Waste reduction in haemodialysis: a multcentre quality actvity.
The delivery of haemodialysis (HD) as a renal replacement therapy option for patients with end-stage kidney disease comes at a high financial and environmental cost. Renal nurses are pivotal in promoting 'Green' nephrology initiatives to support sustainability of HD delivery and minimise environmental impact. A quality improvement activity in waste reduction in a regional HD centre with rural HD satellite units was completed. There were 1671 occasions of service (OOS) evaluated, comparing the average weight of clinical waste per OOS pre- and post-implementation. Post-implementation clinical waste decreased by an average of 0.34 kg per OOS, equating to over $40,000 in potential health service savings per annum. This is a promising environmental initiative with significant potential cost savings that has been adopted across the health service as part of the delivery of quality health care.
Clinical waste, haemodialysis, waste reduction, green nephrology.
Haemodialysis (HD) is one renal replacement therapy (RRT) option for patients with end-stage kidney disease. HD therapy results in high financial health care management costs and substantial clinical waste that leads to significant negative environmental impacts (Connor et al., 2010).
In 2014-2015, 260 million kg of waste produced by Australian hospitals (DHS, 2008) contributed to the $161.6 billion overall cost of health care (AIHW, 2016). A large proportion of this waste was clinical waste, which has the potential to cause disease (Department of Environment and Heritage Protection [DEHP], 2015). One example of clinical waste is the single-use HD extracorporeal circuit at the end of dialysis therapy containing dialysate and/or 0.9% sodium chloride and blood. This waste is managed according to national clinical waste guidelines (DEHP, 2015). Other examples in a HD unit include used soiled gloves, gauzes, disposable linen protectors, and filled sharps containers.
Each HD in-centre therapy generates an estimated 2.5 kg of clinical waste (Connor et al., 2010). This equates to an estimated 390 kg of clinical waste per patient per year. Connor et al. (2010) cite that this increases to an estimated 650 kg per person per year for home HD therapy. As at 31 December 2014, there were 9,619 patients in Australia receiving HD (Australia and New Zealand Dialysis and Transplant Registry, 2015). This can be extrapolated to an estimated 3,750 tonnes of health care clinical waste per year in HD units in Australia alone. Globally, the clinical waste generated from HD is approximately 600,000 tonnes per annum (Piccoli et al., 2015).
Most dialysis waste is managed as landfill or incinerated, and both have reported adverse effects on health and the environment (Agar, 2015). Production and treatment of clinical waste, plus transportation and electricity, all adversely contribute to the carbon footprint and, ultimately, have a detrimental impact on climate change (World Health Organization [WHO], 2016).
Health professionals are becoming more aware of the environmental impact of health care delivery and are well placed in the health care system to be positive drivers for environmental stewardship initiatives (WHO, 2016). To align with the initiative: Reduce, Re-use, Recycle (DEHP, 2014) and the WHO (2016) recommendations, a regional HD unit and associated rural satellite HD units have implemented a waste reduction quality improvement (QI) strategy.
The aim of this QI activity was to implement an effective waste reduction strategy which could show environmental and financial gain with no negative impact on patient safety or quality of care. A secondary aim was to evaluate staff attitudes towards the introduction of this waste reduction strategy.
Study design and setting
The quality improvement model of Plan, Do, Check, Act (Wick, 2009) was chosen as the most appropriate implementation model for this QI activity. This QI aligns with Standard 15 of the EQuIPNational Standards: Corporate Systems and Safety--waste and environmental management support safe practice and a safe sustainable environment (The Australian Council on Healthcare Standards, 2017).
The waste reduction QI activity was implemented in a Hospital and Health Service with one regional hospital HD hub, one regional satellite HD unit and five rural satellite HD units servicing 201 patients. All were included as part of the QI activity implementation and the financial/environmental impact projections. The clinical waste weight was collected and measured exclusively from the regional hospital HD hub.
Clinical waste in these HD units is managed as per the Clinical and Related Waste Management Plan 2014-2019, which is based on relevant environmental, infection control and WHS policies, legislation, standards, and guidelines (Cairns and Hinterland Hospital and Health Service, 2014). Clinical waste is placed into the solid, rigid-walled waste receptacles lined with a biohazard-indicated yellow plastic bag, and then placed in a rigid-walled waste transport bin (DEHP, 2015). The clinical waste for this regional HD unit and associated satellite HD units is then transported 360 km to be autoclaved and compacted prior to being buried as landfill (C Walker, personal communication, 8 November 2016).
