Reimaging Patient Safety for Dialysis

Introduction: Arteriovenous fistula/graft (AVF/AVG) are commonly used for dialysis. Vascular access related morbidity accounts for 20% of hospitalization. Blood vessel rupture, a serious complications of AVF. Case Description: 79-year-old male with End Stage Kidney disease on hemodialysis through Left AVF was admitted. Nephrology was consulted for hemodialysis. Patient was initially evaluated by a nephrology fellow and the case was discussed with the attending physician. Hemodialysis was initiated through the AVF. Physical examination of the fistula was described as a thrill and a bruit without any signs or concerns for erythema, even though the attending physician noted the presence of scabs on the patient’s access, prompting consideration for vascular evaluation. Despite this observation, the patient underwent dialysis again during which bleeding from AVF was observed at the conclusion of treatment. The vascular team was immediately notified, he was taken to the operating room where AVF was ligated. Discussion: We have implemented follow-up strategy to prevent similar catastrophes in the future. Nephrology team received dedicated lectures with strong emphasis on physical examination skills. They were instructed to include images of AVF/AVG after obtaining patient consent, which heightened their awareness of the importance of thorough physical examination. They were encouraged to promptly consult the vascular surgery team if any concerns arose. In the hemodialysis unit nurses received more frequent dialysis education sessions to accommodate the increased turnover rate among them. Significant improvements were observed. Almost all charts now include images of dialysis access. Additionally, fellows are more aware of the patient access conditions. We have also noticed an increase in phone calls from dialysis unit nurses ensuring better communication and patient care.