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Sunday July 10, 2011 MYT 12:00:00 AM
Monday September 9, 2013 MYT 2:05:52 PM
by dr milton lum
There is a particular need for dialysis patients to be in constant communication with the doctors, nurses, and other healthcare professionals like dietitians and technicians to avoid medical errors.
THE primary function of the kidneys is to filter the blood to get rid of waste products, toxins, and excess water and electrolytes from the body, while reabsorbing useful chemicals. Many medicines are also excreted by the kidneys.
The kidneys also help in the regulation of blood pressure and produce hormones that regulate the production of red blood cells as well as those that regulate the growth and maintenance of bones.
The functions of both kidneys can be performed sufficiently by one kidney.
Kidney (renal) failure occurs when the kidneys cannot perform its functions, leading to the accumulation of toxic substances in the body with consequent harm to health.
Renal failure can be acute or chronic. The former occurs rapidly and the latter, gradually over many years during which the kidneys are destroyed slowly.
When the kidneys fail, its functions have to be taken over by dialysis or kidney transplantation. Although the latter is the preferred treatment, it is not done often enough because of an insufficiency of donors, while some patients are not suitable candidates for transplantation.
As such, the survival of most patients is dependent on dialysis.
According to the 18th report of the Malaysian Transplant and Dialysis Registry 2010, the number of new dialysis patients increased from 2,112 in 2001 to 4,740 in 2009. The number of patients undergoing dialysis increased by almost 300% from 7,837 in 2001 to 21,245 (762 per million population) in 2009.
Diabetic patients accounted for the majority of new dialysis patients. With the increase in numbers of people with diabetes in the population, it can be expected that there will be an ever increasing need for dialysis, unless there is a marked increase in the number of transplantations.
All patients expect that the care they receive from a healthcare facility would improve their medical condition(s). This is the case most of the time. However, adverse events do occur and may result in harm and even death to patients. This is because modern healthcare is complex, although effective.
The medical profession recognised the problems of medical errors about two decades ago following the publication of a few studies in several countries. This led to the patient safety movement in which doctors, healthcare professionals and laypersons endeavoured to establish a culture of safety in which safe practices are a priority.
Concomitantly, the reporting of adverse events and “near misses” are encouraged in a non-punitive environment so that faulty systems of care are unearthed, with a view to reducing the incidence of such errors.
Dialysis is a treatment modality in which safety issues are obvious as there is exchange of body fluids in an external environment. Although patient safety is the primary concern of all the attending staff, the degree of safety is enhanced when patients are directly involved in their care.
The more a patient and his or her family understand dialysis, the safer the process will be for the patient. Although the attending staff in dialysis centres comply with standard operating procedure, the fact remains that everyone is human – so mistakes can and do occur.
The problems that can occur in dialysis can be patient and/or technical ones. The former includes blood pressure changes, especially low blood pressure; infection of the blood; muscle cramps, headaches, chest pain; nausea and vomiting; fever and itching.
The latter include clotting in the dialyser and/or blood lines, introduction of air into the dialyser and/or blood lines, leakage of blood, excessive loss of blood (exsanguination), breakdown of red blood cells (haemolysis), reactions to the dialyser, and occasionally, power failure.
Although it is understandable to experience depressive feelings when a person has to undergo dialysis, it is vital to get over them as soon as possible and participate actively in the treatment. This approach contributes significantly to the safety of dialysis. The initial step is to acquire knowledge about dialysis, its processes and complications.
The measures that one can take include:
Communication is a sine qua non of active involvement in one’s medical care, whether it is dialysis or other treatments. There is a particular need for dialysis patients to be in constant communication with the doctors, nurses, and other healthcare professionals like dietitians and technicians.
Although this may present challenges to some patients, it is vital to remember that safe dialysis is much dependent on the patient’s ability to communicate with the attending staff.
The approaches include making eye contact with the attending staff and being calm when there is a problem. If one does not understand something, one should request the attending staff to explain in a different way. It is alright to ask more than once as the objective is to understand the treatment prescribed by the doctor.
The attending staff’s responsibility is to assist every patient understand his or her treatment. It is alright to repeat the doctor or nurse’s answers to be sure that one knows what it meant.
All attending staff are required to adhere to standard operating procedures to prevent errors from occurring. Not only patients but also their family or friends who accompany them for treatment should have an understanding of these basic measures.
All dialysis centres have standard operating procedure (“SOP”) to ensure safety and prevent errors from occurring. The SOP involves all the activities that affect patient care, eg medical checks prior to and after dialysis, needle insertions, disposal of needles and other consumables, setting up of the dialyser, etc.
It is vital that the staff adhere strictly to the standard operating procedure. One should be conversant with all the routine involved. If there is any omission or if anything is done differently, you should ask about it without any hesitation. If the reply is unsatisfactory, you should check with the nursing sister or manager and/or doctor first before proceeding with the dialysis.