Ethical approval was obtained from the Chair of the Human Research Ethics Committee. This waste minimisation QI activity was evaluated against the 2014 Ethical Considerations in Quality Assurance and Evaluation Activities to identify if there was any evidence of risk, burden, inconvenience or possible breach of privacy (National Health and Medical Research Council, 2014). As this activity was an extension of a pre-existing procedure for draining of the dialyser and disposing of the HD circuit into clinical waste, the perceived risk was minimal.
All disconnected patient extracorporeal HD circuits post-HD in the regional HD unit during the months of September 2015 and September 2016 were included in the study. Throughout the implementation phase of this QI waste reduction strategy, there were 82 employed nursing staff across the health service, with more than 200 patients receiving HD, totalling between 2,501 and 2,662 occasions of service (OOS) monthly.
Prior to the implementation of the QI activity, standard unit practice post-HD was to return the patients' blood via the HD machine with online substitution fluid or 0.9% sodium chloride, then disconnect the extracorporeal circuit from the patient. Dialysate was drained from the dialyser by connecting the dialysate outlet tube to the shunt interlock. The dialysate inlet tube was then connected to the shunt interlock. This procedure was timed at 47 seconds. The undrained HD extracorporeal circuit was removed from the HD machine and discarded as clinical waste. The extracorporeal circuits have a filling volume of 206 to 252 mL (Fresenius, 2016: Fresenius Medical Care, 2010). The weight of the unopened extracorporeal circuit totalled 0.5 kg.
An acquired process instructed clinicians for one HD machine model (Fresenius 5008[R]) to include drainage of the HD extracorporeal circuit, in conjunction with dialysate from the dialyser. The extended draining of the extracorporeal circuit and dialyser (EDECD) was then trialled successfully. Following consultation between Biomedical Technical Services, clinical staff and the nurse educator, this procedure was extended to cover varying HD machine models (Fresenius 4008B[R], Fresenius 4008S[R], Fresenius 4008H[R]). The EDECD procedure was timed, which commenced after the patients' blood was returned and the used extracorporeal closed circuit was disconnected from the patient, and until the circuit had completely drained or it was evident that the draining process had ceased. The time to perform the new EDECD procedure ranged from 1minute 29 seconds to 2 minutes 56 seconds on different HD machine models.
Instructions were given to senior nurses to evaluate, make required changes and re-trial the process until the written instructions were deemed clear and accurate. The final written instructions listed in Tables 1 and 2 also included some troubleshooting options which were later finalised into a health service procedure.
HD machine draining efficiency variations
The major difference between the different HD machines is that one model uses online dialysate fluid for priming, fluid boluse and blood return, whereas the other model uses 0.9% sodium chloride attached to the circuit by an intravenous giving set. To minimise possible results contamination and to compare the efficiency of the EDECD procedure between HD machine models, the weight of the combined HD circuit and dialyser were recorded from both HD machine models (Fresenius 4008[R] and Fresenius 5008[R]) pre-implementation of the QI activity, and then compared to the weight of the combined HD circuit and dialyser post-implementation of the EDECD procedure.
Management of the drained HD circuit product
The 0.9% sodium chloride/online fluid and/or dialysate and blood by-products remaining in the HD circuit and dialyser are drained into the HD machine waste line that feeds into the tundish and to the hospital sewer system. Discarding the waste in this method aligns with the National Guidelines for Waste Management in the Health Industry (1999). This sewerage is then treated according to local government guidelines. The local treatment plant has a range of on-site recycled water initiatives in place (Cairns Regional Council, 2015).
Personal protective equipment (PPE)
Goggles, gloves and gowns are worn by the HD staff from the initiation of dialysis termination through to the correct disposal of clinical waste. To perform the EDECD procedure, there were no requirements for additional PPE or time to don PPE. If nursing staff leave the HD machine in the draining phase, staff are required to adhere to the 5 Moments of Hand Hygiene (Hand Hygiene Australia, 2016) and don PPE to complete the extracorporeal circuit drain and removal and the machine cleaning.
