access flow question

jnette, ASN, EMT-I · Mar 5, 2005

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.

If the patient usually has a decent AP, but then SUDDENLY falls greatly.. this is certainly possible. Yes, the needle may be resting against the vessel wall.. could be due to a poor stick or the patient may have moved his/her arm and thereby the needle. Usually if we notice a big change in the patient's usual AP we readjust or prop the needle in an attempt go get a better AP. If the AP remains at the low reading for several days or more, then it would appear that something is going on inside the access itself.

The access flow test itself, though, is affected by other things as well.. machine alarms (tmp, conductivity, etc.)

imperial · Mar 5, 2005

J'nette: Thanks. It seems that the AP never has been that high (250) and usually is in the high 100's. or 210. It was the second day for the access flow test. The staff did have a difficult time cannulating the arterial site. I believe I was told the tmp was also higher. My understanding is the tmp is difference between AP and VP so that would mean, if I understand you correctly, that the access flow would be affected then by a poor stick. i.e. poor stick, AP 250 therefore tmp higher therefore access flow test affected. Also, I think the VP usually runs 180 and it was 110. This particular unit apparently just started and was recently trained to do the access flows. This persons flow was 1250, then the second one done, a day later was 900.

I think I understand whaty ou have said and thanks. (I come in contact with patients who have many questions who are not able to ask staff for various reasons, often as the staff is busy and some just don't know). thanks..

jnette, ASN, EMT-I · Mar 5, 2005

J'nette: Thanks. It seems that the AP never has been that high (250) and usually is in the high 100's. or 210. It was the second day for the access flow test. The staff did have a difficult time cannulating the arterial site. I believe I was told the tmp was also higher. My understanding is the tmp is difference between AP and VP so that would mean, if I understand you correctly, that the access flow would be affected then by a poor stick. i.e. poor stick, AP 250 therefore tmp higher therefore access flow test affected. Also, I think the VP usually runs 180 and it was 110. This particular unit apparently just started and was recently trained to do the access flows. This persons flow was 1250, then the second one done, a day later was 900.
I think I understand whaty ou have said and thanks. (I come in contact with patients who have many questions who are not able to ask staff for various reasons, often as the staff is busy and some just don't know). thanks..

We, too, are still learning all the ins and outs of these access flow tests.. we just started doing these a month ago ourselves.. I'll see if I can get more info on this for you when I go back to work on Monday.

If not mistaken, the LOWER flow result is the BETTER. I do know that if the the access flow result is > 2000 the access has issues which need to be addressed. But I will try to glean a bit more info on this, and get back with you.

Are the staff remembering to reduce the BFR (blood flow rate) to 300 when initiating and all throughout the AF Testing?

imperial · Mar 5, 2005

The staff do reduce BFR to 300.. Also, they stated that anything over 800 was good, or over 600, believe it was 800.

It would seem if the needle was pressing on the vessel that it would have some effect on blood flow, but then I am NOT a dialysis nurse, just interested. But, then, both AP and VP were diffferent. So many things with dialysis. I went to the http://www.kidneyoptions.com site, which is FMC's site and they did not have information on this.

jnette, ASN, EMT-I · Mar 5, 2005

The staff do reduce BFR to 300.. Also, they stated that anything over 800 was good, or over 600, believe it was 800.
It would seem if the needle was pressing on the vessel that it would have some effect on blood flow, but then I am NOT a dialysis nurse, just interested. But, then, both AP and VP were diffferent. So many things with dialysis. I went to the http://www.kidneyoptions.com site, which is FMC's site and they did not have information on this.

Sure.. anytime the needle is up against the vessel wall, it will impede the BFR and affect the art. or ven. pressure. But other things can, too.. ie if the patient is beginning to clot off in his/her access, if there is scar tissue build-up.. many times it is just the actual stick SITE itself.. she may have better areas in her access site to stick, but we must rotate the sites.. can't always stick in just the "easy" places or we end up with pseudoanyeurisms or ruin the graft. So this patient may have some areas in her graft or fistula that are not as good as other areas (scar tissue, narrowing, some occlusion, etc.)

Could also be that her dilayzer was beginning to clot off.. this, too, will affect the pressures. She might need an increase in her hep bolus or the use of a hep. pump on her machine.

Lots of different reasons for pressure variences,including BP... not just the "stick". And hardly anyone has the same art/ven pressure values every time. It pretty much varies from tx. to tx. Nothing new and certainly nothing alarming.

imperial · Mar 5, 2005

Thanks Jnette, you certainly are knowledgeable. thx. there is so much to learn about this and oh so fascinating, for sure. Seems like alot of trial and error.

I believe this is the patient who has a buttonhole that staff have been using a sharp needle as they are unable to use dull, too painful...

I also heard that FMC has a program that can be put on machine which is similar to the Critline, however, they are not using it as of yet. It is my understanding that it is in 'patent litigation', something to do with taking part of the technology from another similar program??? There was an article on the net about it sometime ago.

