RM23

With further investigation and speaking with other units, I am now wondering if this is not a case of microemboli. A collegue has suggested that in some patients, when heparin is dropped low to 500 from 1K, often there are microemboli. Has anyone had experience with this situation, now that I have given more information. It is baffling and might add the patient's BP usually when this occurs is wnl... There is another aspect that I have been thining about and that is of perhaps tiny air bubbles or aggregates therefore, perhaps rinsing dialyzer better? Then, again, anyone have any experience with prerinsed dialyzers?

SassyLassy: Your honesty in what is happening is appreciated and well respected. It is obvious that you have a sincere interest in the patient and shame on FMC and any other corporation that does not have the patient as their priority. In a case such as this, I would think the Nurse Educator/Inservice/Training RN would be there for you. I realize that they travel from clinic to clinic however, it is situations such as this that contribute to errors that can be deadly. It is hard place that we nurses are caught in when we want/need our jobs and then are not provided tools (education, training) that we need to deliver care. Dialysis is a speciality in and of itself and nurses need to be trained as it is the RN who is held accountable when errors occur as well as techs, LVN's looking towards the RN for direction. There are so many physiological aspects of dialysis that whoever is adminstering the treatment really needs to be aware of...ofcourse, to have an untrained tech or nurse not understand fully.. i.e. i overheard a tech say to a patient,,, experiencing chest pain.. 'oh steve (tech) told me that when someone has chest pain i can give oxygen;.. ofcourse not knowing why.. etc.. what if the patient had copd and was given too much oxygen??? goodness,,,, deadly. mistakes do happen

Are these units of which you speak one of the larger companies, i.e. Davita, FMC? To my knowledge there is suppose to be an intensive training prior to being put on the floor to go through, yet another training. Dialysis treatment is not something to take lightly and does, in fact, take alot of education about the machines and physiology. Many mistakes happen especially when staff are short, overworked, have one crisis and then are behind schedule, etc. A simple mistake i.e. taking too much fluid off can cause death, not to scare you, but does happen. There are so many aspects to delivering a treatment and the problem is that many companies train as they want to and do not give full information. A perfect example is that most, after t raining, techs and nurses, will say that bleeding is from too much heparin and will lower the dose without checking any other possible cause. Scarey, you betcha. Many staff only know a few reasons for situations occuring. Now with mostly techs doing the treatments, that is even scarier esp the new ones who are put to the wolves and become omnipotent.. lol... think they know it all.. be the best you can be.. educate yourself.. and go to the higher person and tell them u need to be adequately trained in order to be responsible for deliveyr of care in the unit. if you are the only RN you will be the one held accountable and you wll be the one overseeing the unit. What surprises me that if you are the only RN with little training, and, you will be the one who will take the fall if something happens while u are there,,,,this is a big problem... i bet u work for one of the larger companies lol.

Did you go to Mt Sinai Hospital in Florida by any chance? Are you near WHidby Island?

The BOrdlerline patient is very challenging to work with. Having worked with borderline patients (and staff) for many many years, I have just a few simple rules. 1. Leave your own baggage at home for if you don't the borderline will push your buttons and you will react. 2. All staff must have the same approach otherwise treatment does not work. Staff must be constant and consistent, to say the least, MUST BE CONSISTENT> 3. I have learned that when staff become upset, irritated, annoyed, angered with the borderline then someone needs to look at their own behavior, etc. Meaning, all staff have baggage, as I stated, that they bring with them to their jobs. Often identification comes into play. ALl this baggage, etc must be left outside the unit doors otherwise your buttons will be pushed. Remember the borderline is a mental health patient who we must remember probably had a terrible upbringing of which contributed to the now behaviors, etc. This person is going to need long term therapy to make a difference and the acute settin gis not going to cure just bandaid. I used to tell my staff.. "if the patient is pushing your buttons, making you angry, upset, etc. ask yourself what is happening that this patient has made me react the way I am? Do I react to schizophrenics or depressed patients the same as I am reacting to the Borderline? Good luck ladies and gentlemen...

As a note re the post of worker's compensation attorneys. If the attorney does w/c then they are paid directly by the state, usually. It is a set fee of either 12 or 15 %, not sure. Worker's compensation attorneys can not ask for money from you as it regulated by either federal or state laws. Contact a w/c attorney, dont let the hospital ignore the problem. Hospitals do not want to take responsibility and admit there was a mistake, etc. and they certainly do not want w/c cases as their insurance rates go up. Having been in many a meeting with risk managment, insurance ppl and hospital management, I know they will not accept responsiblity. BUT, yhou can file a w/c claim,, GO FOR IT and take care of yourself.. don't listen to them.. they are not out for your best interest, unfortunately that is the name of the game.. good luck, sorry you are having such a hard time.

