Toileting during Dialysis

[Lynx25]

I am currently at a LTC facility, where several of our patients go out 3 times a week for outpatient dialysis.

Currently, the facilty we send them to does NOT toilet our patients while they are there. They refuse to assist someone from wheelchair to toilet, and incontient patients get their treatment cut off EARLY, and the transport company is called to take them back to us.

Is that typical?

Is that reasonable?

It's a four hour treatment, is it unreasonable that someone would have to pee?

[SE_BSN_RN, BSN]

The simple reason is that they are there for dialysis. Nothing else. The nurses don't have orders from the MD to check blood sugar or administer insulin. Nor do they likely keep insulin at the dialysis facility. They are at the dialysis center for a specific purpose- dialysis. Like I said above, it's often not possible for the staff to leave the dialysis center/floor to transfer patients and in some cases the policy at their facility does not allow them to transfer patients. If the patient were to be injured or fall during transfer the facility would be liable. Or the nurse/tech were to be injured while transferring, their workman's comp would not cover it.

That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.

[SE_BSN_RN, BSN]

You know, it just struck me that we're all complaining about the same thing---LACK OF STAFFING!! And why is that? Because every area of nursing is understaffed. And why is that?

You guessed it. MONEY. It's all about the Benjamins, not patient care, and certainly not nurses' ability to do their jobs with adequate supplies, staff, and time. We've got to know healthcare is in ruins when we can park somebody in a dialysis chair for 4 or 5 hours and let them sit in their own waste because there aren't sufficient staff members available to toilet them.

What a cluster-mug. It's stuff like this that turns nurses against each other. How much longer are we going to take it without fighting back?

YES YES YES!! Finally SOMEONE gets it! But one call to a state health department on a complaint about someone at dialysis sitting in their own waste for 4 hours may change the course of those dollars!

[Brookeylea]

It is not possible. As a tech or nurse you have a 3 patient assignment, with my clinic there vitals are taken every half hour and before and after tx. We dont let patients leave with a BP less than 100. There is no physical way we can change a patient. Like one of ours who doesn't move, she just lays there, our chairs that they sit in do not fit in the bathroom and we our facility does not have the necessary supplies to toilet the patiets, not to mention there is no time in the day!

[traumaRUs, MSN, APRN]

1. Changing pts or allowing them to use a urinal/bedpan while on dialysis is clearly an infection control issue - this is one big room, no privacy of any kind.

2. Using the cloths that are used to disinfect chair/equipment often contain bleach and they are surely not supposed to be used to clean an incontinent pt.

3. The bathrooms in dialysis units are very often not large enough to assist pts. Hoyer lifts will NOT fit in any of the bathrooms of the units where I go.

4. Comes down to quality of life: if the pt is incontinent, unable to indicate when they need to go (so that they can be disconnected and walk to the bathroom), maybe its time to have a "is this worth it" talk.

5. I work in some very rural clinics and a very large, inner city clinic. The NH will come occasionally to clean a pt up.

Other solutions: if Mom or Dad is incontinent and can't get to the bathroom by themselves, they need a family member or sitter provided by the NH to come and stay with them (in the waiting room). Many of my pts have sitters provided by the NH - I do have a high percentage of pts that are mentally ill and so cannot be expected to cooperate with dialysis unless someone sits by them and holds their hand and/or encourages them to sit still, not pull at their needles, etc..

[Double-Helix, BSN, RN]

That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.

One of the role of LTC is to assist the resident with ADL's. So of course it wouldn't fly for staff to say they wouldn't do something that is central to their function as a facility. MJB2010 wrote an excellent post about why it's not always possible to toilet a patient during dialysis.

I'm not sure what would be said to the patient, because I've never been in the situation. I do know that administration tends to make policies that don't seem very well thought out or practical in the real world. (Such as liability while transferring patients.) But if we wish to keep our jobs, these are things we need to adhere to- or escalate the situation to get the policy changed.

For example, when I was a CNA in LTC, our facility was attached to some independent living apartments. It wasn't an ALF, but the apartments had emergency call buttons in case someone were to fall or be sick or injured, etc. If an emergency button was pushed, the policy was to send a CNA from the facility to the apartment to check on the occupant. We were given a "kit" with a master key, gloves, some bandaids, a phone, and I don't remember what else.

Here's the kicker- we were not allowed by administration to do anything except call 911 and stay with the occupant if they needed help. We could not assist them up if they had fallen (understandable). We could not perform CPR, according to our policy, if we found a person in arrest. We were told that if we did these things while on the time clock, our actions would not be covered by our employer.

Fortunately, I never was faced with the situation where I found an occupant in serious distress or arrest. I'm not sure what I would have done. I'd like to think I would have performed CPR anyway, despite the facility's policy, and risked my job and possibly CNA certification. But that's a life or death situation for the victim. Would I risk my job at an outpatient dialysis unit to bring a 300lb, two-person assist patient to the bathroom?

[Natkat, BSN, MSN, RN]

The sad fact is that it is the policy at the dialysis clinic to not toilet patients. The clinic cannot spare staff to do this. The pace is frantic, staff is not authorized to do any lifting, it is an infection control issue and a safety issue. Neglect bordering on abuse? Okay. But go ahead and try to get either facility to go along with that mind set far enough to make sure there is enough staff available to take responsibility for it on either end and see what happens. As someone said very eloquently, we have been thrown into an impossible situation. Blaming, finger pointing and fighting will get us nowhere. We should join together and find ways of changing policies so that we can give better patient care.