Also, someone asked me if FMC recently gave raises to their staff. Are you aware of this, you are at an FMC unit right? thx.

jnette, ASN, EMT-I · Mar 5, 2005

Thanks Jnette, you certainly are knowledgeable. thx. there is so much to learn about this and oh so fascinating, for sure. Seems like alot of trial and error.
I believe this is the patient who has a buttonhole that staff have been using a sharp needle as they are unable to use dull, too painful...
I also heard that FMC has a program that can be put on machine which is similar to the Critline, however, they are not using it as of yet. It is my understanding that it is in 'patent litigation', something to do with taking part of the technology from another similar program??? There was an article on the net about it sometime ago.
Also, someone asked me if FMC recently gave raises to their staff. Are you aware of this, you are at an FMC unit right? thx.

Ironically, just the opposite. Our annual raise percentage was just CUT.

But FMC does things differently across the nation... you'd think they would be consistent, but all their clinics nationally are different. What happens in one area of the country, doesn't necessarily happen in another, even though it's the same company. Seems like some area get some fine advantages, such as better staffing ratios, etc. while others get the shaft.

As far as pay, they go by the local geographic wage "norms". But you'd think that a wage increase or decrease would be consistent across the board.

Guess not. :stone

imperial · Mar 6, 2005

How interesting that FMC cut raises as they made 1.5 billion net profit last year, or so I read at the stock market site..............guess Dr Lazarus, chief honcho of FMCNA does not believe those doing actual care deserve raises. Personally, I have seen staff work and they DO deserve a raise.................esp those that do what they should be doing with deliveyr of care... I always support more money for those who are dedicated employees. Shame on FMC and any other company that does not provide raises of a substantial amount. Afterall, the ones at the top are making millions off of patients..................I don't understand when these large dialysis corps claim they are not making money when all the documented financial info states otherwise...........

RRN · Mar 6, 2005

Ironically, just the opposite. Our annual raise percentage was just CUT.
But FMC does things differently across the nation... you'd think they would be consistent, but all their clinics nationally are different. What happens in one area of the country, doesn't necessarily happen in another, even though it's the same company. Seems like some area get some fine advantages, such as better staffing ratios, etc. while others get the shaft.
As far as pay, they go by the local geographic wage "norms". But you'd think that a wage increase or decrease would be consistent across the board.
Guess not. :stone

FMC took over BMA and NMC.. When you take over other facilities and their staff and ways of doing things it takes time to change. Also FMC has grown by leaps and bounds buying up independent clinics. They are trying to make policy and procedures universal. They are trying to start a travel nurse division of their own. To cut out the middle man. In order for that to be successful they need to have universal..P&P's...

One problem with universal P&P's lie with the nephrologists. In Maine I kept leaving the package insert lying around where the MD's could see it . The MD's somehow thought Zemplar had to be given the last 15 minutes of treatment. The nurses finally comprimised at 30 minutes. After 13 weeks of my leaving the package insert lying around the policy was changed to give Zemplar any time during the treatment. I neve did find out why they waited 1 hour before giving Epo??????

Also, at another unit,FMC. we could not convince out Nephrologist that Venofer requires NO test dose. His answer was "We will give a test dose for a year and if we have no untoward reactions I will allow it to be given without me being present and a test dose"

That is one reason there are not universal P&P's.

In, Maine, at that Fresenius unit we never UF a patient. The Nephrologist felt that the patient's labs were never that good so might as well dialyze them for an extra treatment.

I would love it if all the units were universal. That would make my life better.

jnette, ASN, EMT-I · Mar 6, 2005

How interesting that FMC cut raises as they made 1.5 billion net profit last year, or so I read at the stock market site..............guess Dr Lazarus, chief honcho of FMCNA does not believe those doing actual care deserve raises. Personally, I have seen staff work and they DO deserve a raise.................esp those that do what they should be doing with deliveyr of care... I always support more money for those who are dedicated employees. Shame on FMC and any other company that does not provide raises of a substantial amount. Afterall, the ones at the top are making millions off of patients..................I don't understand when these large dialysis corps claim they are not making money when all the documented financial info states otherwise...........

Just as any other major health industry corporation, the nurses and staff are at the bottom of the "receiving" totem pole. While they spend millions on advertising and marketing tools, the latest technology, etc... what would they have if they didn't have the staff to utilize the new equipment, etc?

It's just more of the same ol' same ol'. Not only that, but two years ago, they ALSO took away our retirement plan... and replaced it with their joke of "profit sharing". I got a hefty check of eighty $$ for the year. I can really retire on $80.00 a year... :rolleyes:

Shame on them is correct. And to add insult to injury, they are constantly breathing down our necks to NOT accrue ANY overtime.. yet they keep on sending us more and more unstable patients who require far more time to assist.. all these extra minutes here and there add up.. shall we just close up shop at three o'clock regardless and shove everyone out the door?

Truly, it does get quite frustrating, and have seriously been looking into other options, because this is simply no way to treat the staff OR the patients, all of which truly deserve better.

imperial · Mar 6, 2005

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.