Developing a trigger tool to monitor adverse events during haemodialysis in children: a pilot project.

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

Improved blood pressure and left ventricular remodelling in children on chronic intermittent haemodialysis: a longitudinal study.

OBJECTIVES: We aimed to examine longitudinal changes in left ventricular (LV) structure and function and evaluate factors associated with LV remodelling in children on chronic haemodialysis. METHODS: Retrospective longitudinal study including all children from the start of chronic haemodialysis with two or more m-mode 2D echocardiograms and tissue Doppler studies. Left ventricular mass (LVM) in g/m2.7, geometry and LV function were compared at baseline (dialysis start) with follow-up studies at least 6 months following commencement. Left ventricular hypertrophy (LVH) was defined if greater than 95th percentile as per age-specific centiles. We also defined LVH as indexed LV mass index (LVMI) > 51 g/m2.7 and using LV mass-for-height z-scores greater than the 95th percentile. Biochemical data, interdialytic weight change and blood pressure level were assessed for their association with change in indexed LVM. RESULTS: Twenty-three of the 32 children < 18 years were included (n = 5, < 5 years) with last follow-up study performed following dialysis after a median (IQR) of 21 (10-34) months. The prevalence of LVH reduced significantly (69.6%, (n = 16/23) vs. 39.1% (n = 9/23), P = 0.002); LV geometry improved (13% concentric and 56.5% eccentric vs. 8.7% and 17.4% respectively) with mean ± SD reduction in indexed LVM (50.8 ± 23.1 g/m2.7 vs. 38.6 ± 14.7 g/m2.7, P = 0.002) and LV mass-for-height z-scores (0.67 ± 1.66 vs. - 0.46 ± 1.88, P = 0.002) from baseline to last follow-up respectively. There was no change in systolic function (LV fractional shortening, 37% vs. 38%, P = 0.39) and diastolic function (mean E/E' 10.8 vs. 9.0, P = 0.09). Multiple regression analysis identified improved systolic BP control (ß = 0.41, P = 0.04) as an independent predictor for change in indexed LVM. CONCLUSIONS: LV structure and function can improve in children despite long-term chronic intermittent haemodialysis. Cardiovascular health in this population does not always deteriorate but can be stabilised and indeed improved with optimal blood pressure management.