Clean hands are vital as many infections are spread by touch. There are several ways that prevent the transmission of infections, eg washing hands with soap and water, application of germicidal gel or foam to the hands, and the use of gloves.
Every attending staff has to clean their hands before and after touching a patient. If you notice that a staff member has not done so, you should remind them. If the problem persists, you should speak to the nursing sister or manager and/or doctor.
The dialyser and the dialysing solution have to be the correct one. All dialysers have to be cleaned, disinfected and tested to ensure that it is working properly before it is used for the next patient.
The doctor would issue specific instructions and prescribe a specific solution for a patient, depending on various individual factors, including response to treatment.
The dialyser and dialysing solution should be labeled with the patient’s name. You should ask to see the labels before commencing the dialysis. This request should never be refused. If you are uncomfortable with the response, you should speak to the nursing sister or manager and/or doctor.
The medications have to be the correct ones. Most patients on dialysis take different medicines that are often prescribed by different doctors for different reasons. These medicines are often of different dosages and are taken at different times of the day.
Medication errors are the commonest cause of medical errors in many dialysis patients. Mistakes in dosages and drug interactions are common in dialysis patients, especially when there is hospitalisation or changing medical condition(s).
The errors include getting the wrong medicine, getting the medicine at the wrong time, getting the wrong dose and/or not getting one’s medicines.
All these errors can cause harm. You can prevent medication errors by being familiar with the medicines that have been prescribed.
Having a list of the medicines you’re taking and updating it when there are changes in the medicines or its dosages would be very helpful.
If the medicines given are new or different from those on your list, you should check with the nursing sister or manager and/or doctor first before permitting its use.
Patients who are on dialysis are prone to falls. The reasons include changes in blood pressure, medications, tripping on equipment in the dialysis centre, etc.
You should be aware and be honest about how you feel irrespective of any arrangements you may have in mind.
You should also walk carefully, avoiding the equipment in the dialysis centre. The nurse or doctor should be informed if any falls have occurred even if no specific question has been asked.
It would be helpful if information about the fall is provided to facilitate diagnosis, treatment, if necessary, and prevention.
Dialysis centres in the country are operated by the public and private sectors. The former include the Health Ministry, public universities and the armed forces. The latter include private hospitals and centres as well as non-governmental organisations.
According to the 18th report of the Malaysian Transplant and Dialysis Registry 2010, the number of dialysis centres increased from 230 in 2001 to 618 in 2010. Dialysis was provided to 30% of patients by the Health Ministry, 25% by non-governmental organisations and 40% by the private sector.
Dialysis was funded by the government in about 57% of cases, non-governmental organisations in about 10% and self funding in about 22%.
All dialysis centres have to adhere to standard operating procedures prescribed by the Health Ministry. These are directives in the case of dialysis centres operated by the public sector.
Dialysis centres operated by the private sector have to comply with the provisions in the Private Health Care Facilities and Services (Private Hospitals and other Private Health Care Facilities) Regulations 2006 (“PHCFSR”).
The PHCFSR requires that the person in charge of a private haemodialysis centre or head of hospital haemodialysis centre be a “nephrologist, registered medical practitioner, physician or paediatrician” who has a current annual practicing certificate issued by the Malaysian Medical Council.
The physician or paediatrician in charge of a dialysis centre is required to “possess not less than 200 hours of training and experience in haemodialysis treatment under the supervision of, and maintain an affiliation with, a nephrologist.”
The registered medical practitioner in charge of a dialysis centre has to “possess not less than 200 hours of training and experience in haemodialysis treatment under the supervision of, and maintain an affiliation with, a nephrologist or a physician possessing the qualifications, training and experience required” by the PHCFSR.
Dialysis can only be performed by a registered medical practitioner, registered nurse or registered medical assistant, who has the required training and experience in dialysis treatment and care.
The PHCFSR also contain safety and technical requirements, eg facilities and equipment, monitoring of patients, cross infection control, disposal of wastes, safety of personnel and environment, etc.
The rationale for the medical personnel and other requirements in dialysis centres is to ensure the safety and quality of the dialysis treatment and care provided.
It is regrettable that some uninformed quarters have recently questioned the need for a trained doctor to be in charge of a dialysis centre. They need to be reminded that dialysis is not without problems and there is a potential for adverse events for the patient all the time.
Although a trained doctor cannot provide an absolute guarantee than no adverse events will occur, it certainly will reduce considerably the likelihood of its occurrence.
Dialysis cannot and should not be approached from an economic perspective. Safety should always be the prime consideration. To sacrifice safety would not only result in higher economic costs but also human costs, which may include avoidable complications and premature death.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
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Health, Lifestyle, Health, dialysis, kidneys, renal failure
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