Transcript
Safer patient care through audit and practice development: Introduction of a Renal Dialysis Arteriovenous Fistula Care Bundle Tool Betty McManus, Anne Hamilton, Staff Education, Haemodialysis Unit, Belfast HSC Trust, N. Ireland
Renal dialysis fistula care bundle: Ongoing care Review tool Elements Observation
Hand hygiene
Cushion to support AVF arm
Inspect AVF and needle sites
Fistula cleansing pre scab removal
Scab removal when using Buttonhole technique
Fistula cleansing post scab removal
Needle insertion
Butterfly taping
All elements? (fills in automatically)
1 2 3 4 5 Total number of times an individual element was performed % When all elements of care were given
Elements Hand hygiene
Cushion under AVF arm Inspect needling sites Fistula Cleansing
Additional guidance • • • • • • • •
7 step Hand washing pre procedure/Alcohol Hand rub Personal protective equipment Use of alcohol Hand rub at key stages during procedure 7 step hand washing at end of procedure/ Alcohol Hand rub Stabilises arm and tissue Easier to maintain same entry of angle when using buttonhole technique Assess fistula F- feel, I- inspect, S- sound, T- taut, U- update, L- lying and standing BP, A- assistance
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Clean fistula site with clinell® wipe for 30 seconds and allow to air dry
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Scab removal (Buttonhole) Needle insertion
Background A patient dialysed by Arterio-Venous Fistula (AVF) developed a MRSA bacteraemia. A root cause analysis (RCA) proved inconclusive. However a RCA group was established to discuss and implement change.
Method A review group identified the current cleaning regime with clinell wipes as the key issue. This was not robust enough to penetrate AVF sites. We developed a new cleaning procedure using sterile single use Chloraprep Sepp 0.67mls applicators. (Properties recommended in the Epic 2 Guidelines)
Butterfly taping
• • • • •
Actions to be taken
Clean AVF sites with chloraprep ® applicator ( 0.67mls) using repeated up and down, back and forth strokes to each site ( clean for 30 seconds and allow to air dry)/ Variance Removal of full scab using pickers Cleansing fistula post scab removal Stretch skin around fistula site with thumb and forefinger (Buttonhole technique) Use of tourniquet Correct taping method to secure needles
Anne Hamilton, Betty McManus, Staff Education, Haemodialysis Unit, Belfast Trust
Initial audits showed that there were inconsistencies in practice • • • • • •
Visors not always used Tourniquet not always used Cushion to support arm not always used Skin not always cleaned for 30 seconds Skin not always dry before needle insertion Butterfly taping not always used.
Previous cleaning practice for buttonhole needling • Patient cleans AVF with alcohol gel • Clean AVF with a clinell wipe to sites • Remove scabs and clean again using 2 wipes for 30 seconds and allow to air dry (same wipes used for both sites) • Needle fistula . New cleaning regime for buttonhole needling • Patient cleans AVF with alcohol gel • Clean AVF with a clinell wipe to sites • Remove scabs and clean each puncture site with Chloraprep Sepp 0.67mls applicator for 30 seconds and allow to air dry • Needle fistula.
Chloraprep Sepp 0.67mls Applicator • Sterile single use glass ampoule • 2%Chlorhexidine in 70 % isopropyl alcohol • Rapidly kills broad spectrum skin dwelling micro-organisms • Effective against MRSA, VRE, C Diff • Reduces cross contamination. An ongoing care bundle exists for central venous catheters (CVC) but not for AVF yet 50% of our patients now have AVF. The recommended type of vascular access for Haemodialysis is an AVF and is recognised as the ‘Gold Standard’ ( McCann et al., 2009). We have developed a care bundle tool for AVF which uses the key elements of care. We incorporated additional guidance for each element to enable the auditor to successfully use the tool. We developed and delivered a training programme. Auditing commenced to ensure procedure adherence.
Further audits showed improvements in practice • • • • • •
Visors used by all staff Tourniquets used when required Cushion used to support AVF arm Skin cleansing - 30 seconds Skin dry before needle insertion Butterfly taping used by all staff.
Conclusion The audit tool has proved invaluable as minor discrepancies in practice were discovered. Auditing practice using this tool is a systematic approach of measuring and improving clinical care. We now audit the whole of the dialysis population. We have achieved 100% adherence to our AVF procedure with no infections. This has had a positive impact on staff and patients.
Key Points • The recommended type of access for Haemodialysis is an Arterio-Venous Fistula (AVF) and is recognised as the ‘Gold Standard’ • AVF is a surgical procedure to join an artery and a vein, usually in the arm. Over several months the vein enlarges allowing insertion of a large needle to provide vascular access for Haemodialysis. • The Department of Health recommends using 2% Chlorhexidine gluconate in 70% isopropyl alcohol to prepare the skin • The AVF audit tool is based on the Epic 2 Guidelines and is a systematic approach of measuring and improving clinical care.
