Q&A: Joint Commission Focuses on Dialysis

This member-only article appears in the September issue of Patient Safety Monitor Journal.

In patient safety, when hospital accreditors take an interest in something, you should as well. That is why you should be paying extra attention to your dialysis procedures. Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD), and surveyors have been cracking down on compliance.

Jennifer Cowel, RN, MHSA, is president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, is an associate of the company. They are both Joint Commission alumni and spoke with PSMJ about maintaining a safe dialysis program.

The following Q&A has been lightly edited for clarity.

Q: What are the top dialysis problems being identified? Where are they landing on the SAFER matrix?
Cowel: Regarding where the findings are being scored, we are not seeing red, or high risk, scored for the dialysis findings. In recent months, The Joint Commission seems to be carefully limiting those issues that land in the high-risk category.
We are seeing the dialysis in the yellow and orange bands. We do caution that you should not minimize the impact of those yellow and orange findings. We have seen hospitals with very few high-risk findings result in an adverse outcome.
The few high-risk findings noted are related to patient safety where the patient’s graft, fistula, or dialysis site is not openly visible during the treatment, and infection control where poor PPE or no PPE is worn as required, as well as not following isolation practices when required.

We have seen numerous findings in dialysis in recent months including the calibration of the meter used to test pH/conductivity not tested per the manufacturer instructions for use (IFU). The manufacturer IFU for the meter requires this be performed at least monthly by a designated technician.

Good: [The above] depends upon the meter used. For one meter, the calibration is required to be tested each day of use prior to testing the dialysis machine conductivity. I would say that it depends upon the meter being used and staff must follow their policies and procedures as well as manufacturer’s IFUs.

Editor’s note: The conversation then pivoted to other common findings, as Cowel lists below.
Cowel: In multiple reports we have seen the lack of an eyewash station in dialysis scored. Staff use bleach in the water treatment room of the dialysis unit, but there is no eyewash accessible as required. When bleaching of a portable machine is done in a patient room, the lack of an eyewash is scored.

When a patient’s catheter was locked with high-concentration heparin, the hospital policy required a special check of the heparin, per the hospital’s policy on high-risk medications, but this was not done in dialysis.

We have seen an increased focus on medications administered during or before dialysis treatment. They are expecting both a proper order, but also we have seen the dialysis nurse transport multi-dose vials of heparin, but these should not be considered multi-dose vials because they are used in the patient care setting. They should be considered [a single-dose vial].

When hospital policy requires nurses to evaluate the vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, the record should document that this was done.

The record for a new dialysis patient had no indication that consent was received, no record or a conversation about risks and benefits. Some hospitals have also been accepting the consent obtained at the patient’s chronic dialysis unit as the consent to provide inpatient dialysis. The hospital must obtain a consent for hemodialysis provided to any patient, whether it is acute short-term dialysis or to a chronic patient in the inpatient setting. The length of time the consent is good for should be based on hospital policies.

In the dialysis unit, the surveyors are reviewing the orders and verifying the medications or fluids administered match the order. They score when the nurse administered 100 cc normal saline (NS) instead of 200 cc NS per the protocol order set for hypotension during dialysis.

Good: There is also a new monitor used by a dialysis company that staff were not trained to use or [tested] on. This is an extremely unsafe situation and would definitely be scored as high risk on the matrix.

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