Tablo

Duncan6 · Jun 8, 2023

@intergrativenurse Thanks for the info. The concept looks really cool, but I definitely have some concerns.

Krissi MacInnis Kelley · Dec 4, 2023

Using the Tablo at busy acute unit at large hospital.

Tablo - I really have gotten to where I cannot stand these machines! Many years in HD using Cobe, Baxter 500 & 1500, Fresenius and B Braun. I would take any of these "real" dialysis machines any day no matter how cumbersome. Ease of transport is my last concern! I cannot perform certain functions and way too automated so much so I get nervous when a problem arises with these machines.
Honestly these are truly home use. A trained monkey could push the buttons without alot of thought or background knowledge!
They are unreliable. Break down ALOT. The power cord is easily dislodged and electrical shorts are frequent melting the cord. We also had a ton of issues with the cartridges giving alot of trouble. They are slow! They go thru set up super automated steps and so time consuming.
There are alot of alarms that are truly false alarms.
Missing features like UF profiling and no heparin pump, no IV pole, etc

These probably are well suited for home use. Home. Use. Only.

In my honest estimation, they are very inappropriate for acute inpatient dialysis.

The cons far outweigh the pros.

They are not cheaper the long haul. Paying staff to be longer at their jobs working with these insufficient and time consuming machines gets expensive.

Krissi MacInnis Kelley · Dec 5, 2023

Adding to my post and Hey Duncan!

Well, I am totally not sure how to recirc a pt - say you to temp disconnect but not ending a tx, or maybe needle problem etc. I am not sure how this can be achieved. Maybe the pause button but I have not tried this yet.

You can only adjust fluid goal by increments of 50 - not 1 or 10 or 75. You get the idea.

I focus on UFR more than anything so it's important to me that it is completely adjustable.

I ALWAYS get an alarm for the red topped acid cap on the machine (similar idea to wands on dialysis machine) saying the cap is not on - can't recall exact verbiage - but always I get this message and I would go adjust the cap - now I just hit the continue on the screen and it goes to the next step - I don't even fool with the cap anymore. "False" alarm.

It does drain the extracorporeal system at end of treatment - something I know the B Braun does. So fluid goes in the saline bag. This bugs me; 1. If you have to set up system again for various reason(s), the saline bag looks like it might get so full as to burst. Really. I have seen this. And it's all clean really (no blood because you did not start); 2. It makes the red bag waste SO HEAVY for the poor individuals that take care of hospital waste - many of who are females - and well, it does not seem right to me. In the the adult unit at the end of the day, multiple systems in the red bags are weighing so heavy. Doesn't seem fair to the others. In the day, the spent saline (no blood) went down the drain and the extracorporeal system (blood) went in the red bag, and the EC system, used, does have some weight and is heavy enough on it's own.

So now, too, it seems a portion of the cartridge/cassette tubing is not "resting" as it should when placed in position for use, and one of our great nurses determined that this is potentially messing up the saline roller clamp, causing an alarm/failure state. We use a pen to push that little bit of tubing in proper position. It's small and when the cartridge is in the machine, it's very hard to see. Using our phones for light beam.

You know I did this yesterday, pushed that tubing back a little with a pen and it worked.

How does that look?...to the...patient...other staff members...families...shining our lights on the inside of machine, poking about on our knees or in squatting position to get a treatment going...

Duncan6 · Dec 8, 2023

@Krissi MacInnis Kelley

Thanks for your feedback. I have been with my rehab hosp since July, running treatments since September with Tablo. I have some annoyances and I do prefer a traditional HD machine, but it works for the rehab setting.

Did you get any kind of training? Some of your issues have fixes that they should have covered. My company is national and they sent me out to Las Vegas for a week of manager training to run the program and learn the machines. We have a national group of dialysis program managers and we ask each other questions all the time. I also have the Outset customer support for technical issues. I'm sorry you have had such a bad experience!

1. Melting cords should not be happening- can you talk to your facilities director or whoever is over maintenance? I have never had that happen.

2. I had machine issues for a while, but we've worked out the bugs. I do agree it's geared too much for home use- it takes away too much of my clinical judgment and technical know-how. I have to outsmart it and prevent any issues that might arise.

3. I don't mind the uf increments too much, in my setting being within 50ml is acceptable. Acutes may be a different story.

4. The acid cap alarm is weird- do you have a contract with Outset? They have a 24/7 customer support number/email and you should have a Field Service Specialist who can fix those issues.

5. You can recirc- just hit pause treatment, and it will ask if you want to end tx or take a break. Choose take a break and it should walk you through the steps. Just use a recirc cap and makes sure the saline line is open (it already should be) like any other machine. It will leave an option to resume treatment.