[just keep swimming]

I can't figure out how to multiquote....sorry.

That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.

I agree! However I also have to agree that it can be a huge infection control risk not to mention that PCTs are not all trained in proper tranfers, etc.

2. Using the cloths that are used to disinfect chair/equipment often contain bleach and they are surely not supposed to be used to clean an incontinent pt.

In my clinc, the wipes do not contain any chemicals until they are put in bleach water. They are large, heavy duty, and very soft.

It is not possible. As a tech or nurse you have a 3 patient assignment, with my clinic there vitals are taken every half hour and before and after tx. We dont let patients leave with a BP less than 100. There is no physical way we can change a patient. Like one of ours who doesn't move, she just lays there, our chairs that they sit in do not fit in the bathroom and we our facility does not have the necessary supplies to toilet the patiets, not to mention there is no time in the day!

It is possible, it's called teamwork. Someone can cover you while you take a pt to the restroom.

Trauma,

While I completlely understand where you are coming from I just cannot do it. If someone throws up all over themselves don't the staff find a way to clean them up or change their shirt? I guess I see it as the same. Unfortunately, these patients do not always get to choose when they dc dialysis becuase it is their family that is holding on and has the power to make that decision. I know it's not right, and if I could change their minds I would, but that is a process that often takes a long time. I feel that even if they are at that point, we need to do our best to ensure quality of life until the end finally comes...but that's a topic for a different thread.

For those of you who say that it is not possible and there is not enough time in the day....I work in a 26 chair, inner city unit with many patients in wheelchairs. Our schedule is grueling and as a nurse, I have 24 pts with no other nurse and only 5 PCTs until 0900 everyday. After that, we add one more nurse and one more PCT. We find time. We work together to make time. We cannot enlist the help of family or LTC staff because we do not allow visitors (we had issues with drug deals in the unit and had to change to a no visitor policy).

I really do get where you all are coming from. The last thing you want when you are in the middle of turnover and have your schedule worked out so tight that a deviation of 3 minutes can through your day off, is someone asking to use the restroom. The only thing that keeps me from saying no is thinking about what I would want for myself and my family.

[lapoRtaN]

In our facility it is mainly an infection control issue. Most of our LTC pts are diapered. And it is rarely a problem. A few times we had the patients family come clean the patient. But we do not have the supplies on the unit because it put the other patients at risk for infection. So it is more involved than you think. It is not just lazy

Staff or whatever. LTC is where the patients live and reside. Of course the expectations are higher.

[PrettyLady87]

The simple reason is that they are there for dialysis. Nothing else. The nurses don't have orders from the MD to check blood sugar or administer insulin. Nor do they likely keep insulin at the dialysis facility. They are at the dialysis center for a specific purpose- dialysis. Like I said above, it's often not possible for the staff to leave the dialysis center/floor to transfer patients and in some cases the policy at their facility does not allow them to transfer patients. If the patient were to be injured or fall during transfer the facility would be liable. Or the nurse/tech were to be injured while transferring, their workman's comp would not cover it.

That statement is VERY TRUE!

I've worked in a dialysis facility for about 8 years and let me just say...if the patient is not ambulatory, then the patient MUST have an attendant with them during treatment for those simple things like bathroom assistance, and eating. Nurses CANNOT leave the floor while they are responsible for 5-8 other patients just for ONE patient to use the bathroom. Dialysis nurses are NOT responsible for insulin injections (and yes we do NOT have insulin at our facilities). Ignorant people, do the research on dialysis facilities BEFORE criticizing our line of work and our responsibilities as nurses and doctors. We cannot make ourselves liable for mishaps because we were treating conditions outside our vicinity.

[MJB2010]

There were also occasions where I was alone on the floor watching all the patients. Techs call out, water room needs tending to, lack of available staff, And guess how fun it is to code someone alone....... Not that fun. Luckily the emts and transportation people that brought the patients to and from dialysis were awesome. If they weren't so helpful. We never would have got by.

[SE_BSN_RN, BSN]

That statement is VERY TRUE!

I've worked in a dialysis facility for about 8 years and let me just say...if the patient is not ambulatory, then the patient MUST have an attendant with them during treatment for those simple things like bathroom assistance, and eating. Nurses CANNOT leave the floor while they are responsible for 5-8 other patients just for ONE patient to use the bathroom. Dialysis nurses are NOT responsible for insulin injections (and yes we do NOT have insulin at our facilities). Ignorant people, do the research on dialysis facilities BEFORE criticizing our line of work and our responsibilities as nurses and doctors. We cannot make ourselves liable for mishaps because we were treating conditions outside our vicinity.

Hmm, well, by calling us ignorant people for not doing research, I just find it ignorant that you can't take a person to the BATHROOM! Maybe you can help me understand why a nurse would not be able to take someone to the bathroom. If you are an RN, your job is to educate people. Try dong that before you criticize us for not knowing. It's people like you that scare all the new ones away. Geez.

[traumaRUs, MSN, APRN]

Again, dialysis equals doctor's office equals there is no staff to take pts to the bathroom.

This is not a hospital, not LTC, it is outpt where pts are expected to be self-sufficient.

Dialysis is not about keeping folks alive as long as possible, its about quality of life.

If these pts are not cognizant, it is necessary to have a family conference about continuing dialysis. And...no this should not take any length of time. This is the nephrologist or mid-levels responsibility!