Dialysis Vascular Access
It is agreed that monitoring the access site is still the single most important precaution that one can take; however, there are other things that can be done to try to detect VND. In clinics, patients who are confused or agitated should be moved closer to the nurse’s station so they can be observed more closely. Taping the needle securely is also important. Using a chevron configuration to tape the needle down helps to secure it. The type of tape used may be a personal preference, but many agree that paper tape provides better adhesion. It is cautioned that if tabs are used on the ends of the tape, make sure they are small and doubled over completely. This could be a problem if the sticky side of the tape comes in contact with the patient’s clothing, covers or bed sheets and catches, pulling the needle out. There have even been reports that warmed blankets can cause some tape to warm enough to melt and lose its stickiness.
In 2007, Redsense Medical AB (Halmstad, Sweden) received US Food and Drug Administration (FDA) approval for their blood loss detection device. Nurses working in a Swedish county hospital in Halmstad had witnessed VNDs on a number of occasions. A few key people from the haemodialysis department discovered that these incidents were by no means unique and that existing alarm systems were renowned for not working. They got in touch with someone who specialised in developing medical devices. The Redsense blood loss detector was developed using a patented optical sensor to detect bleeding. The alarm reacts almost instantly to the first drop of blood. It does this with a loud audible alarm and a flashing red lamp on the alarm unit.21 Redsense remains the only FDA-approved device for the detection of VND.
Van Waeleghem et al. recommended that staff, patients and caregivers all should be aware of VND and the consequences.22
Not only should
the clinic staff be alert for VND, but the patient, if capable, should be watching their blood lines and venous needle. All patients should be assessed for their level of risk of VND and, if appropriate, an alarm device intended for monitoring VND should be used. Additional protection can be provided by devices intended to detect blood loss to the environment. It is suggested that blood lines should be looped loosely to allow movement of the patient. Staff-to-patient ratios should be adequate to allow routine monitoring of the vascular access during treatment.20
Consequences
The patient prognosis depends a great deal upon the severity of blood loss and if the VND was recognised early and treatment instituted in an emergent fashion. Patients who lose less than 40 % of their total blood volume and receive appropriate therapy have the best prognosis, whereas patients who lose over 40 % of their blood are more likely to suffer from permanent life-altering consequences such as stroke and other permanent disabilities. Instances of VND can be expensive, requiring emergent care, hospitalisation and associated expenses.
Cost of Venous Needle Dislodgement Several areas of cost should be examined. The first is the cost of medical care (figures are based on the cost of treatment in the US; conversions from US dollars to euros are based on the exchange rate at the time of writing).
Minor Venous Needle Dislodgement • Limited intervention in the form of blood transfusion: approximately US$620 per unit (€435.86).
150 • •
• An extra dose of Epogen®: approximately US$520 (€365.56; can be administered in the dialysis clinic.
• Total cost: approximately US$1,000 (€703).
Research published in April 2010 found that the cost of blood transfusions is significantly underestimated and establishes the true cost to be from US$522 (€366.96) to US$1,183 (€831.64) per unit.23
Serious Venous Needle Dislodgement • Hospitalisation for blood loss anaemia (for four days): approximately US$114,000 (€80,142) • One day of anaemia therapy includes Epogen, blood transfusion, iron and possibly plasma expanders or albumin, which works out to approximately US$28,500 (€20,035.50) per day.
•
Emergency room: may cost approximately US$15,000 (€10,545) or more, depending upon what is done. • For example, a patient in the emergency room for four hours received oxygen at 2 l/minute, a blood draw for routine panel and an abdominal computed tomography scan. The bill was US$16,483 (€11,587.54).
• The cost of intensive care unit hospitalization for one day ranges from approximately US$10,000–20,000 (€7,030–14,060) and upwards.
• The cost range is approximately US$114,000–$150,000 (€80,142–105,450) and upwards.
The above approximate costs were derived from internet research using US hospital websites that provide pricing information on emergency department charges, room charges (including intensive care), procedures and medications. Other costs include lost income from patients not having treatments, the cost of liability claims and the cost of brand image damage.
Liability
In the US, malpractice and wrongful death claims related to VND can be costly. Patients or surviving family members may seek legal counsel in instances when serious harm or even death is the result. Reasons for VND claims may include:
• •
the patient not being monitored closely, resulting in VND;
medical personnel silencing the pump alarm but not checking the access site, resulting in VND;
• blood lines being secured to the bed or chair and becoming caught, resulting in VND;
needles not being taped securely, allowing the needle to pull out, resulting in VND;
the clinic not using an available blood loss alarm; and • patient death.
Examples of Venous Needle Displacement Legal Cases Disconnection of Haemodialysis Venous Needle Resulting in Exsanguination of the Patient
In this case, the patient’s family claimed that the patient was confused and left unattended during the dialysis treatment. The venous needle became disconnected from the patient and the patient bled to death before anyone came to check on them. Analysis of the medical records failed to show any documentation after the patient was hooked up to the machine. This case was settled out of court hours before a jury trial was scheduled to begin. As part of the settlement, the dollar amount agreed to was confidential.
EUROPEAN NEPHROLOGY
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