Forgot, address of Renal Advantage, Inc is 115 east park drive, brentwood, TN 37027 615-661-1100

There is a Renal Advantage Inc. RAI. The CEO is Mike Klein. If this is the company that you are speaking about I can provide the following information. In July, the company announced plans to purchase 73 dialysis centers from Davita and Gambro. They may have also purchased your unit, if this is the company. THe CEO, Mike Klein sent a form letter to all patients assuring that there would be few, if any, changes in the care and told patients/families that ""the staff you now and trust will continue to serve you, and we seek to support them at all levels"". The principle differences are a new name, focused programs and efforts aimed to privde higher level of service. The patients will have to sign new forms, etc, provide information that was previously given to unit due to a new company purchasing unit. I would then assume that staff, due to new ownership, might have to reapply just as a means of paperwork... ie applications, etc. as with any company there are forms that employees must fill out, etc. I would not worry too much and realize this is the process. Hope this is helpful.

I am delighted to see all of you students washing your hands. There is a major problem, as you all are well aware, of health care associated infections (nosocomial). There, often, is a lack of full understanding of cross contamination. Recently, to share with you, I was at one of our local hospitals, known for their fine delivery of patient care. While visiting a friend, I noted a handwash dispenser readily available to anyone entering or leaving the patient room. You just had to swipe your hands under the dispenser nozzle as you either entered or left the patient room. While I was visiting, 6 staff entered and left the room. While in the room, touched the following: siderails, call bell, door knobs, table top/overbed table, sheets, television. Out of the 6, no one, I repeat NOT one staff person either washed their hands either while entering or leaving. Further observations noted were that they entered other patient rooms and proceeded to deliver patient care. This is frightening and how infections are spread. MRSA lives for hours and hours on environmental surfaces, along with other infectious agents. Thanks for washing your hands.

The multi billion dollar industry that dialysis now is, I would think they could equip their units with a new pump or two ! __________________ J'nette: The above statement is disturbing. I can only imagine the great frustration you must have when it is so very apparent that you are a dedicated RN who places the patient as 'priority'. The distressing part of this scenario is the profits coming in for the dialysis industries and why areas as you mention are not addressed. It is a safety issue! I have to admit that it certainly sounds like the big guys do not take into account many aspects of delivery of care. If a new piece of equipment would benefit the patient, then why does the clinic manager and/or physician/medical director, not request such equipment? WHen we know, for a fact, that the big guys within the dialysis industry, as well as those educators (training staff) are contributors to many guidelines, recommendations, etc i.e. CDC recommendations, then one has to ask why do some units not adhere to these guidelines, etc. Just throwing this out for feedback. Continue to be the great nurse you are, caring, concerned and being a patient advocate.

What you are saying is of some concern considering errors can kill on dialysis. In the new regulations, an RN to be a unit manager must have one year clinical and six months of dialysis maintenance. From what I hear you saying, this is pretty scarey that the RN does not have more than six weeks of dialysis considering all the potential problems that arise, as well as being the supervisor of techs. Very scarey.

I am interested in knowing about the training nurses and technicians (patient care) receive with various companies, i.e. DaVita, FMC, RCG. Do larger corporations focus on patient's 'really' being active in their treatment? Are family allowed to stay with patient's during treatment, if not when can they visit. Do all corporations teach self-cannulation? Thanks. Randy

Mary: Curious, to what extent to your techs-patient care receive training? Are you in a large unit?

i believe they have a webiste... critline.com but not sure. If you call the company their nurse educators are wonderful about helping and answering questions.

hh Are you all aware that the 'new' proposed language for ESRD regulations has been published to the Federal Register (2/4/05)).. This means that these proposed regs are open for public comment for ninety days, at which time, public comments are reviewed by those developing new regulations. I would suggest that anyone who is involved with dialysis/ESRD takes time to read these as they will affect staff and patients. The new regulations are not prescriptive as the existing ones are and are more outcome oriented. Additionally, many existing regs are being deleted. Now is the time to be heard if you have concerns about delivery of care. Please take time to read. put in your search engine 'federal register february 4, 2005',, (without quotes) then click onto CMS - ESRD and you can pull up.. 50 pages of good worthwhile reading..........