Record keeping in a dialysis unit involves many different facets and is important to ensure safe and appropriate delivery of dialysis to patients. This involves recording of each individual dialysis [Table 1], for an individual patient [Table 2], records of dialytic and medical care of the patient over the course of his treatments and the water quality and safety parameters for the whole unit [Tables 3-7]. In addition, dialysis units should evaluate their performance to assess their current performance with a goal for continuous quality improvement [Table 8].
Table 1.
Recording for each hemodialysis treatment
| Recommended | Suggested | Ideal |
|---|---|---|
| Initial weight | BP during HD | Kt/V from machine |
| Final weight | UF rate | |
| Dry weight | ||
| Initial BP | ||
| Final BP | ||
| Dialyzer | ||
| Station | ||
| Access | ||
| Hours on HD | ||
| BFR | ||
| Dialysate flow rate | ||
| Dialysate (Na, k, Ca, bicarb) | ||
| Conductivity | ||
| Temperature | ||
| Anticoagulation | ||
| Medications administered |
BP: Blood pressure, BFR: Blood flow rate, HD: Hemodialysis, Kt/V: Kinetic urea modeling, UF: Ultrafiltration
Table 2.
Recording for each patient
| Recommended | Suggested | Ideal |
|---|---|---|
| Consent at the start of treatment | Monthly labs | |
| Consent every 6 months | Vaccinations | |
| Monthly assessment covering | ||
| Adequacy | ||
| Anemia | ||
| Access | ||
| Hypertension and volume | ||
| Cardiac status | ||
| Transplant discussion | ||
| Nutritional status | ||
| CKD-MBD | ||
| Functional status and occupation | ||
| Quality of life |
CKD-MBD: Chronic kidney disease mineral bone disease
Table 3.
Water treatment monitoring log
| Date | Component | Action | Pressure drop | Comments | ||
|---|---|---|---|---|---|---|
| Backwashing | Rinsing | Regeneration | ||||
| Sand filter 1 | ||||||
| Sand filter 2 | ||||||
| Activated carbon filter 1 | ||||||
| Residual chlorine | ||||||
| Activated carbon filter 2 | ||||||
| Residual chlorine | ||||||
| Softener | ||||||
| Hardness | ||||||
Table 7.
Performance indicators
| Date | Colony count | Endotoxin activity | ||
| Post RO | Final | Post RO | Final | |
RO: Reverse Osmosis
Table 8.
Recording for each dialysis unit
| Recommended | Suggested | Ideal |
|---|---|---|
| Mortality | Anemia (Hgb, EPO doses, IV iron) | Quality initiatives (percent with Hgb>10) |
| Cause of death | CKD-MBD (calcium, phosphorus, iPTH, calcium bath, phosphate binders, cinacalcet) | Percent with phosphorus at goal. |
| Access (AVF, cathetertunneled or temporary, catheter bloodstream infections) | Percentage with AVF, Rate of | |
| Adequacy (measured Kt/V and machine Kt/V) | Percent patients achieving adequate Kt/V and percent treatments achieving adequate Kt/V | |
| Nutritional status (albumin) | Percent albumin >3.5/4.0 | |
| Complications | Rates of dialysis hypotension, unachieved dry weight, fever, new HBV/HCV diagnosis | |
| Sentinel events | Investigation and root cause analysis of sentinel events |
HBV: Hepatitis B virus, HCV: Hepatitis C virus, Kt/V: Kinetic urea modeling, AVF: Arteriovenous fistula, iPTH: Intact parathyroid hormone, CKD-MBD: Chronic kidney disease mineral bone disease, Hgb: Hemoglobin, EPO: Erythropoietin, IV: Intravenous, CRBSI: Catheter-related bloodstream infections
Table 4.
Water treatment monitoring log
| Date | Component | Action | Component | Pressure drop | Comments | ||
|---|---|---|---|---|---|---|---|
| Backwashing | Rinsing | Regeneration | |||||
| Cation resin | |||||||
| Anion resin | |||||||
| 5 µm filter | |||||||
| 1 µmfilter | |||||||
| RO membrane | Backwashing | High pH cleaning | Low pH cleaning | Disinfection | |||
| Ultrafilter/0.2 µmfilter | |||||||
| Loop flow/velocity | |||||||
Table 5.
System performance data
| Date | Component | Comments | ||||
|---|---|---|---|---|---|---|
| Component | Inlet Pressure | Outlet pressure | Permeate flow | Reject Flow | ||
| Raw water pump | ||||||
| High-pressure Pump | ||||||
| Transfer pump | ||||||
Table 6.
System performance data
| Date | Component | Comments | |
| Permeate conductivity | Deionizer conductivity | ||
Dialysis units that are reusing dialyzers need to have additional monitoring and recording to ensure that patients are receiving good quality and safe dialysis [Table 9].
Table 9.
Recording for reuse of dialyzers
| Patients’ name | Diagnosis | Frequency of dialysis | ||
|---|---|---|---|---|
| Dialyzer name | Dialyzer Type | |||
| Material | Original sterilant | |||
| Reprocessed by Name with signature | No dialyzer use | FBV/TCV | Leak test | Date |
FBV: Fiber bundle volume, TCV: Total cell volume
Each dialysis:
We recommend recording initial weight, final weight, dry weight, dialyzer, station number, initial BP and final BP, number of hours of dialysis, access used, BFR, dialysis flow rate, dialysate composition used (Na, K, calcium, bicarbonate), conductivity, temperature, anticoagulation, any other medications administered.
We suggest recording BP during the treatment and UF rate.
We suggest for HDF recording replacement rate and total UF.
We SUGGEST recording online kT/V from machine for each treatment where available.
Each patient
We recommend HD consent for treatment at start of dialysis at that unit and then every 6 months.
We suggest recording monthly labs, vaccination history, home medications
We suggest Monthly assessments by physicians (nephrologists/dialysis physicians)
-
We suggest addressing and recording the following issues every month:
- Adequacy
- Vascular access
- Anemia
- Cardiac status
- HTN and volume assessment
- Possibility for transplant
- Bone mineral disease
- Functional status, occupation, activity
- Medications
- Quality of life.
Dialysis unit
We recommend recording all bacterial culture and endotoxin results done monthly, RO and membrane filter pressures. Dates and type of maintenance and dates of filter changes.
We suggest recording and including as part of an annual audit.
Mortality, cause of death
Anemia status (Hb, EPO doses, IV iron administered),
Bone mineral disease (calcium, phosphorus, iPTH, calcium bath prescribed and delivered, phosphate binders, cinacalcet).
Access (fistula, catheter, fevers on dialysis, bacteremia)
Adequacy (percentage with adequate dialysis and interventions for those not adequate)
Nutritional status (albumin)
Complications: Hypotension, fever, codes, admission to hospital, sentinel event (and its investigation)
CRBSI and rate.