Developing a trigger tool to monitor adverse events during haemodialysis in children: a pilot project,Pediatric Nephrology

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Developing a trigger tool to monitor adverse events during haemodialysis in children: a pilot project
Pediatric Nephrology ( IF 2.6 ) Pub Date : 2022-08-01 , DOI: 10.1007/s00467-022-05673-4
Ramnath Balasubramanian ₁ , Rachel Folwell ₁ , Arran Wheatley ₁ , Heidi Ramsey ₁ , Carmen Barton ₁ , Christopher J D Reid ₁ , Manish D Sinha _{1,

2}

Affiliation

Abstract

Background

We developed a paediatric haemodialysis trigger tool (pHTT) for application per haemodialysis (HD) session in children receiving intermittent in-centre HD and systematically monitored adverse events.

Methods

Single-centre quality improvement study performed over two 8-week cycles. Data collected prospectively using a ‘per-dialysis session’ pHTT tool including 54 triggers across six domains, adapted from a recently described haemodialysis trigger tool (HTT) for adults. Each trigger was evaluated for level of harm following assessment by two authors. Following a period of training, HD nurses completed the HTT at the end of each dialysis session.

Results

There were 241 triggers over 182 dialysis sessions, with 139 triggers in 91 HD sessions for 15 children, age range 28–205 months, over an 8-week period (first cycle) and 102 triggers in 91 HD sessions for 13 children, age range 28–205 months, over a further 8-week period (second cycle). After interventions informed by the pHTT, the harm rate per session was significantly reduced from 1.03 (94/91) to 0.32 (29/91), P < 0.001. There was a significant difference between the distribution of triggers by harm category (P < 0.001) and between the proportion of triggers across the various domains of the pHTT (P = 0.004) between the two cycles. No triggers were evaluated as causing permanent harm.

Conclusions

This pilot study demonstrates potential benefits of a bedside tool to monitor adverse events during haemodialysis in children. Thus, following interventions informed by the pHTT, the harm rate per session was significantly reduced. Under standard patient safety systems, the vast majority of triggers identified by the pHTT would remain unreported and perhaps lead to missed opportunities to improve patient safety. We propose the use of a paediatric HTT as part of standard care by centres providing HD to children in the future.

Graphical Abstract

A higher resolution version of the Graphical abstract is available as Supplementary information

中文翻译：

开发触发工具以监测儿童血液透析期间的不良事件：一个试点项目

摘要

背景

我们开发了一种儿科血液透析触发工具 (pHTT)，用于在接受间歇性中心 HD 治疗的儿童的每次血液透析 (HD) 疗程中应用，并系统地监测不良事件。

方法

单中心质量改进研究在两个 8 周的周期内进行。使用“每次透析会话”pHTT 工具前瞻性收集数据，包括六个领域的 54 个触发器，改编自最近描述的成人血液透析触发器工具 (HTT)。在两位作者进行评估后，对每个触发器的危害程度进行了评估。经过一段时间的培训，HD 护士在每次透析结束时完成了 HTT。

结果

在 182 次透析治疗中有 241 次触发，15 名儿童在 91 次 HD 治疗中有 139 次触发，年龄范围为 28-205 个月，超过 8 周的时间（第一个周期），在 13 名儿童的 91 次 HD 治疗中有 102 次触发，年龄范围28-205 个月，再持续 8 周（第二周期）。在 pHTT 通知干预后，每次治疗的伤害率从 1.03 (94/91) 显着降低到 0.32 (29/91)，P < 0.001。在两个周期之间，按危害类别划分的触发因素分布 ( P < 0.001) 和 pHTT 各个领域的触发因素比例 ( P = 0.004)之间存在显着差异。没有触发因素被评估为造成永久性伤害。

结论

这项试点研究展示了床边工具监测儿童血液透析期间不良事件的潜在好处。因此，在 pHTT 通知的干预措施之后，每次会话的伤害率显着降低。在标准患者安全系统下，pHTT 确定的绝大多数触发因素仍未报告，并可能导致错失改善患者安全的机会。我们建议在未来为儿童提供 HD 的中心使用儿科 HTT 作为标准护理的一部分。