Additional equipment required
To perform the procedure, the only additional equipment required includes the dialysis line clamp and dialyser caps. The dialysis line clamps are pre-existing in the HD unit so incurred no extra cost. The dialyser caps, which are part of the dialyser set, are placed on the HD machine and kept to be used in the EDECD procedure, resulting in a cost-neutral practice. A box of spare dialyser caps is kept in the unit in the event they are accidentally discarded in the lining procedure.
The total clinical waste generated for the regional HD unit pre-implementation of the EDECD procedure was obtained for one month (September 2015) and compared to the total clinical waste generated in the same unit for one month post-implementation (September 2016). All the regional HD unit clinical waste was measured by the hospital Clinical Waste Co-ordination Service. During this period of time, the weighing equipment and process remained the same (K Stevens, personal communication, 20 April 2017). The total clinical waste for each month was divided by the total number of patients per month to calculate the average clinical waste generated per OOS.
Due to large distances (up to approximately 325 km) between the central HD unit and satellite HD units educational strategies involved videos of nurses performing the new EDECD procedure on the HD machine models and written instructions. This information was circulated to all HD units in the health service. Follow-up emails and phone calls were made to discuss any queries regarding the EDECD procedure. The commencement date of 1 September 2016 was communicated with all units. The written procedure for the EDECD was submitted to the Renal Clinical Service Team for approval prior to intranet publication.
A total of 82 staff members were sent a staff survey two months post-implementation. The questionnaire consisted of nine questions about the implementation of the new EDECD procedure. Questions consisted of how staff received training on the procedure, utility of new drain process instructions (written and video), confidence in their practice with the new procedure, confidence in teaching new staff about the procedure, extra time required for the procedure, continuing of other nursing tasks during the procedure, commitment to continuing with the procedure, environmental impact of the procedure and attitude towards involvement in further green initiatives. The survey was pilot-tested with a research nurse who provided recommendations and feedback on question design.
After implementing the EDECD procedure, the total clinical waste decreased, from 833 kg from 761 OOS in September 2015 to 685 kg from 910 OOS in September 2016. This equated to an average of 1.09 kg clinical waste per OOS pre-implementation to 0.75 kg per OOS post-implementation, resulting in a net reduction in clinical waste weight by 0.34 kg per OOS. These results are illustrated in Tables 3 and 4. Comparing the clinical waste from pre-implementation to the clinical waste post-implementation, there was approximately 31% reduction in clinical waste weight per OOS. Overall, this equates to an 18% reduction in overall clinical waste during this time period, despite a 19.6% increase in OOS.
In relation to the varying HD machines' draining efficiency variations using the EDECD procedure, the clinical waste weight decrease varied from 0.2 kg to 0.7 kg per OOS. The total average clinical waste reduction in a HD unit utilising both HD machine models (Fresenius 4008[R] and Fresenius 5008[R]) was calculated at 0.45 kg. Table 5 lists the weight (kg) of HD circuits pre- and post-implementation of extended circuit and dialyser drain procedure.
There was a 74% response rate (n=61) from the staff survey. As shown in Table 6, staff were generally shown the procedure by a colleague (61%). The table also shows that most staff (95%) felt confident and would continue performing the procedure (92%) and they also thought that the procedure would have a positive impact on the environment (92%). There was a range of responses to the timing of the procedure, with almost half the staff indicating it would take between 1 and 3 minutes extra to perform the procedure. Over 60% of staff also indicated that they would continue doing other nursing tasks during the procedure. Finally, it was noteworthy that 87% of staff wanted to be involved in further green initiatives.
The implementation of this cost-neutral QI activity has resulted in a substantial 31% decrease in the weight of clinical waste generated per OOS in a regional HD hub with no negative impact on patient safety or quality of care. As management of clinical waste and completing the EDECD procedure is standardised across the health service, it is postulated that there will also be a substantial decrease in clinical waste weight throughout the health service.
Clinical waste weight and savings projections
The baseline data obtained from the regional HD hub was used to calculate the projected clinical waste reduction in the delivery of between 2,502 and 2,662 OOS per month in the health service. The projected clinical waste weight reduction per annum in the health service ranged between 10.2 tonne and 10.8 tonne.
According to Connor et al. (2010) the average clinical waste produced per dialysis OOS is 2.5 kg. After conducting this QI activity, it was interesting to note that this regional HD unit's baseline clinical waste per OOS was lower pre-implementation (1.2 kg per OOS) and further reduced post-implementation (0.75 kg per OOS) which can be interpreted as our HD units already effectively managing clinical waste. Some of the 2.5 kg may reflect the incorrect disposal of general waste into clinical waste which is a continual battle for health care services (Omar et al., 2012).
