Needle Dislodgement

This was an interesting article done:

"ASN 2008 abstract –Estimated 414 episodes of venous dislodgement in U.S. dialysis population of 350,000. They estimated mortality between 10-33%, meaning the number of fatal incidents in the U.S. may be between 40-136 annually (2008,Sandoni, et.al.)"

As dialysis staff, we need to make sure that all lines are secured properly and that all accesses, needles and lines need to be visible during the ENTIRE dialysis treatment.

Covering up these areas are NOT permitted in my clinic - period! If a patient has an issue with this, I tell them to bring someone in to sit with them for their entire treatment and keep an eye on them because my staff is not going to be responsible for any accidents. Most patients don't have someone to sit and look at the access every 15 seconds!

This is a written policy and I give all the patients a copy on admission and make sure they understand the importance of this. This is signed by the patient and placed in their charts.

In my 25+ years of dialysis, I have never had a venous needle dislodge.

Access sites should be visible and staff should be checking -- Unfortunately, many units are cited for this ...(not having site uncovered) Many units do NOT allow visitors -- There are alot of articles on needle dislodgement as well as some incidents that have been made public where patients have died. I do not think I am allowed to post other websites, as I did before -- therefore, unfortunately, I can't reference for you

I have read alot about this and there are, as I mentioned, numerous articles regarding this dangerous situation, in fact, a few where patients have died have made public/media attention, over the years --

If patients are educated then often this can be prevented...I haven't seen patients disturbing their needles -but I have seen sites covered -- in fact, I happen to be in one unit where a staff, thank god, noticed blood on the floor.. the site was covered, not exposed.. if she did not see the blood on the floor, the patient would have died.. i have also observed, in numerous clinics staff not checking sites, when they do BP checks, etc.

Thank you for your post, well it seems obvious that covering up the access site would cause problems, however I recently attended a dialysis conference where I interacted with a number of dialysis nurses who suggested that these types of policies are not in place. That patients like to keep warm and cover themselves during treatments.

Your clinic's policy should be replicated given your success rate.

The abstract you suggested is one I have seen, but not much else. Thanks again.

From your posts, it seems that clinic culture in conjunction with protocol might dictate incidence of dislodgements. Other than the RedSense monitor which is now required by VA dialysis centers, any other safety mechanisms that you might have come across during your practice?

I have patients who wear long sleeve sweatshirts to the clinic and they have an area that is velcroed down when needles aren't in and they unvelcro the area to allow needles to be placed and they can be seen at all times.

They also do this for catheters in the chest and leg grafts and fistulas. They are really neat!

I read a website some years back of a family member of a dialysis patient who would sew these clothes for patients, but I can't remember the site.

I also have a policy about "no heads or faces being covered." When a patient has their face covered, you have a hard time telling if they are passed out from hypotension. If they are that cold, they can wear a tossle hat. (remember there is a ruling in the conditions for coverage, from CMS requiring us to maintain a temperature in our clinic that is reasonable for patients - which at times is hard to please all patients in the clinic).

It's all about "educating" the patient about why these "safety" measures are necessary and not trying to take away their "independence or ability to make their own decisions."

If your patient is "that" cold, turn the temperature up on the machine, if their blood pressure is stable to allow this. They seem to like this.

Agree that the education of patients is most important -- once someone understands the rationale for such, they are more likely to follow --- staff education is also important and I have found, unfortunately more than I would like, that staff don't take this seriously... some staff think as teenagers 'this will never happen'.... When patients are cold it is a problem and I have known where temps on machines have been turned up higher than is safe which results in potential for hemolysis.. some patients have run temperatures only to find out that the machine temp is too high

@ anurseadvocate - what kind of machines do you use? All of the dialysis machines that I have ever worked with only go up to 38 degrees celcius which is safe. The ranges goes from 35-38 degrees. This is a "nursing" judgement and we don't need an MD order to adjust the temps.

With the exception of a patient with Dementia and a Schizophenic patient (both who pulled their own needles out)....every other incident of needle dislodgement I have run across was due to an inadequate tape job... it's very frustrating. I suggest re-educating direct patient care staff re: proper taping procedures.

From your posts, it seems that clinic culture in conjunction with protocol might dictate incidence of dislodgements. Other than the RedSense monitor which is now required by VA dialysis centers, any other safety mechanisms that you might have come across during your practice?

I have to say that I am not impressed with the RedSense monitor. Maybe they have made improvements to it now, but when it was studied in my unit it alarmed for everything!

I have been in hemodialysis for 8 years and have never seen a VND that was not intentional or caused by a patient standing up mid run without making sure there was enough slack in the lines. Maybe this is because I was taught, and have taught all those who came after me, what a serious event this could be. It makes me especially nervous because of the lack of alarms due to VND.

I agree with other posters that the best way to prevent this is to keep the access visible; we also leave the light above the patient on at all times to prevent shadows that may hide the dark color of blood. Proper taping is also a must!

Actually, some providers do require a physician order for the temperature on the machine -- some physicians might want the temperature lower because of hyptotension (some FMC medical directors do such). Some facilities have a range.. the FMC 2008 machine goes beyond 38 as I recall..... Often technicians will raise the temperature to keep a patient warm, but in effect, this often does not help --sometimes... but then should a technician be making such a judgement call especially if the patient runs a low BP? Should the tech first be checking with the RN? Just my thoughts.