6. There is an option to skip the draining into the bag at the end. If you are in the step-by-step mode it will give you the option to drain or skip draining. Before checking it off, click on skip draining and you should be fine.

7. Not sure what the cartridge issue is- I've never had that problem. I know my clinical specialist from Outset recommended that once you push the cartridge into the green bars, use your hand to push the cartridge firmly into place- starting with the venous chamber area and then across finishing with the blood pump area. Maybe that will help?

And did they tell you that you can adjust the blood clot timer? You can change it from 3 minutes to 10 minutes to allow you time to work on needle issues, etc without feeling under the gun. That has helped save my sanity more than once.

If you have access to tablohub.com it has a lot of training videos on it that may help when issues arise, I believe it also has the user guide.

Hope this helps- best of luck to you!

Krissi MacInnis Kelley · Dec 9, 2023

Hi Duncan,

Thank you for taking the time to write! No, I did not receive any "formal" training and I am sure that I could have used some LOL! I will try the take a break for record when it arises. I am sure there are things on that machine that I could be using, but I will be honest, the reason is I am a bit cautious about pushing some of the prompts because I am not sure where that will take me. I am glad you told me that. We really do have melting cords because even the Outset guy told us they do not fit properly, do not make a proper contact. It's like their engineering for stuff is a bit off. IDK. Kinda the same thing with the cartridges. It sounds like the support is saying to you that once the cartridge is snapped into place, you press with your hand to further "seat" the cartridge? I will try that. I have tried to push the cartridge in with a slight upward pressure to see if this helped the roller clamp/tubing issue, but I don't think it really did anything to help. My theory is the cartridge lot was just bad, just off. Because we had so many issues.

Yes, I worked in rehab too, and I just think acutes needs more flexible features. And, similar to you, it's too automated and restricted for us professionals to happy with; strictly for use outside the home with basically lay persons. Recently, I wanted to recirc some heparin in the system prior to beginning treatment - (heparinize the extracorporeal system) and I was not at all sure how/if it was going to work in a Tablo - machine, that is the sort of thing outside the scope of a Tablo machine. Now, that day, trying to accomplish this, I got messages again about replace the cartridge and I had used the heparin in that set up. So now what? I cannot just go get another heparin. It needs a physician order, it must be signed off, it must be released by pharmacy...it's this sort of stuff that makes me mad about Tablo.

We do use the automated NS flush feature and we normally set it q30min 50mL -100 ml. I am not too familiar at all with the blood clot timer.

I will certainly keep your suggestions and advice and use them when need be. I did think of asking my manager for some Tablo training from Outset. They never told me there are training videos and a user guide! I will definitely seek those out!

Thank you so sincerely for all your tips! I really appreciate it!

Good luck to you as well and I hope your holiday season is merry and bright.

H.E.R. · Jan 4, 2024

Response to Diabo,RN, Duncan6, K.M.Kelley &........I am a RN 34yrs in Acute HD PD, Chronic HD PD.. Started as PCT/pt.care tech in chronic HD setting back in 1975. Have used/operated many machines...and feel as your input was important, would like to voice mine.

Tablo HD machines were created for "home HD". After using these HD machines in Acute setting for about a year, findings:

1-Tablo HD machine does offer quick set up w/ cartridge..BUT Tablo req'd pt.info input w/ ea change of pt., every step needing confirmation, hence: TIMELY

2-Inability to manipulate Tablo machine settings during Emergent HD Tx (w/ shut-downs, errors, etc) too timely for this true scenario; pt admit in CCU w/ serum potassium/K+ 9.. with all typical sx's..and cardiac arrest just itching to happen.

Rapid response w/ quick Fresenius HD machine set up and pt. lived.

2-Tablo blood pump cartridge with recall in 2023, cartridge would not sit into pump roller properly...error after error after error..in ACUTE/CCU setting.

3-Unable to make rapidly needed Table HD machine change of settings based on pt.change of status...errors, shut downs....making this machine a possible danger.

4- Numerous occasions with tear down of Tablo HD machine, following prompts of pulling yellow lever to release blood tubing from roller pump...blood pump roller stopping jamming tubing resulting in torn tubing and bloody NS..cleanup..hence: time.

5- Outset Tablo maintenance rep's installed timed: heat and chem disenfects..does not work in Acute setting and interfers with HD machines use. YES I do understand hep status, mach.use,etc.

Summary...Tablo HD machine not a safe machine for patient nor nursing staff in hospital based Acute settings... this nurses' experienced opinion.

The Tablo HD machine may work very well for home use. Hocost effectiveness.

pe this helps other nurses and/or administration with making the very critical decision on which HD machine to use in the Acute setting for patient and nurse safety and cost effectiveness.