Decreasing waste is one of the seven elements of a climate-friendly hospital, as endorsed by the WHO (2009). This QI activity addressed two more of the seven elements of a climate-friendly hospital: energy efficiency and transportation (WHO, 2009). By reducing the clinical waste, there is likely to be a direct reduction in transportation requirements and subsequent fuel consumption. This is significant for this health service as the clinical waste is transferred via road to the designated clinical waste management process plant over 360 km from the regional HD hub.
The autoclave used to manage the health services clinical waste has a capacity of 800 kg per cycle (S Barbagello, personal communication, 8 December 2016) and the reduction in weight could equate to a reduction of 12 or more autoclave cycles required per annum. This decrease in electricity generation and consumption required for processing each autoclave cycle necessary to manage clinical waste is another positive environmental outcome.
The current cost of managing clinical waste in this health service is $3.95 per kg (C Walker, personal communication, November 2016). The projected clinical waste savings for this health service is between $40,306 and $42,900 per annum. This figure is likely to increase in alignment with the predicted 3% annual increase in patient numbers (Kidney Health Australia, 2015). Interestingly, the annual increase in patient numbers in this health service has been 9.6% over the last five years (January 2011-January 2015), with the last year (January 2016-January 2017) showing a 12.6% increase (J. Hole, personal communication, April 26, 2017). Using this projected data, the potential cost savings for this health service may be significantly higher.
In direct contrast to current belief that hospital environments encourage environmental 'numbness' (McGain & Naylor, 2014), the renal staff in this QI activity took ownership of this positive waste minimisation strategy, irrespective of the EDECD procedure taking extra time to complete. Staff were keen to trial the new procedure and this provided many opportunities for staff peer education and feedback. This aligns with Trastek et al. (2014) who identify that clinicians prove they are effective change drivers in health care by clinician-engaged change being embraced more than corporate-directed change.
By openly discussing waste and environmental issues, staff are conscious of the health care environmental costs. Open dialogue concerning environmental issues and green dialysis initiatives allowed staff to feel pride in their accomplishments and fosters a culture that supports staff to progress other possible green dialysis initiatives.
Implications for clinical practice
Undergoing this QI activity has provided a platform for staff to discuss the importance of economic and environmental sustainability in health care. Staff have seen firsthand the synergistic effects of implementing one change, resulting in multifaceted positive environmental outcomes. Implementing positive environmental projects such as this can raise staff awareness of the importance of being more conscientious about adopting carbon-friendly initiatives. Also, the monetary savings from this project can contribute to other much-needed health care services.
The waste minimisation strategy for this individual health service, including the tabled weight differences between different HD models, may be a good starting point that can be benchmarked and cross-referenced to similar services. The provision of education using media, emails, procedures and phone calls can be easily replicated in other renal units, including units with large distances between satellite and central units. There is also the potential to replicate these promising waste minimisation results in home HD units.
Renal nurses from every HD unit in this health service have portfolios that cover the 10 National Safety and Quality Health Service Standards (ACSQHC, 2012). Since the introduction of this QI activity, it has become apparent the importance of having interested staff manage a portfolio for Standard 15 of the EQuIPNational Standards (ACHS, 2017) as part of their professional development and to continue the momentum of environmental stewardship in the pursuit of health care and environmental sustainability in HD.
Dissemination of the findings of this project to the multidisciplinary team and interdepartmentally will continue to raise awareness of the environmental and health care issues and hopefully encourage fellow health professionals to consider researching and implementing department-specific, low-carbon, environmentally sustainable practices. By having health professionals who are well informed on environmental and health care sustainability issues as well as 'on the job' experience and appreciation of what is essential in quality patient care, opportunities for quality patient care advancements being integrated with environmentally conscientious processes may be successfully implemented. McCoy and Hoskins (2014) suggest our qualifications and experience place health professionals in good stead to be actively involved in roles that enables policy makers and the general public to be well informed on climate change issues.
