RESIDUAL STRIP TESTING

Purpose:

To ensure the level of disinfection present in the dialyzer in preparation for its next use.

Scope:

This policy shall be properly disseminated to all staff and be strictly observed in the unit.

Policy:

After completion of the rinse procedure, the dialyzer should be tested to determine the level of the
residual chemical present.

1. After rinsing the dialyzer for 10 minutes, use a 3cc syringe and small- borne needle to draw a 1cc
sample of solution from the extracorporeal circuit using the venous injection site.

The venous and arterial lines may be separated if poorly clamped and the blood pump is
stopped, but a false positive may occur from Pericidin residue on the first connector using this
method.

2. Place several drops from the syringe on the pad of the test strip. After 2 second, shake off the
excess. If no color is immediately apparent on the test strip, there is less than 1 part per million
(ppm) of Pericidin remaining and no further rinsing is required. Refer to the product insert for
additional information on the use of test strips.

3. If the result is higher than 3 ppm, further rinsing is necessary. If the residual Pericidin is
acceptable but the patient is not ready to begin dialysis, continue recirculating the dialyzer at
the blood pump settings of 100 ml per minute and zero negative pressure, to conserve saline,
until the patient is ready to be connected to the dialysis machine.
 QUALITY ASSURANCE PROGRAM

Purpose:

To provide the dialysis staff some guidelines to be strictly followed that would help in the avoidance of
many adverse events

Scope:

This policy shall be properly disseminated to concerned persons and shall be strictly observe in the
clinic.

Activities

 Strict observance of universal precautions

 Patient monitoring

 Monthly chemistries to include:

a. Complete blood count
b. Blood Urea Nitrogen
c. Serum Creatinine
d. Ionized Calcium
e. Inorganic Phosphorus
 Serum albumin to assess nutrition every two (2) months
 Hepatitis B and Hepatitis C every six (6) months
 Monthly Urea Reduction Ratio and KT/V for dialysis adequacy
 Lipid profile every six (6) months

 Dialysis clinic monitoring

 Policies on:
a. Procedures
b. Management of complications during hemodialysis
1. Hypotension
2. Chills
3. Chest pain
 Preventive Maintenance program for machines and water treatment system

 Follow the prescribed standard and guidelines of care

PREVENTION OF HEPATITIS INFECTION

Purpose
 This precautionary measures will prevent b transmission of blood borne viruses and
bacterial pathogens in dialysis setting.
 To protect patients and staff from unnecessary exposure to a potentially contaminated
environment and to prevent cross- infection and secondary infections.

Scope

All dialysis staff is requested to know and strictly follow this policy. Newly hired dialysis staff
shall be properly oriented with this policy before rendering duty. Regular yearly reorientation
shall also be conducted to ensure understanding and compliance.

Measures

 Reducing the number of blood transfusion to the minimum compatible patients well
being.
 Improving the general conditions within the unit and avoidance of overcrowding.
 Restricting the use of non disposable equipment to individual patients and the use of
disposable equipments where possible.
 The observance of staff and patients to the standard precautions set by the unit against
cross infection:
 Hand- washing is the most important procedure for the prevention of infections.
 Needle prick protection- Do not recap contaminated needles which were used
to inject medicine directly to patient or to venous bloodlines. Disposed of
contaminated needles immediately in nearby impenetrable container.
 Gloves-Staffs that are directly in contact with patients are required to wear
gloves and to use separate gloves for every patient.
 Machine disinfection-external surface of the dialysis machine must be clean
with hypochlorite solution. All visible blood spills or any traces must be wiped
off immediately.
 Laundry- Handle all used linens soiled with blood and body secretions as
potentially infectious. Used lines are carefully collected and placed into a leak
proof bag and brought out of the unit to the laundry area.
 Blood spill- All spilled blood should be meticulously removed and wiped off
immediately with gloved hands using Sodium Hypochlorite solution.
 Screening- All personnel assigned to the unit must be screened initially and then
annually for HBsAg , HBsAb, and hepatitis C virus,
 Hemodialysis patients must have an HbsAg drawn prior to initiation of dialysis
and must be monitored every 6 months.
 Vaccination- If the result are negative, the staff member will be given hepatitis B
vaccine per hospital policy.
 Environment- The environment shall be thoroughly cleaned between each
treatment and as necessary for spills of blood and body fluids.
 Equipments and Supplies- All disposable equipment that has come into contact
with blood or blood products will be considered infectious waste and disposed
of by gloved personnel.
HOUSEKEEPING:
PURPOSE: To maintain cleanliness inside the Dialysis unit

