During World War II, Dr. Willem Kolff revolutionized medical science by creating the first \u2018artificial kidney\u2019 from everyday items like juice cans, sausage casings and parts of an old washing machine. This wartime innovation laid the foundation for modern dialysis, a lifesaving treatment for kidney failure patients.<\/p>\n
Today, VA is making improvements to dialysis that could be just as revolutionary.<\/p>\n
\u201cOur population of Veterans with chronic and end-stage renal disease is growing all the time,\u201d said Rita Tassinari, Phoenix VA<\/a> specialty procedures nurse manager. \u201cDialysis is the lifesaving and life-changing procedure keeping those patients alive.\u201d<\/p>\n Dialysis patients often undergo treatment three times a week for three to four hours each session, sometimes for years while awaiting a transplant or other outcomes. With so much at stake, preventing complications is crucial.<\/p>\n In 2008, VA\u2019s National Center for Patient Safety (NCPS) analyzed clinical reports of bleeding incidents and found that bloodline disconnections were a leading cause of dialysis leaks. They issued a patient safety advisory and provided recommendations for the early detection and prevention of bloodline disconnections.<\/p>\n In 2010, a patient alert was also issued reinforcing the need to keep access sites visible and portraying the protective value of using Fresenius HemaClips where Fresenius bloodlines are employed.<\/p>\n \u201cWe focus on evidence-based solutions to address safety challenges specific to the Veteran population,\u201d explained Rabeh Hijazi, biomedical engineer.<\/p>\n These leaks can be dangerous, especially considering the hemodialysis pump runs 400-500 milliliters per minute.<\/p>\n To mitigate this risk, NCPS recommended facilities assess the fit of HemaClips with their existing catheters. \u201cIt is a plastic piece that acts as a lower lock,\u201d said Boby Jose, president of the Phoenix chapter of the American Nephrology Nurses Association.<\/p>\n Jose\u2019s advocacy for the HemaClip stems from a tragic experience earlier in his career where a patient lost their life due to the absence of such a safety measure. \u201cWe\u2019ve never had that happen here, but it is the kind of event that if it happens, it is almost always catastrophic.\u201d<\/p>\n Despite the HemaClip\u2019s potential, clinicians faced a hurdle. The manufacturer states it is intended only for Fresenius blood tubing. To address this limitation, NCPS collaborated with frontline clinicians and the Simulation Learning, Evaluation, Assessment, and Research Network (SimLEARN) to conduct a thorough evaluation as well as the application of the product on the different tubing.<\/p>\n \u201cSimulation provided us opportunities for real-time feedback and debriefing. This process helped us identify areas for improvement, reinforce effective practices and address any gaps in knowledge or skills,\u201d Hijazi added.<\/p>\n The team developed a simulation scenario to test the Fresenius HemaClips on four different manufacturers\u2019 tubing. \u201cWe tried countless ways to make it fail and it did not fail,\u201d Tassinari said. \u201cBy replicating realistic clinical scenarios, the simulation helped staff recognize and understand potential safety hazards and error-prone situations associated with Fresenius HemaClips and bloodlines. There is a lot of value in simulation. It allows you the opportunity to try things out before you try them on a live patient. It gives you permission to fail. It also allows you to try things that maybe you wouldn\u2019t necessarily be able to try with a patient.\u201d<\/p>\n Based on these simulation results, NCPS provided technical information to approximately 250 VA nephrologists to make informed decisions, impacting care for more than 6,000 outpatient Veterans and numerous inpatients requiring acute treatment.<\/p>\n For Tassinari, this work is of particular significance. \u201cMy father was a World War II Veteran who died when I was younger. Working here is the closest I have felt to my dad in such a long time.\u201d<\/p>\n To learn more about how simulation supports frontline staff and improves patient care, visit SimLEARN<\/a> and subscribe to its newsletter<\/a>.<\/p>\nAddressing a critical safety concern<\/h2>\n
Simulation: A key to safety innovation<\/h2>\n
A personal connection to service<\/h2>\n