Variations to practice
As the nursing staff were not required to oversee the EDECD procedure, the draining process did not infringe on the actual nurse-to-patient time. As indicated from the results of the staff survey, nursing staff often continued with other nursing duties during the EDECD procedure. Nursing staff then returned to the machine to continue with any required steps and to perform circuit removal and cleaning of the machine. In contrast to the work of Roland et al. (2010), the extra tasks involved in this procedure did not have a negative impact on staff completing a task. Staff quickly learned the variations in the draining efficiency between the different HD machine models, as well as between various HD filters and adjusted their work flow and nursing duties accordingly. Anecdotally, staff reported that clot formation within the circuit, particularly in the venous bubble trap or in the dialyser affected the EDECD procedure, resulting in incomplete circuit drainage and resulting staff frustration. Anecdotal feedback suggests nursing staff value this waste minimisation strategy and accept the extra nursing steps involved as a fundamental part of providing an ecologically sound practice.
The weight of the waste during this QI strategy may have deviated due to the incorrect disposal of general waste into clinical waste, which is a well-identified variable and continual battle for health care services (Omar et al., 2012; Southorn et al., 2013). Weight of waste may also deviate due to increases in other activities, such as central venous access dressings, number of staff disposing PPE, increase in sharps/syringes, variable patient presentations and management of intradialytic complications.
The waste reduction QI activity compared clinical waste generated in the month of September 2015 to the month of September 2016. The variations in the standard of patient care, infection control guidelines and the type of dialysis equipment, including HD machines used in the delivery of patient care over this time line were reviewed. These variations, along with the patient presentations, management of intradialytic complications and general functioning of the regional unit were deemed within the acceptable parameters of the overall delivery of a HD unit (James, 2010). Major changes such as redevelopment and the introduction of digital hospital that occurred during this study had no effect on the generation of clinical waste.
The clinical waste weight was only measured for the Regional HD Hub and did not include the Regional HD unit and satellite units. The QI activity was only able to use the Regional HD Hub as the clinical waste weight in that hub is weighed separately from other clinical waste within the hospital, whereas the clinical waste in the associated regional HD unit and rural satellite HD units is collected in conjunction with waste from co-located health services. Their waste could not be individual extracted for the purposes of this QI activity. As the management of the HD patients, the various HD machines and the clinical waste management are standardised across the health service, the clinical waste data obtained from the regional HD hub was used to project total health service HD units waste reductions and cost savings.
Whilst there has been a call to arms for national and international reduction of greenhouse gas emissions (Australian Academy of Science, 2015), health care providers have a responsibility to minimise their carbon footprint and the associated social issues aligned with projected climate change. Health care professionals are caring and innovative and are excellently positioned in the health care system to be able to identify potential areas of improvement. These professionals can then provide quality initiatives that deliver economically sustainable health care and environmental practice improvements whilst maintaining the highest quality of patient care and staff safety. This quality improvement activity is one example of renal nurses embracing environmental stewardship and deliberately striving to find initiatives that have positive environmental and financial gains with no negative impact on patient safety or quality of care. As stated by WHO Director-General Dr Margaret Chan, "A healthy planet and healthy people are two sides of the same coin" (WHO, 2015).
Thank you to all the nurse unit managers, renal nursing staff and administration staff at Cairns haemodialysis unit and associated satellite haemodialysis units, Kate Heath (Team Leader Casemix, Costing, Coding and Quality Audit, Cairns Hospital), Christopher Walker (Environmental waste coordinator, Cairns Hospital), Biomedical Technical Services staff (Cairns Hospital), Katrina Streich (Library Technician, Cairns Hospital), Stella Green (Research Nurse), Sam Barbagello (JJ Richards & Sons Pty Ltd Waste Management Solutions, Cairns), Dr Bronwyn Hayes (CN haemodialysis unit, Cairns Hospital), K Stevens (Operational Officer, Support Services Cairns Hospital), Janet Hole (Nurse Unit Manager Cairns Haemodialysis Unit, Cairns Hospital), and Jamin Claes (Renal Nurse Navigator Cairns Hospital).
Agar, J. W. M. (2015). Reusing and recycling dialysis reverse osmosis system reject water. Kidney International, 88, 653-657. DOI 10.1038/ki2015213.
Australia and New Zealand Dialysis and Transplant Registry. (2015). ANZDATA Registry 38th Report summary Australia. Retrieved from: http://www.anzdata.org.au/v1/report_2015.html on 11 January 2017.
Australian Academy of Science. (2015). The science of climate change: Questions and answers. Australian Academy of Science, Canberra, 2015. Retrieved from www.science.org.au/climatechange on 11 January 2017.