SCOPE: This policy shall be properly Implemented and shall be strictly observed

POLICY:

1. There are sufficient personnel to ensure comfort & protection of the patient and relatives.
2. The entire clinic is maintained at all times in a clean and Sanitary conditions and is free from
accumulation of dirt & rubbish, is well ventilated & free from all foul, state and musty odour.
3. Walls & ceiling with all fitting lights, fans are kept clean & refinished as often as necessary.
4. Mopping , sweeping & dusting is done in a sanitary manner.
5. Accumulated waste materials is removed periodically.
6. After discharged of the patient the bed, chair bedding & room furnishing used by the patient are
thoroughly cleaned.
7. Adequate provision are made each nursing unit & special service for the storage of Janitor
supplies & equipment.
8. Methods & procedures should be instructed to prevent entrance & harbouring of rodents of
insects & vermin.

ACTION:

 Dusting done every Monday morning before starting hemodialysis session

 Routine cleaning task done every after hemodialysis session
 General cleaning of the units done monthly every second Wednesday of the Month.
 PEST & VERMIN CONTROL
POLICY:

1. Each facilities daily sanitation inspection of housing & work areas shall include cheking of the
presence of pest or vermin.
2. Deficiencies in the pest & vermin control program shall be reported to the Sanitation officer or
other designated staff and corrective action taken. A copy of deficiency report & subsequent
pest controls services shall be maintained by the chief administrative officer or designee.
3. When not in use, materials, devices or substance used for eradication on control of pestinence
or vermin shall be stored in appropriate containers. Secured in an area inaccessible to
unauthorized persons.
4. Central officer Staff may be assigned to monitor the facility pest & vermin control program on
an annual basis & shall report any significant findings to the designee.
5. Pest control services shall not allowed to use pest control products that endanger health or
safety of persons in the facility.
6. Documentation of the product use shall be kept on file by the facility business officer.
7. Items that have been contaminated damaged or destroyed as a result of pest or vermin shall be
disposed appropriately.

ACTION:

 Daily inspection of facility clothing, beddings & linens are inspected before and after
hemodialysis session for signs of parasites & other pestinence which especially when complains
are received.
  Appropriate corrective action taken to disinfect & eliminate such problems.
 Educating, recognizing & reporting regarding the presence of pests.
 Find and eliminate sources of moisture in various plumbing areas such as leaky pipes and
clogged drains.

WATER TREATMENT FOR HEMODIALYSIS

PURPOSE:

To ensure that water for hemodialysis are treated accordingly to maintain a continuous water supply
that is biologically and chemically compatible according to its use.

POLICY:

 Water treatment system and dialysis machines are decontaminated and disinfected periodically
or whenever necessary.
 Major Preventive maintenance shall be done at least monthly or as need arises and must be
recorded.
 Periodic water analysis shall be done as follows:

 HPC less than 200 CFU/ml

 Fecal coliform less than 1.1 MPN/100ml
 Analysis of 20 chemicals every six (6) months
 TDS of product water are performed, monitored and recorded weekly

ACTION:

 When test results exceed AAMI water standard limits, unit shall temporarily cease operation
until repeat test of the falling parameter complies with the given standard.
 Corrective actions shall be undertaken in the area of suspected cause that may include:
 Cleaning and Disinfection/ replacement of R.O. membranes
 Distribution of the product water distribution system, including the entire loop
 Disinfection of the water hose on the dialysis machine
 Unit will perform the above corrective actions and patients will be notified of the situation as
mandated by DOH
 Vina Ilagan-Vasquez

