Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
Lee SH, Tang HL, Cheuk A, Ho LF, Au CP, Hui KC, Zao YK, Chan POA, Hung MS, Leung SY, Lau TK, Lee TF, Yeung HM, Lo KP, Poon YM, Yik WMJ
Affiliation :
Renal Unit, Department of Medicine and Geriatric, Princess Margaret Hospital, HKSAR
Introduction :
Haemodialysis (HD) is a crucial treatment for patients with end-stage renal failure (ESRF) using vascular access like arteriovenous fistula (AVF) or Central Venous Catheter (CVC). Catheter thrombosis is a common complication requiring catheter removal. To prevent thrombosis, catheter lumens are commonly locked with an anticoagulant, such as heparin, between dialysis sessions. The optimal concentration of heparin for locking solutions remains uncertain. In our hospital's HD unit, we currently use a concentration of 5000 units/ml. This evidence-based practice project aimed to evaluate the effectiveness and safety of low-dose heparin lock (1000 units/ml) compared to high-dose heparin (5000 units/ml) for maintaining HD CVC patency and implement the use of low-dose heparin lock.
Objectives :
Implement the use of low-dose heparin lock (1000 units/ml) as the locking solution for HD CVC in the HD unit of PMH based on an Evidence-Based Practice model and process.
Methodology :
Following the Johns Hopkins Evidence-Based Practice (JHEBP) model, we formulated a practice question using the PICO (patient population, interventions, comparisons, outcomes) approach. A literature search revealed no significant difference in catheter thrombosis or malfunction between 1000 units/ml and 5000 units/ml heparin. Considering the risks associated with high-dose heparin, we recommended the use of low-dose heparin locking solution. Frontline staff received training, and the clinical operation guideline was updated to facilitate the implementation of low-dose heparin lock. A study was conducted monitoring HD patients with CVC before and after the switch, assessing the rates of thrombolytic agent use, catheter manipulation and other adverse events, as well as potential cost savings.
Result & Outcome :
The study included 65 HD patients with CVC and in two defined phases. Phase 1 (October 18-31, 2023) used a locking solution with 5000 units/ml, while Phase 2 (November 1-14, 2023) used 1000 units/ml. During the study period, 252 HD sessions were observed in Phase 1 and 262 HD sessions in Phase 2. Phase 1 had 2 episodes (0.79%) of Urokinase use, while Phase 2 had three episodes (1.15%). Catheter manipulation during HD occurred in 43 (17.06%) episodes in Phase 1 and 35 (13.36%) episodes in Phase 2. No catheter reinsertions were necessary due to malfunction. Additionally, a cost saving of HKD 1,170.3 per week for the study samples was identified, with an estimated annual projection of HKD 60,855.6 in savings. The findings support the adequacy and safety of low-dose heparin for maintaining tunnelled HD CVC patency. This EBP project successfully translated the latest scientific evidence into nursing practice, providing important insights for improving patient care and potentially reducing costs associated with HD treatments.