Australian Commission on Safety and Quality in Health Care. (2012). National Safety and Quality Health Service Standards. Sydney: ACSQHC.
Australian Institute of Health and Welfare. (2016). Health expenditure Australia 2014-15. Health and welfare expenditure series no. 57. Cat. No. HWE 67. Canberra: AIHW.
Cairns and Hinterland Hospital and Health Service. (2014). Clinical and related waste management plan 2014-2019. Cairns: CHHHS.
Cairns Regional Council. (2015). Water Infrastructure. Retrieved from
https://www.youtube.com/watch?v=_wskmK_1YDQ&list=PL4C07102A39419B30&index=7 on 11 January 2017.
Connor, A., & Mortimer, F. (2010). The Green Nephrology survey of sustainability in renal units in England, Scotland and Wales. Journal of Renal Care, 36(3), 153-160.
Connor, A., Mortimer, F., & Tomson, C. (2010). Clinical Transformation: The Key to Green. Nephron Clinical Practice, 116, c200-c206. DOI: 10.1159/000317200.
Department of Environment and Heritage Protection. (2015.) Reduce, reuse, recycle. Retrieved from https://www.ehp.qld.gov.au/waste/minimisation/reduce_reuse_recycle.html on 11 January 2017.
Department of Environment and Heritage Protection. (2015). Guideline: Clinical and related waste ESR/2015/1571(V1). Industry Sector Regulation and Support, Environmental Services and Regulation: Queensland Government.
Department of Environment and Heritage Protection. (2014). Waste--Everyone's responsibility: The Queensland waste avoidance and resource productivity strategy (2014-2024). Brisbane: Queensland Government.
Department of Human Services. (2008). Waste minimisation in healthcare User guide. Melbourne: Victorian Government Department of Human Services. Retrieved from www.dhs.vic.gov.au/environment on 11 January 2017.
Fresenius Medical Care. (2016). Blood lines brochure. Retrieved from http://www.fmc-au.com/disposables/item/bloodlines-brochure on 11 January 2017.
Hand Hygiene Australia. (2016). Hand hygiene Australia. Retrieved from http://www.hha.org.au/hha-nhhi.aspx on 11 January 2017.
James, R. (2010). Incineration: Why This May Be The Most Environmentally Sound Method of Renal Healthcare Waste Disposal. Journal of Renal Care, 36(3), 161-169.
Kidney Health Australia. (2015). Pre-Budget Submission 2016-2017 Federal Budget Charting a Comprehensive Approach to Tackling Kidney Disease "Proposals to guide increased risk assessment, support early detection and improve the treatment of kidney disease". Retrieved from https://www.treasury.gov.au/~/media/Treasury/Consultations%20and%20Reviews/Consultations/2015/2016%20Pre%20Budget%20submissions/Submissions/PDF/Kidney%20Health%20Australia.ashx on 11 January 2017.
McCoy, D., & Hoskins, B. (2014). The science of anthropogenic climate change: what every doctor should know. British Medical Journal, 349, g5178. McGain, F., & Naylor, C. (2014). Environmental sustainability in hospitals--a systematic review and research agenda. Journal of Health Services Research & Policy, 19(4), 245-252.
National Health and Medical Research Council. (1999). National Guidelines for Waste Management in the Health Care Industry. Retrieved from https://www.nhmrc.gov.au/guidelines-publications/eh11 on 11 January 2017.
National Health and Medical Research Council. (2014). Ethical Considerations in Quality Assurance and Evaluation Activities. Retrieved from https://www.nhmrc.gov.au/guidelines-publications/e111 on 11 January 2017.
Omar, D., Nurshahida Nazli, S., & Karuppannan, S. A/L. (2012). Clinical Waste Management in District Hospitals of Tumpat, Batu Pahat and Taiping. Procedia--Social and Behavioural Sciences, 68, 134-145.
Piccoli, G., Nazha, M., Ferraresi, M., Neve Vigotti, F., Pereno, A., & Barbero, S. (2015). Eco-dialysis: the financial and ecological costs of dialysis waste products: is a 'cradle-to-cradle' model feasible for planet-friendly haemodialysis waste management? Nephrology Dialysis Transplantation, 30(6):1018-1027. DOI: 10.1093/ndt/gfv031.
