Improving the care of dialysis patients in the Emergency Department

Allsopp, K
Richard Bright Renal Unit, North Bristol Trust
PROBLEM: Dialysis patients may present to Accident and Emergency (A&E) with a variety
of complaints, some unrelated to their kidney disease. Many A&E staff report that they are
unfamiliar with dialysis patients; so there is a real risk of inappropriate management. Clinical
experience in both areas of A&E and Renal increased my own awareness of a need to share
knowledge amongst specialities.
PURPOSE: I planned to improve the safety and experience of dialysis patients attending
A&E by improving knowledge amongst A&E staff by using a multipronged approach.
DESIGN: Using informal interviews to identify learning needs, I designed a teaching
package for A&E staff. I then designed a care plan for use in the A&E department. I then
undertook an audit of dialysis patients attending A&E in a large district general hospital with
a satellite dialysis unit on site, but no continuous renal medical staffing. I then designed a set
of guidelines for use in A&E departments and sent these to the lead consultants in each
hospital served by the regional renal unit.
FINDINGS: Both Nursing and Medical staff in 2 of 4 regional A&E departments were very
keen to have teaching sessions and guidelines to adhere to. The other 2 departments did not
come forward to participate when asked.
LEARNING NEEDS: Case studies of inappropriate treatment/management of dialysis
patients in A&E. Examples including cannulation of fistula/IV fluids causing pulmonary
oedema/unnecessary catheterisation/inappropriate analgesia/Blood transfusion given whilst
not receiving dialysis.
CARE PLAN: tested care plan and modified it; version 4 currently in use. Feedback from
nurses: Regular turnover of A&E staff within department can lead to unawareness so use of
care plans depends on staff knowing about and remembering to use them.
AUDIT: Carried out over 6 month period after 4 years of tri-monthly teaching sessions and
care plans. 18% from a total of 15 patients admitted to A&E with dialysis related problem.
82% non-dialysis related. All patients received appropriate treatment and those requiring
dialysis that day received it. Positive findings.
GUIDELINES: Using mnemonic eGFR : ‘e’mergency ‘G’uidelines ‘F’or ‘R’enal patients. 3
versions tested: sent to 4 departments. 2 A&E Clinical Directors replied positively and asked
for electronic version….Feedback ‘Very useful and often referred to, eGFR
Mnemonic particularly good’ Consultant Royal United Hospital, Bath
‘All very sensible advice, thank you’ Consultant Bristol Royal Infirmary, Bristol
CONCLUSIONS: With increasing prevalence of dialysis, particularly amongst the elderly
with significant co-morbidities, the numbers of dialysis patients presenting to A&E will
continue to increase. However, A&E staff have numerous competing priorities so need help
and guidance.
RELEVANCE: Most Renal Patients know more about their treatment than staff but are
disempowered, particularly when acutely unwell. Sharing Knowledge amongst specialties
helps to improve patient safety.
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