Nephrologist

Licence #: 76143

Policies on Disinfection, Cleanliness, Maintenance

A. DIALYSIS MACHINE AND ARTIFICIAL KIDNEY SET

1. After the Ist and 2nd session of hemodialysis , all machine should be
properly rinsed and disinfected according to the machine's operating manual
2. In cases of ( +) Hepatitis B and C patient , the machine should be disinfected
with chlorox and formalin
3. Parts of dialysis machine are cleansed with any detergent soap and water
except for the sensor for air detection.
4. Artificial kidney should be labelled with patient's name and date. The set that
is intended for re-use must be preserved with formalin 6% in one liter of
Plain NSS.
5. Refrigerate the artificial kidney set, which is highly recommended to control
growth of bacteria inside the artificial kidney. After reprocessing the
artificial kidney set , it should be refrigerated for storage
B. UNIT
1. Cleanliness of the unit must be observed
 Changing of linens and disinfecting the mattress every after the
session
 Lavatory and dining table must be cleaned at all times
 Spills and blood leakage should be wiped immediately with chlorox
 Daily maintenance is to be observed with close supervision to all
janitorial personnel assigned in the area.
 Airconditioner filter must be cleaned twice a week
 Proper implementation of waste disposal scheme as being formulated
by the hospital waste management committee
 General cleaning of the unit should be done monthly every second
Wednesday of the month
PATIENT REFERRAL/ TRANSFER TO ANOTHER FACILITY
EMERGENCY HEMODIALYSIS REFERRAL FROM ONE FACILITY TO ANOTHER FACILITY

1. Assess the patient and stabilize as resources and skills are available.
2. Identify the facility where the patients needs to be referred .
3. Inform the patient/ next to kin regarding referral to another facility.
4. Contact referring facility: Notify the doctor in the Nephrology department regarding the
patient’s condition and get an approval to transfer.
5. For in- patient transfer/referral requires the accepting hospital to have an available bed, and
acceptance by a physician who has admitting privileges
6. A designated hospital hotline shall be made accessible for the purpose of patient referral
7. Prepare for the Transfer. Ambulance, Equipments & Medications.
8. Qualified medical/paramedical personnel must be present in the ambulance when transferring
the patient.
9. Ensure continuity of care and patient safety during the transfer process.

NON EMERGENCY REFERRAL

1. Prompt and appropriate levels of health care provided.

2. Maintain Continuity of care from a primary health care centre to the hospital vice versa.
3. Mutual respect and professionalism must be observed in the process of transfer of patients.
4. Primary Health Care Centre must be aware about the service, contact details and the distance
between hospital facilities and the centre
5. For urgent referrals, patient must be accompanied by the qualified medical staff and
immediately transported to the hospital while verbal referral between centre is being
established.
6. Proper documentation of the transfer process will serve as reference for monitoring, evaluation
and future plans for improvement of the referral system.
7. The appointment date of the patient needing referral can be secured directly by referring facility
from the receiving hospital. The patient will be notified by the referring facility for the
appointment dates.
 8. The receiving facility must send a complete feedback form to the referring facility after the
referral is completed.

IN- PATIENT HEMODIALYSIS PATIENT REFERRAL FROM ONE FACILITY TO ANOTHER

1. The referring facility must contact the receiving facility to find the status of bed availability and
receive an approval before the transfer is made
2. Prepare all documentation, includes: latest hemodialysis record, hepatitis b profile, latest
laboratory result,& referral letter from nephrologist
3. Organize ambulance service for transfer.

Vina Ilagan- Vasquez

Nephrologist
License #: 76143

MANAGEMENT OF COMPLICATIONS OF CHRONIC HEMODIALYSIS THERAPHY

 HYPOTENSION

CAUSE:

 Excessive UF below the Patient’s dry weight

 Large interdialytic weight gain or short treatment that would result in compelling one to remove
a large amount of fluid within a short period of time.
 Due to lack of vasoconstriction, Maintain hgb at 11-12 epo or blood transfussion
 Ingestion of intradialytic foods in hypotension prone patients. Foods should be avoided 2 hours
prior to HD

MANAGEMENT:

1. Place in Trendelenburg Position.

2. May need nasal oxygen to provide increased myocardial oxygen for a stronger cardiac output.
3. 0.9% saline, glucose (D50,50), mannitol, albumin, Hypertonic saline (probably more useful than
0.9% if patients also has cramps- otherwise not available locally and probably also quiet
expensive)
4. Slow blood flow rate- useful only in settings where plate dialyzers are used, Qb should be
slowed only as last resort if the above measures do not improve a patiet’s blood pressure. Avoid
lowering the Qb. This is because as long as Qb is low, the patient remains underdialyzed.