Roland, B., Di Martinelly, C., Riane, F., & Pochet, Y. (2010). Scheduling an operating theatre under human resources constraints. Computers and Industrial Engineering, 58, 212-220.
Southorn, T., Norrish, A. R., Gardner, K., & Baxandall, R. (2013). Reducing the carbon footprint of the operating theatre: a multicentre quality improvement report. Journal of Perioperative Practice, 23(6), 144-146.
The Australian Council on Healthcare Standards (ACHS). (2017). EQuIPNational Table. Retrieved from: http://www.achs.org.au/media/38984/table_equipnational_standards.pdf on 11 January 2017.
Trastek, V. F., Hamilton, N. W., & Niles, E. E. (2014). Leadership Models in Health Care--A Case for Servant Leadership. Mayo Clinic Proceedings, 89(3), 374-381.
Wick, G. (2009). Concepts and principles of quality management. Nephrology Nursing Journal, 39(5), 539-543.
World Health Organization (WHO). (2016). Climate change and health fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs266/en/ on 11 January 2017.
World Health Organization (WHO). (2009). Healthy Hospitals--Healthy Planet--Healthy People: Addressing climate change in health care settings. A discussion draft paper published by the World Health Organization and Health Care Without Harm. Retrieved from www.who.int/globalchange/publications/climatefootprint_report.pdf on 11 January 2017.
World Health Organization (WHO). (2015). Address by Dr Margaret Chan, Director-General of the World Health Organization. Why the climate change agreement is critical to public health. Paris, France 8 December 2015. Retrieved from http://www.who.int/dg/speeches/2015/climate-change-paris/en/ on 11 January 2017.
Submitted: 12 January 2017, Accepted: 6 June 2017
Kylie Dunbar-Reid, RN, PG Cert (Critical Care & Renal Nursing), MNurs Nurse Educator--Respiratory and Renal portfolio, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Queensland Government, QLD, Australia
Elizabeth Buikstra, BSc (Hons), MBA, MPJM, PhD, MAPS Clinical Services Support Coordinator, Cairns Hospital, Cairns and Hinterland Hospital and Health Service Queensland Government, QLD, Australia
Correspondence to: Ms Kylie Dunbar-Reid, PO Box 902, Cairns, QLD 4870, Australia Tel: 07 4226 6502 Email: email@example.com
Table 1: Procedure for draining blood lines and dialyser post-completion of haemodialysis: Fresenius 4008[R] Equipment Personal protective equipment (PPE) Dialysis line clamps Dialyser caps Clinical waste receptacle General machine cleaning agent Procedure After completion of haemodialysis and disconnection of the extracorporeal circuit from the patient: 1. Connect the venous line to the arterial line with a recirculation adaptor. 2. Ensure saline is clamped off 3. Remove arterial line from blood pump 4. Remove venous line from venous clamp 5. Remove venous transducer, ensuring it is upwards 6. Clamp (or kink) the venous bloodline at the dialyser. 7. Remove the dialysate supply coupling (blue) and replace the cap onto the dialyser. 8. Place the dialysate supply coupling (blue) into the shunt interlock. 9. Ensure all clamps are open. 10. Close shunt interlock. NOTE: if using HdF, remove HdF tubing and clamp NOTE: if the lines are not draining, remove Bibag[R], close Bibag[R] cover, lines should continue to drain. 11. Once the line is drained, remove the cap from the dialyser, open then close shunt interlock to drain the dialyser. 12. Once dialyser drained, place the red coupling into the shunt interlock and close. To clean machine, press CLEANING 13. Select heat disinfection and press Start. 14. Clean external machine surfaces with hospital recommended cleaning solution and practices. Exceptions to practice This procedure may be aborted and machine stripped, placed into heat disinfect and cleaned as per unit practice if there evidence that the draining process is not completing (i.e. with the presence of a blood clot in the venous bubble trap, in the presence of a streaky dialyser, prolonged time). Table 2: Procedure for draining blood lines and dialyser post-completion of haemodialysis: Fresenius 5008[R] Equipment Personal protective equipment (PPE) Dialysis line clamps Dialyser caps Clinical waste receptacle General machine cleaning agent Procedure After completion of haemodialysis and disconnection of the extracorporeal circuit from the patient: 1. Select remove all lines. 2. Connect the venous line to the arterial line with a recirculation adaptor. 3. Disconnect the venous transducer (face upwards). 