NOTE: Tablo HD machine repair and maintenance cost. Tablo can talk a real good deal..An experienced personnel for " hosp.Dialysis services" is required for safety and cost effectiveness.

Krissi MacInnis Kelley · Jan 5, 2024

Hi H.E.R,

I think you are right on track with everything and I DO think Tablo can talk real good deal...

Just yesterday, I just had an error: .... ! Venous Drip Chamber Level

Message: We have to stop treatment for today

Really? These machines are completely ridiculous! Yes, this just scary in the acute setting. And you are spot on about the time they take. They cost a lot of time in many different ways.

So here goes another cartridge change and more time.

I read a home HD pt post - he stated he a troubles with Tablo "breaking" down all the time and he finally got rid of it and got a Nxstage. Stated he never had any machine issues since he made the change.

Thank you for your input and I appreciate your on target comments!

Duncan6 · Jan 5, 2024

I would agree with all your assessments of tablo. I had a tmp alarm the other day, I could have worked on it, it most likely just needed flushed and it did an end tx. So frustrating! Outset also pushes cross training. I have not been able to find any hd nurses, and the rehab hospital wants a dialysis nurse that will work the floor also. That didn't happen. No surprise. So they want me to train rehab nurses for dialysis. "Tablo says they can be trained in 4 hours". I don't think so. I have to explain repeatedly how much more there is to learn than just setting up a machine.

I've been trying to stay positive with the machine, and there are some things that are good about it, but more often than not I'm frustrated with it.

H.E.R. · Jan 5, 2024

I also tried very hard to see the good in the Tablo... too many issues I could have corrected safely. Tablo was created to prevent "home" HD pt's from hurting themselves.. understandable, but doesn't work in the acute setting where good nephrology nursing skills saves lives !! Hope to see other nurses and techs opinions/input. This teaches us. What a great career...go nurses!

Krissi MacInnis Kelley · Jan 10, 2024

Hey H.E.R.

I also tried to weigh the pluses and the minuses of the Tablo. But I always came back with very little plus in the acute setting. Now yesterday I had alarm messages about the jugs and conductivity. I changed out the 'straws' several time and I cleaned and reattached the red and blue caps, - no results - I changed out the whole system - and still no results. I had to go get another machine. Going to get another machine, I am thinking A. There won't be an extra because will always have some sitting in the back out of commission, or B. if there is another available, - will it work. Because you just don't know and lose faith in these machines. My CN is wondering what is taking SO long!??!!**$$%%??!!

So one of my nurse HD co worker, said well, he does appreciate that they are lighter to push, quieter than the Fresenius with millennium noisy with low water pressure -that's what he listed.)

I would rather deal with brute weight and some noise (or alot of noise and I HATE noise) - in order to have a machine I can manipulate in acute HD and rely on. Many years on Fresenius and I would say if maintained and PM'ED as manufacturer recommends, they are really very reliable and trouble free.

I don't even like the drain the dialyzer/system feature - I now use 'skip drain'. I can't think of one thing I like about tablo. Not. One.

Tablo was invented for home HD patients and I agree - they are very controlling and will protect a home patient. But that very essence of 'train a monkey' (push button - no critical thinking needed) sux for us professional HD nurses - who run into all sorts of situations and circumstances continually at WORK and we don't have time for monkey business (no pun intended).

Good HD nurses DO save lives everyday(!) and we need solid, reliable machines with features we can incorporate to give the best tx for that pt for that particular situation. Period.

Krissi MacInnis Kelley · Jan 10, 2024

Duncan,

Oh boy - 4 hours! Where do these people come from? Dialysis is a speciality and it takes both knowledge but most of all experience. You just have to do it - over and over in all different types of circumstances. There are just so many intricacies and so many reasons for so many different things that are going on in a treatment.

I worked with an awesome HD tech years ago - he told everybody: hey, we are not flipping hamburgers here (in regard to HD treatments).

So true.

H.E.R. · Jan 10, 2024

Yes Krissi..I agree.. I've worked with Fresenius machines and portable RO's. Give me a reliable machine that can meet the medical needs of a hospitalized ESRD pt over less noise anyday. Now to really address the core issue... Is the Acute Care management, ie: CEO'S, CFO's, Nursing Administrators, ETC REALLY aware of these issues.. and these Tablo HD machine issues can be and are a danger to the patient... which can be a legal (financial) liability to the institution. All it'll take is a knowledgeable pt and/or family member. Come on Administration "see" what we "know" and do the financially (for institution) and ethically right thing... tomorrow it might be one of any of our family members. Thanks Krissi and Duncan 6 for great input.

H.E.R.