![<\/a>HemaClips during dialysis<\/figcaption><\/figure>\n<\/div>\nIn 2008, VA\u2019s National Center for Patient Safety (NCPS) analyzed clinical reports of bleeding incidents and found that bloodline disconnections were a leading cause of dialysis leaks. They issued a patient safety advisory and provided recommendations for the early detection and prevention of bloodline disconnections.<\/p>\nIn 2010, a patient alert was also issued reinforcing the need to keep access sites visible and portraying the protective value of using Fresenius HemaClips where Fresenius bloodlines are employed.<\/p>\n\u201cWe focus on evidence-based solutions to address safety challenges specific to the Veteran population,\u201d explained Rabeh Hijazi, biomedical engineer.<\/p>\nThese leaks can be dangerous, especially considering the hemodialysis pump runs 400-500 milliliters per minute.<\/p>\nTo mitigate this risk, NCPS recommended facilities assess the fit of HemaClips with their existing catheters. \u201cIt is a plastic piece that acts as a lower lock,\u201d said Boby Jose, president of the Phoenix chapter of the American Nephrology Nurses Association.<\/p>\nJose\u2019s advocacy for the HemaClip stems from a tragic experience earlier in his career where a patient lost their life due to the absence of such a safety measure. \u201cWe\u2019ve never had that happen here, but it is the kind of event that if it happens, it is almost always catastrophic.\u201d<\/p>\nSimulation: A key to safety innovation<\/h2>\nDespite the HemaClip\u2019s potential, clinicians faced a hurdle. The manufacturer states it is intended only for Fresenius blood tubing. To address this limitation, NCPS collaborated with frontline clinicians and the Simulation Learning, Evaluation, Assessment, and Research Network (SimLEARN) to conduct a thorough evaluation as well as the application of the product on the different tubing.<\/p>\n\u201cSimulation provided us opportunities for real-time feedback and debriefing. This process helped us identify areas for improvement, reinforce effective practices and address any gaps in knowledge or skills,\u201d Hijazi added.<\/p>\nThe team developed a simulation scenario to test the Fresenius HemaClips on four different manufacturers\u2019 tubing. \u201cWe tried countless ways to make it fail and it did not fail,\u201d Tassinari said. \u201cBy replicating realistic clinical scenarios, the simulation helped staff recognize and understand potential safety hazards and error-prone situations associated with Fresenius HemaClips and bloodlines. There is a lot of value in simulation. It allows you the opportunity to try things out before you try them on a live patient. It gives you permission to fail. It also allows you to try things that maybe you wouldn\u2019t necessarily be able to try with a patient.\u201d<\/p>\nBased on these simulation results, NCPS provided technical information to approximately 250 VA nephrologists to make informed decisions, impacting care for more than 6,000 outpatient Veterans and numerous inpatients requiring acute treatment.<\/p>\nA personal connection to service<\/h2>\nFor Tassinari, this work is of particular significance. \u201cMy father was a World War II Veteran who died when I was younger. Working here is the closest I have felt to my dad in such a long time.\u201d<\/p>\nTo learn more about how simulation supports frontline staff and improves patient care, visit SimLEARN<\/a> and subscribe to its newsletter<\/a>.<\/p>\nTo learn more about the National Center for Patient Safety, visit the VHA National Center for Patient Safety<\/a>.<\/p>\nDisclaimer of endorsement<\/h2>\nReference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government.<\/p>\n","protected":false},"excerpt":{"rendered":"During World War II, Dr. Willem Kolff revolutionized medical science by creating the first \u2018artificial kidney\u2019 from everyday items like juice cans, sausage casings and parts of an old washing machine. This wartime innovation laid the foundation for modern dialysis, a lifesaving treatment for kidney failure patients. Today, VA is making improvements to dialysis that […]<\/p>\n","protected":false},"author":8,"featured_media":321958,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[257,5,1306],"tags":[],"class_list":["post-321956","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-dialysis","category-health","category-visn-22"],"_links":{"self":[{"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/posts\/321956","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=321956"}],"version-history":[{"count":3,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/posts\/321956\/revisions"}],"predecessor-version":[{"id":321962,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/posts\/321956\/revisions\/321962"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=\/wp\/v2\/media\/321958"}],"wp:attachment":[{"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=321956"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=321956"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/adn.monetizemail.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=321956"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}](\"https:\/\/adn.monetizemail.com\/wp-content\/uploads\/2024\/11\/Hema-Clip-in-arm_r1-2.jpg\"){kind=link}