Background and objectivesHaemodialysis centres in France are being converted into “medicalised dialysis units” where the full-time presence of a physician is no longer required. This has prompted managers to ask questions about safety. Dialysis sessions require many nursing skills, in particular at the start of the session which is a critical phase because of the age of the patients (mean age, 73 years) and the number of comorbidities, and because of renal insufficiency symptoms such as hyperkalemia, salt and water overload, and fatigue. The use of a haemodialysis generator and extracorporeal circulation requires technical skills, and decoagulation and care of vascular access add to the risks. Our objective was to introduce a checklist for nurses that would help the nurse decide whether to start the dialysis session or not.ProgrammeThe checklist was built from the clinical processes and protocols currently used in the unit, such as those dealing with clinical situations where a physician should be called, patient monitoring during a dialysis session, and patient welcome. The checklist had to be short, simple, easy to use, and unambiguous. It was formatted in order to answer the question: “what must be checked before starting dialysis in order to ensure the safety of a dialysis session?” and included the following sections: reading the medical file and consulting data on earlier dialysis sessions, checking the generator setting and the physician's dialysis order, and clinical assessment of the patient. Each item of each section had to be ticked Yes or No. The presence of certain symptoms (ticked Yes) meant that the session could not start and a physician had to be called. The checklist was validated by all nephrologists and pilot tested for self-care dialysis in a small dialysis unit by experienced nurses. In September 2009, its use was extended to a new set of dialysis centres converted into medicalised dialysis units. The checklist is attached to the patient's monitoring record and signed by the nurse.ResultsThe checklist was rapidly accepted by all the nurses and pleased physicians and patients. The clinical assessment of the patient reassured nurses, physicians and patients with regard to safety. Nurses completely changed their way of managing dialysis sessions, and transformed technical care of the dialysis patient into global care. After 2 months of checklist use, 137 checklists were reviewed. In 7% of cases a physician was called and in 22% of these cases some adaptation was required before the start of dialysis. In the absence of the physician, the nurse became the patient's main contact, thus completely changing the nurse's role throughout the dialysis session. The nurses even asked for checklist use to be extended to dialysis centres (where a nephrologist is on permanent duty).ConclusionThe use of a checklist can enhance safety at the start of a dialysis session. Its use can better delineate the roles of physicians with regard to their respective competencies and enhance the quality of dialysis. This is p...

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For 25 years, our institution specialising in the treatment of all stages chronic renal failure patients, treat 25% of its patients by peritoneal dialysis (PD), this allowing us to achieve quantitative regional goals. Peritonitis is one of the most common complications of PD. To improve the quality and safety of PD home treatment, our institution has since 2006 initiated a mortality and morbidity review in PD (MMR PD). We suggest to report on the benefits analysis observed in our practice after 3 years.Our institution MMR PD is part of our professional practices evaluation policy. The systemic analysis conducted at the MMR PD takes into account all interacting factors (organisational, technical and human) and go beyond the individual dimension. Its working rules and organisation are described in a written procedure and distributed to all involved professionals. This document specifies the MMR PD responsibility: PD referral physician, frequency of meetings: quarterly, the participating doctors and health executives, terms of case selection, conducting, monitoring improvement actions and their impacts.Over 3 years, 109 cases were analysed including 42 MMR PD for peritonitis. The research of problems encountered during the treatment of patients on PD or the answer to the question ‘how did this happen?’ conducted to the following conclusion: lack of traceability and analysis of systematic treatment problems encountered. This conclusion has helped to re-write and validate by involved professionals the peritonitis management protocol. Therefore the necessary element collection for root cause analysis has been implemented. Three large groups of peritonitis were quickly identified (95% of cases): hand carried peritonitisdigestive bacteria peritonitisrecurring peritonitis For each type of peritonitis, the causes search, the recovery analysis and the implementation of improvement actions have been completed: For hand carried peritonitisCreation a questionnaire to systematically evaluate the quality of patient handlingReassessment and early re-education of the patientChanging the autonomy treatment offer for the elderlyFor digestive bacteria peritonitis (80% are identify 48 h after diarrhoea, digestive disorders, impaction):Preventive treatment: patient education in disorders identification and eviction, antibiotic prophylaxis to be discussed.urative treatment by expanding the antibiotic spectrum for any peritonitis preceded by digestive disordersFor recurring peritonitis, after bibliography review, the most probable hypothesis is the biofilm infection around the dialysis catheter: it was decided to complete the treatment of peritonitis with intra-catheter TAUROLIDINE stasis. The MMR PD has significantly improved our PD home treatment: the peritonitis occurrence in our institution decreased from 1/26 months in 2007 to 1/39.75 months in 2009. Moreover, our results are well above the national average, in 2007 the peritonitis occurrence in France was of 1/33 months (source RDPLF). The MMR PD led to optimise an organisation that...

Introduction La dénutrition protéinoénergétique est fréquente chez les patients en hémodialyse chronique, elle est un facteur de risque indépendant de mortalité dans cette population. Description L’objectif principal de l’étude est de mesurer l’impact de la maladie COVID19 sur l’état nutritionnel des patients en hémodialyse chroniques de notre centre. L’objectif secondaire est d’analyser s’il existe des spécificités au sein des patients âgés de plus de 75 ans (ptsA). Méthodes Étude rétrospective sur 6 mois de notre population de patients en hémodialyse chronique. Résultats Soixante-deux patients COVID+, H/F 38/24. Âge moyen 72,5 ± 14 ans. Poids moyen 77,8 kg ± 18,3 kg, IMC moyen 27,2 ± 6,0, Alb moy à 38,3 ± 6,0 g/L. CRP 25,5 ± 2 mg/L. Quatorze DCD (22,5 %). À 6 mois 20,9 % présentent au moins 1 symptôme de séquelles COVID. Évolution poids : chute à M1 perte de poids moy de −2,8 %, stabilisation jusqu’a M3, reprise avec retour au poids de base de M5. Évolution albuminémie : chute à 31,5 g/L à M1 (−17,7 %), amélioration à 36,1 g/L dès M2, stabilisation et retour aux valeurs de base à partir du M4 à 37,5 g/L. Les ptsA ( Tableau 1 ) pressentent une chute du poids M1 de −3,4 %, poursuite jusqu’au M3 (−5,2 %), reprise de poids partielle (−2,6 %). Évolution albuminémie des ptsA : chute à 28,1 g/L a M1(−23,6 %), amélioration à 33,2 g/L dès M2, puis stabilisation et retour aux valeurs de base à partir du M5 à 36,3 g/L. Neuf pts DCD, (28,1 %). Huit (25 %) pts avec séquelles à 6 mois. Quarante-sept pts ont bénéficié d’un cs diététique (75,8 %), délais moy 76,2 ± 42 js. Conclusion La dénutrition est une des complications fréquentes de l’infection à SARS-CoV2. Son début est précoce et son rétablissement long. Une surveillance clinicobiologique et une prise en charge diététique doivent être préconisées, notamment chez les patients âgés pour réduire les complications liées à la dénutrition.