 MUSCLE CRAMPS DURING HD

CAUSE:
  Unkown
 Commonly associated with hypotension( although many patients with normal BP will experience
cramps)
 Excessive u.f. to below dry weight
 Use of low sodium dialysis bath

MANAGEMENT:

1. Hypertonic saline or glucose ( better because no post dialysis thirst)

2. “High sodium” ( 145 meq/L) HD
3. Vitamin e 400 i.u at bed time is now drug of choice in preventing chronic, repetitive episodes of
leg cramps.
4. Quinine- previous med. Before Vit. E
5. Carnitine Supplementation
6. Stretching exercises.

 NAUSEA& VOMITING

CAUSE:

 Hypotension
 Manifestation of disequilibrium syndrome
 Adverse reaction to dialyzer
 Other non dialysis cause e.g. hypercalcemia.

MANAGEMENT

1. Treatment according to cause.

 HEADACHE

CAUSE:

 Unkown, but common during HD

 May be a subtle sign of disequilibrium syndrome
 IN coffee drinkers, may be assign of coffee withdrawal because HD acutely reduces caffeine
concentration in patient’s blood.

MANAGEMENT

1. May try decreasing blood flow rate during early part of HD

 2. May try decreasing sodium analysis.

 CHEST & BACK PAIN

CAUSE:

 Mild Chest pain often associated with mild back pain in 1%-4% treatment and cause is
UNKOWN. Switching to another dialysis membrane might help Angina Pectoris is common, as
well.

 ITCHING

CAUSE:

 Low grade hypersensitivity reaction to dialyzer or blood circuit components if accompanied by a

minor allergy symptoms.
 Elevated Ca X P product
 Unkown, just becomes more noticeable as patient is forced to sit for prolonged period of time in
dialysis chair.

MANAGEMENT

1. Dipenhydramine, Capsaicin cream( effective only temporarily)

2. Lowering the phosphorous
3. More Hemodialysis
4. Moisturize & lubricate skin with emollients
5. U.V. therapy

 DYSEQUILIBRIUM SYNDROME

CAUSE:

 May be from too energetic HD of a patient during the first few time of treatment.
 Too much extraction of fluid from brain cells when a vigorous HD removes large amounts of
plasma solutes (theory)
 Others feel it may too rapid change in CSF pH. Symptoms range from the mild (n/v, headache) to
the severe (seizures, obtundation and coma).

MANAGEMENT

1. Can be prevented by use of:

  Low Sodium bath
 Use of low-flux &low efficiency dialyzer
 Reducing HD time
2. In chronic setting use of at least a 140 meq/l sodium bath, glucose in the bath and or/ sodium
gradient HD.

TRANSFER/ REFERRAL OF PATIENT’S WITH HEPATITIS

PURPOSE:

To Provide dialysis staff referring guidelines to be followed in transferring patients with positive
Hepatitis result to prevent contamination between patients and dialysis staff.

SCOPE:

Shall be properly disseminated to concerned persons and shall be strictly observed.

POLICY:

 Patients with positive HBsAg result will be asked if willing to be referred or transfer to other
dialysis clinic where there are machines dedicated to patient with such cases.
 Dialysis staff will inquire to other dialysis clinic for the availability of slots for the transferring
patient.
 Will provide referral letter from the attending Nephrologists for reference.
 Will provide:
 Clinical Abstract
 Photocopies of recent laboratory examinations: CBC, POTASSUM, CREATININE.
 Will provide ambulance if requested by the patients.
 Will follow up patient at present dialysis center.
 Vina- Ilagan Vasquez MD

Nephrologist

License # 76143

BACTERIOLOGICAL TEST
POLICY:

 Testing should be performed monthly.