4. Clamp (or kink) the venous bloodline at the dialyser. 5. Remove the dialysate supply coupling (blue) and replace the cap onto the dialyser. 6. Place the dialysate supply coupling (blue) into the shunt interlock. 7. Ensure all clamps are open and doors are closed. 8. Close shunt interlock. Closing the shunt interlock must always be the final step otherwise the process will not work. Note: if the dialyser does not empty, open and shut the shunt interlock again (to 'burp' the system) to allow further drainage of dialyser 9. Once the line is drained, remove the cap from the dialyser, open then close shunt interlock to drain the dialyser. 10. Once dialyser drained, place the red coupling into the shunt interlock and close. To clean machine, press CLEANING 11. Select heat disinfection and press Start. 12. Clean external machine surfaces with hospital recommended cleaning solution and practices. Exceptions to practice This procedure may be aborted and machine stripped, placed into heat disinfect and cleaned as per unit practice if there evidence that the draining process is not completing (i.e. with the presence of a blood clot in the venous bubble trap, in the presence of a streaky dialyser, prolonged time). Table 3: Total weight of clinical waste (kg) per OOS and total number of OOS; comparing September 2015 (pre-implementation of draining circuit and dialyser post-HD) with September 2016 (post-implementation of draining circuit and dialyser post-HD) in the regional HD unit 2015 2016 KG pert OOS 833 685 OOS 761 910 Note: Table made from bar graph. Table 4: Weight (kg) of clinical waste per OOS pre-implementation of extended circuit and dialyser drain procedure and post-implementation of extended circuit and dialyser drain procedure Pre 1QI 1.09 kg per OOS Pos2t QI 0.75 kg per OOS Di3fference 0.34 kg per OOS Note: Table made from bar graph. Table 5: Weight (kg) of HD circuits once HD completed and circuit disconnected from patient: Pre- and post-implementation of extended circuit and dialyser drain procedure Pre-implementation Weight Post-implementation Weight Total of of of extended of clinical extended circuit circuit circuit and circuit waste and dialyser drain dialyser drain reduction procedure: procedure: per OOS circuit type circuit type HD circuit with 1.7 kg HD circuit 1.0 kg 0.7 kg dialyser only with complete drained Fresenius dialyser and 4008[R] circuit drained Fresenius 4008[R] HD circuit with 1.0 kg HD circuit 0.8 kg 0.2 kg dialyser only with complete drained Fresenius dialyser and 5008[R] circuit drained Fresenius 5008[R] Mean average of 1.35 kg 0.9 kg 0.45 kg HD unit utilising both HD machine models Table 6: responses to the staff survey on QI activity: Extending the HD circuit drain procedure (n=61) Question Response choice No. of % responses How were you taught to do the extended circuit drain procedure? Video 10 16 Step-by-step guide 10 16 Shown by colleague 37 61 Combination of above 10 16 If you used the written instructions for this extended circuit drain procedure, did you find the step-by-step instructions easy to follow? Yes 21 34 No 2 3 Not applicable 39 64 If you watched the videos of this extended circuit drain procedure, did you find the videos easy to follow/understand? Yes 19 31 No 2 3 Not applicable 38 62 Do you feel confident in your practice to perform this extended circuit drain procedure? Yes 58 95 No 2 3 Do you feel that once proficient in this extended circuit drain procedure, there is: No extra time required 9 15 0-1 minute's extra time 18 30 1-3 minutes' extra time 29 48 3+ minutes' extra time 6 10 Do you continue to do other nursing tasks during the extended circuit draining procedure? Yes 38 62 No 8 13 Sometimes 16 26 Will you continue doing this extended circuit draining procedure? Yes 56 92 No 3 5 Do you think this extended circuit draining procedure can have a positive impact on waste reduction, cost and environment? Yes 56 92 No 2 3 Unsure 2 3 Would you like to be involved in further green dialysis initiatives? Yes 53 87 No 7 11 Note: Percentages rounded to whole numbers.
|Printer friendly Cite/link Email Feedback|
|Author:||Dunbar-Reid, Kylie; Buikstra, Elizabeth|
|Publication:||Renal Society of Australasia Journal|
|Date:||Jul 1, 2017|
|Previous Article:||The environmental impact of healthcare and haemodialysis: the Jekyll and Hyde dilemma.|
|Next Article:||Pre-dialysis education for patients with chronic kidney disease.|