as we call them, are reversed, and the machine again calculates the clearance with the flow reversed.

The third and final # is the actual result .. and it should be under 2000. If over 2000, this would indicate the access possibly warrants evaluation by a surgeon.

But yes, to answer your specific question, needle placement CAN vertainly make a difference in bloodflow rate as well as arterial or venous pressures.

As can heperanization... if not properly heperanized, a dialyzer run sluggishly or can clot off .. both of which affect the pressures (mostly the arterial in this case). But the staff would have to look for a pattern.. if this is a one time occurance, it may just be needle placement .. of the patient begins to consistently have poor clearance or problems with pressures and blood flow rate, then something might be going on with the access or they might need to

increase the heparin bolus and/or pump amount. Scar tissue could also be forming inside the access, making it more difficult to cannulate, or pushing the needle up against the vessel wall.

If we notice someone who usually has good art/ven pressures and BFR, yet this particular day does not, we take a look at the access, needle placement, attemt to readjust the needle, prop it, etc. Sometimes none of these attempts are successful, and you don't want to fool around TOO much with the needles, as you don't want to end up making it worse, or possibly infiltrating. So you just go with what you can get that day. Are they still dialyzing ok? Certainly. Occasional less than optimal clearance is no big deal.. it happens to all the patients at given times. But if it were a consistent problem, that would be different. That would warrant a closer look at things.

Hope that clarifies it for you a bit. :)

Yes, and, thanks.. I am reading f rom the manual (machine operators) about the access flow but there is not as much information as you have given. One particular case I am speaking of is of concern as staff are not, or it appears have not been adequately trained in the rationale. Therefore, I greatly appreciate your input.

An example is.... when the patient's AP is much higher than usual, the comment made to one patient was 'nothing is wrong until the alarm goes off'... the patient attempted to explain that the alarm goes off when it hits the parameter set.. and, there could very well be a problem. It is for this type of situation, that makes it frustrating for patients, esp those that are educated. It is difficult as staff are busy.. ... Thanks.

Specializes in LTC, WCC, MDS Coordinator.

Thank you so much for the information you have given me. At the facility I work at, we have one pt who three nurses have tried to use the flow meter on and all three of us have not been able to get a reading. This lightbulb appeared over my head while reading the thread....his dialyzer has been only passing by

Thanks again, and my pt thanks you, too! :icon_hug:

kdh

Specializes in Hemodialysis, Home Health.
Thank you so much for the information you have given me. At the facility I work at, we have one pt who three nurses have tried to use the flow meter on and all three of us have not been able to get a reading. This lightbulb appeared over my head while reading the thread....his dialyzer has been only passing by

Thanks again, and my pt thanks you, too! :icon_hug:

kdh

Sure thing ! :)

I used to do reuse for about four years, and know all about cleaning off the "nasties" under those dialyzer endcaps. Thank goodness we no longer do reuse. :p :p

But yes, anytime I noticed a lot of clotting and it barely passing on the renatron, I'd chuck it. It's not worth holding onto if the patient is not getting the dialysis he/she needs. The company can absorb the cost.. after all, it IS about the patient, lest they forget ! :rolleyes:

And yes, when there is sluggish flow or bad reuse percentage, it always pays to look at the patient's heparinazation.. may need to be increased just a tad.. IF not contraindicated (already on some form of anticoagulant r/t cardiac surgery, stent placement or other comorbidities). You get the picture.

The patient may gain tissue weight over the months/years as well, and we need to reevaluate their heparin bolus at these times, too.

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