 Monthly results of microbiological water analysis from 3 sampling points namely:
1. Raw water
2. Product water
3. Point of use
Requirements:
 HPC< 200 CFU/ml
 Fecal Coliform< 1.1 MPN/ 100ml
 The sample ports use n to collect the samples must be rinsed for at least 1
minute at normal pressure and flow rate before drawing the sample.
 Sample should be collect using a clean catch technique to minimize potential contamination of
the sample.
 Bleach or other disinfectant should not be used.

ACTION

 When the test result is above normal the R.O machine membrane should be clean and disinfect
 Disinfection of the product water distribution system including the entire loop should be done.
  Collect sample and sent to accredited laboratory for testing of water sample.

PHYSICAL/ CHEMICAL TEST

POLICY:

 Periodic water analysis for chemical test at point of use shall be done before the initial
operation of hemodialysis centre and six (6) months thereafter.
 Laboratory result of chemical analysis done by DOH recognized water testing laboratory for
dialysis water
 Corrective measures shall be undertaken in the area of the suspected cause for result wich
exceed AAMI water standard limit.

ACTION:

 HDC shall stop operating until corrective actions were taken and water analysis results are
within AAMI standards
 Record of maintenance/ corrective action done
 Repeat testing of affected parameter.

HEMODIALYSIS TREATMENT PROTOCOL

Ensure that all current orders are being consistently follow: ex. Treatment time, blood flow rate
(BFR) Dialysate flow rate (DFR), frequency of dialysis, reuse guidelines if used etc.
If the current orders are consistently being followed address the following parameters in order
listed to improve the adequacy of hemodialysis and maintain the UREA REDUCTION
RATE(URR)>65% or KTV/ 1.2 Implement new dialysis treatment prescription order the changes
with the patient’s next dialysis treatment.
 Increase BFR:
a. If tolerated by the vascular access, increase the BFR 150ml/min increment to
achieve the target URR and KT/V.
b. Maximum BFR= 500 ml/min for external vascular access and the manufacturer’s
maximum allowed BFR< if using a catheter
 Increased DFR:
a. If increasing blood flow rate goal does not achieve goal, increase the dialysate
flow by 100ml/min increments as needed to reach adequacy of target goals.
b. Maximum DFR= 800ml/min or highest flow allowable by the equipment.
If increasing BFR and DFR does not achieve target, ask the attending physician about prescribing
a dialyzer with higher Urea clearance (KOA).
Treatment time –if the URR & KT/v remain below the target, increase the dialysis treatment
time by 15 minute increments as needed to achieve target.
Notes on vascular access in relation to adequacy of dialysis.
 Encourage all patients to have an (AVF) or AV graft (AVG) placed (versus catheter)
 Notify the physician for each treatment that the vascular access is unable to deliver the
prescribed BFR. Monitor venous pressure for signs of excessive pressure during dialysis.
Decreased BFR as needed to maintain venous pressure at less than half of the blood
flow rate. Notify the physician if the VP is consistently greater than half of the BFR.
 Obtain order to draw vascular access recirculation studies if the URR and or KT/V
continue to be below target after implementing new treatment prescription orders.
Draw monthly URR or KT/V, using pre and post BUN samples.
Use K/DOQI recommended Slow pump or stop pump technique for drawing possible BUN
sample.
Review URR or KY/V lab within 3 days of the facility receiving the initial report from the lab
initiate new dialysis prescription order changes with the patient’s next dialysis treatment for all
patients with URR or KT/V result not meeting goal. Repeat KT/V lab sample when new dialysis
treatment order are implemented or results appear incorrect. Repeat incorrect labs on patients
next treatment day.
Notify the physician if repeated URR or KT/v result continue to be inadequate.
Communicate all dialysis adequacy issues to the charge Nurse
Re educate the patients requesting to discontinue dialysis treatment early. Document efforts in
the medical record. Encourage patients to complete entire dialysis treatment time. If a patient
insist on signing off dialysis early, have him/her sign the HAMA and notify the nurse in charge.
Review the facility adequacy result at the monthly CQI/QAPI meetings. Initiate a facility
adequacy improvement plan in the facility’s overall URR or KT/V results show that <96% of
patients are receiving adequate treatment.
Review the adequacy improvement monthly, document evaluation of the adequacy plan and
implement a new strategies and action steps as needed to replace those that are ineffective.
Develop a Patient Specific action plan of care to address barriers as issues impacting adequacy
result for all patients who do not meet adequacy goals. Review the plan of care with the patient
and all the patient’s care.
EQUIPMENT MAINTENANCE SCHEDULE
POLICY: Preventive Monitoring of equipments should be done every Tuesday and Friday

