No abstract

No abstract

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...