SCOPE: This Policy shall be properly disseminated to all staff and be strictly observed in the unit

EQUIPMENT WORK DONE REMARKS DATE SIGNED

SUCTION CHEKED Functioning well 2/3/15

MACHINE CHEKED Functioning well 2/6/15
CHEKED Functioning well 2/10/15
CHEKED Functioning well 2/13/15
CHEKED Functioning well 2/17/15
CHEKED Functioning well 2/20/15
CHEKED Functioning well 2/24/15
CHEKED Functioning well 2/27/15

NEBULIZER CHEKED Functioning well 2/3/15

CHEKED Functioning well 2/6/25
CHEKED Functioning well 2/10/15
CHEKED Functioning well 2/13/15
CHEKED Functioning well 2/17/15
CHEKED Functioning well 2/20/15
CHEKED Functioning well 2/24/15
 CHEKED Functioning well 2/27/15

ECG CHEKED Functioning well 2/3/15

MACHINE CHEKED Functioning well 2/6/15
CHEKED Functioning well 2/10/15
CHEKED Functioning well 2/13/15
CHEKED Functioning well 2/17/15
CHEKED Functioning well 2/20/15
CHEKED Functioning well 2/24/15
CHEKED Functioning well 2/27/15
DEFIBRILATOR CHEKED Functioning well 2/3/15
CHEKED Functioning well 2/6/15
CHEKED Functioning well 2/10/15
CHEKED Functioning well 2/13/15
CHEKED Functioning well 2/17/15
CHEKED Functioning well 2/20/15
CHEKED Functioning well 2/24/15
CHEKED Functioning well 2/27/15

MANAGEMENT OF INFECTIOUS WASTE

 After each dialysis drain the blood in the tubing and dialyzer and rinse the lines with dialysate
acid.
 It is important that there is no visible blood in either the lines or the dialyzer to be able to
dispose with household garbage
 Put cleaned used lines and dialyzer in double bagged, heavy duty black garbage bags. Place the
garbage bag in a sealable container.
 Tubing and dialyzer are clotted place them in a biohazard container that is provided
 Blood filled syringe must be placed in biohazard container.
 Bring the sealed biohazard waste container to your hospital for safe disposal

SHARPS

Place all sharps in the sealable biohazard hard plastic container that is provided.

Sharps are all needles, vacutainers & IV spike.

 The syringe and needle should thrown away as one unit.

DO not attempt to remove, bend, break or recap needle to withdrawn medication or saline it
also must go into sharp container.

Vina Ilagan- Vasque MD

Nephrologist

License # 76143

GUIDLINES IN WASTE SEGREGATION AND COLLECTION

1. Black trash Bag ( Non-infectious, Non biodegradable)
 Plastics ( IV bottles, plastic bag)
 Food wrappers ( cling wrap, aluminium foil)
 Staple wire, paper clips, fasteners
 Carbon papers
 Tetra packs of juices
 Diaper soak with urine
 Syringes used in giving medicines (excluding needles)
 IV administration set used in giving Iv and medicines ( macroset , microset , soluset) with
no contact with blood
 Bottles, aluminium cans
 Boxes, cartoon newspaper

2. Green trash bag (non infectious, biodegradable)

 Left over foods
 Trayliners, diet cards, food napkins
 Paper
  BBQ sticks
 peanut shellsleaves, twigs

3. Yellow Trash bag ( Infectious)

 Betadine balls
 Alcohol balls
 Gauze soak with blood

Vina Ilagan-Vasquez MD

Nephrologist

License #: 76143

CLINIC SCHEDULE:

 Monday to Friday
 7am-3pm
 Saturday & Sunday- Emergency Dialysis
 Holidays- Closed

SCOPE:

This policy shall be properly disseminated and strictly followed by the patients &n strictly observed in
the unit.

POLICY:

1. When patient come from the appointment they must be seated the waiting area until we call
their names.
2. To ensure Safety, confidentiality & infection prevention, we are unable to allow visitors in the
unit.
 3. Only one relative are allowed to enter to the dialysis unit.
4. If times scheduled is unsatisfactory, Staffs will make changes as space becomes available.
5. We are closed on some major holidays. If the Patient are regularly scheduled on a holiday, the
patient will be rescheduled for the day before the holiday or necessary. This may include
dialyzing on a Saturday or Sunday if necessary, or coming at different time than normal
schedule.
6. Patient are allowed to eat during hemodialysis session.
7. Foods should be avoided 2 hrs prior to dialysis.
8. Smoking is not allowed inside and outside the dialysis unit.
9. Televisions are available for the enjoyment of the patient while on dialysis
10. Maintain cleanliness inside the dialysis unit.

PATIENT RESPONSIBILITIES
 The patient should come on assigned time, usually 30 minutes prior to the scheduled treatment
. If some reason that patient will be detained they must notify the staff as soon as possible.
 Take their prescribed medications as ordered
 Patients must bring all their medications at least once monthly for review by the nursing staff.
 Patients should inform staffs for any medical problems that arise
 Take care of their graft or fistula.
 Follow their individual dietary and fluid restrictions
 Follow through with their routine appointments that will be scheduled according to the
physicians orders.
 Know that smoking has been shown to shorten their life with decreased kidney function, as it
does of those with normal kidney function.
 Dialysis unit is a smoke-free environment, therefore the patient must refrain smoking on the
premises
  Patients must treat all the members of the health care team with courtesy and consideration.

APPLYING ASEPTIC TECHNIQUE IN HEMODIALYSIS

PREPARATION PHASE

 Perform hand hygiene

 Patient Preparation-All to be completed prior to commencing the Connection phase:
 Weight /BP’s
 Fluid assessment
 Calculate fluid removal
 Enter time & fluid removal to the machine
 Place tourniquet loosely on arm
  All other relevant machine and patients checks that may be required.

PATIENT CONNECTION

 Perform hand hygiene

 Disinfect tray using detergent/ disinfectant or alcohol-based swipe
 Gather equipment
 Perform hand hygiene
 Set up cannulation Tray
 Open Sterile equipment using anon touch technique(NTT)
 Perform hand hygiene
 Put on gloves (& other relevant PPE
 Disinfect key sites i.e. A-V access
 Cannulate patient to hemodialysis machine
 Clean tray and machine screen with either a disinfectant solution or detergent/disinfection wipe
 Discard all sharps
 Perform hand hygiene before leaving the patient area.

Dra. Vina Ilagan-Vasquez MD

Nephrologist

License #:76143

PATIENT DISCONNECTION

 Perform Hand hygiene

 Disinfect tray using detergent/ disinfectant or alcohol-based wipe
 Gather equipment
 Perform Hand hygiene
 Set up Iv flushes, medications etc..
 Set up run back tray
 Perform hand hygiene & put on gloves
 Disconnect arterial line & connect saline, runback as per procedure
  Disconnect venous line, remove cannula, tape needles, once bleeding has stopped.
 Clean tray & Discharge clean the patient area using a disinfectant
 Remove gloves and perform hand hygiene
 Strip and clean the machine prior to covering the puncture sites then another hand hygiene &
re- application of gloves will be necessary before completing patient care.

Dra. Vina Ilagan-Vasquez MD

Nephrologist

License #: 76143

REPROCESSING OF DIALYZERS
Purpose

To remove excess blood or blood clot in the dialyzer membrane

To prepare dialyzer membrane for disinfection storage

Scope

This policy shall be disseminated to all staff and be strictly observed in the unit.

Policy

Procedure of reprocessing ( Manual)

1. Returning of blood at the end of dialysis should be done using the machine blood pump and
0.9% Normal Saline. Air should not be allowed to enter the blood tubings or the dialyzer. Around
200 ml of Saline will generally suffice to return most of the blood from the circuit. It is advisable
to then add around 100 units to the Saline bottle and further fill the circuit after disconnecting it
completely from the patient.
2. Pre Rinsing- The dialyzers and tubings are removed from the machine and carried to the
reprocessing area in the covered tray to avoid blood spills. The tubings are disconnected and the
blood compartment of the dialyzer is connected to the water source. The blood compartment is
rinsed with water until the effluent is clear.
3. Cleaning- 1% Hypochlorite should be instilled into the blood compartment until it is completely
filled and allowed to act for not more than 2 minutes. Immediate rinse out of the cleaning agent
from the blood compartment is recommended. Hydrogen peroxide is used, it should be instilled
in the dialysate compartment and abckwashing or reverse ultrafiltration started after 1-2
minutes. Peracetic acid based agents usually contain hydrogen peroxide and should therefore
also be instilled in the dialysate compartment.
4. Visual inspection- At this point the dialyzer is inspected for a large number of discoloured fibres
(>20%), large clots in the header, generalized blackening , change in color aesthetically
unpleasing appearance. If the clots in the header appear small and friable the header may be
removed from the dialyzer to be cleaned separately. If the header is removed special care
should be taken to check the O ring and replace it properly. Improper placement of the O ring or
failure to replace it will result in a blood leak when the dialyzer is next used. Abetter
examination of the fiber is possible when the headers are removed. The header and the O rings
should be placed in glutaraldehyde while the dialyzer is being reprocessed. If vthe dialyzer or
the header cannot be made free clots or too many fibres appear blackened should be discarded.
5. Rinsing- The cleaning agents should be rinsed out of the dialyzer with water.
6. Backwashing or Reverse Ultrafiltration- 1 end of the blood compartment is connected tom the
water supply, which is turned off, while the other end is left open. 1 end of the dialysate
compartment is capped, while the other is connected to a water supply with ector.pressure of 1
to 1.3 bar through Hansens connector. The water should enter the dialysate compartment and
exit through the blood compartment. This step is most critical and is carried out for at least 15
minutes with periodic 1-2 minute rinsing of the blood compartment. The direction should be
reversed at 5 minute intervals.
7. Test of Performance- The blood and dialysate compartment are both filled with water and both
openings of dialysate compartment are capped.
8. Filling with disinfectant- The air from the blood compartment is once again rinsed out with
water, and the dialyzer filled with disinfectant from below, allowing the disinfectant to displace
water. Care should be taken that both the blood and the dialysate compartment are completely
filled with the disinfectant.
9. Labelling & Storage- The patients , name, the reuse number and the date should be marked in
indelible ink and affixed to the dialyzer. The dialyzer should be placed in a sealed polyethylene
bag and stored in a rack with separate compartments for each dialyzer. The minimum period of
storage at ambient temperature should be 24 hours, for complete action of the disinfectant.If
the dialyzer is stored for 7 days prior to subsequent use, it should be refilled with disinfectant at
this point of time. Verification of the name on the label should be confirmed by both the dialysis
personnel and also the patient prior to the start of the subsequent dialysis.
10. Priming and checking for residual disinfectant- The dialyzer should be primed with at least 2000
ml 0.9%Normal saline using the dialysis machine blood pump at a sped of 150ml/min. The
dialysate lines should be connected and the dialysate compartment filled with dialysate flowing
500 ml/min prior to starting the priming procedure. Failure to “dialyze” the disinfectant out may
result in inadequate removal and reactions after starting dialysis. The pressure leak test may
also be performed at this time. After 1000 ml of saline priming the effluent from the venous line
should be checked for the presence of residual disinfectant. This involves using a commercial
test strip which gives a magenta colour. Similar testing with starch iodide paper may be done for
peracetic acid and sodium hypochlorite and absence of color change with litmus or pH papers
for citric acid.
11. Prior to priming, the patient and the technician of or dialysis nurse should verify the identity of
the patient and the label on the dialyzer. Automated reprocessing techniques usually follow
the same sequence of steps or a slight modified cycle.