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V 543

An in-service was initiated to all DPC staff and the Interdisciplinary Team (IDT) on 12/1/21 by the Clinic Manager regarding the importance assessing and managing patients with hypertension and on following physician's orders and the facility policy on charge nurse (CN) notification for hypertensive patients. Specific emphasis was placed on the revision to the Hypertension procedure with removal of the parameter of reporting DBP>100mmHG, to ensure that it mirrors the reporting parameters as set in the facility standing order with signs of hypertension being set at "Systolic blood pressure (SBP) >180 mmHg." Following the facility standing order was also reinforced during the in-service and states to give "Clonidine 0.1mg PO for systolic blood pressure (BP) that has been greater than 180 mmHg for two hours (may repeat x 1)." The following was also discussed during the in-service:
Hypertension:
- All DPC staff must report patients with an SBP >180 mmHg to the nurse in charge.
- The nurse in charge must complete an assessment of the patient and follow the facility standing order for administering Clonidine (unless different specific parameters for the patient was ordered by the physician and documented on the patient's medical record).
- The nurse in charge is to follow up with the patient, in a timely manner, to ensure that clonidine administered was effective. If patient's SBP remains elevated the physician is notified for further orders, if indicated.
- No patient is to be discharged from the facility with an SBP >180 mmHg without notifying the nurse in charge, who will notify the patients physician for further orders, if indicated.
- The facility quality indicator for SBP is for all patients to have a post dialysis sitting SBP of <160mmHG. The patients post sitting SBP must be entered into the clinic portal (the facilities computerized tracking system) to monitor and report those patients not meeting goal, to the patient's physician.
- The nurse in charge must ensure that all assessment, intervention, and follow up assessment findings is documented on the patient treatment record. As well as, any notifications to, or orders received by the patient's physician.
Estimated Dry Weight (EDW):
- Each patient must have evidence of a physician order for the EDW on their medical record and this must be documented on the daily treatment sheet.
- A post treatment assessment of the patients EDW must be conducted to ensure the patient's post weight is within 1 kg +/- their EDW and that there is no evidence of fluid overload, such as edema or abnormal lung sounds.
- If the patient's post treatment EDW is > 1kg +/-, the nurse in charge must be notified, and the nurse in charge must notify the patient's physician for further orders if indicated.
- Each patients pre and post weight will be entered onto the Fluid Management Report in the clinic portal at the end of each treatment day. The CN will review this report and if the patient is not achieving their EDW for 3 consecutive treatments, the physician must be notified, the patient evaluated, and a new EDW obtained, if indicated.
Treatment safety checks:
- Per policy, safety checks must be conducted every 30 minutes during the treatment to ensure the patient vital signs, including blood pressure, is stable and this must be documented on the patient treatment record. It is unacceptable to miss these 30-minute checks.
- Also, per policy, all entries must be legible.
- Documentation of the 30-minute safety checks and all documentation on the treatment record must be legible in order for staff to safely determine the patient's condition and progression throughout the dialysis treatment.
The IDT team will meet with patient #2 by 11/29/21 to address incidents of hypertension and barriers to meeting their blood pressure goals. The IDT will establish goals and reasonable timelines in order for patient to achieve their individualized blood pressure goals (including evaluating the patient current EDW). This information will be documented in the patient Comprehensive Assessment and Plan of Care (CA/POC). All active patient records have been reviewed and any patient not meeting their individualized blood pressure goals will have a CA/POC implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
The nurse in charge will round on all patients, at least twice per shift, to ensure (A CN rounding tool was developed to monitor this action:
- DPC staff are reporting incidents of patient with SBP >180 mmHG, and that there is documentation on the medical record that the charge nurse was notified and the patient's physician was notified, if need be, and that the standing orders and facility procedure are followed as outlined above.
- After each shift of patients has completed treatments, the CN is to review the treatment records and verify the BP's are being reported as outlined above.
- Additionally, the CN will enter the patient's post sitting SBP on the SBP tracking report into the clinic portal. Any patient not meeting a post sitting SBP <160mmHG will be reported to the patient's physician, at the end of the week, for further review and orders if indicated. Those patient's continually not meeting the goal will be referred to the IDT and a CA/POC will be implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
- Additionally, the CN is to review the post treatment records to ensure the patient's pre and post EDW was assessed and patient is not discharged with a post treatment weight > 1kg +/- their EDW, without notifying the CN. Any patient not meeting their EDW for 3 consecutive treatments will be reported to the patient's physician for further orders, if indicated. Those patient's continually not meeting the goal will be referred to the IDT and a CA/POC will be implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
- Additionally, all records will be reviewed by the CN to ensure there are no missed 30-minute safety checks and that all treatment documentation is legible. Any discrepancies will be reported to the CM immediately.
The clinic manager will spot check one day of treatment records once a week for the next 12 weeks to ensure (A CM monitoring tool has been developed to document these findings):
- SBP's are being reported to the nurse in charge and Clonidine is being administered as outlined above.
- The CN is conducting a reassessment of the patient to ensure the patient's SBP has improved and if not, the physician is notified and this is documented on the patient's treatment record.
- All pre and post assessments of the patient EDW is documented on the treatment sheet and that no patient is discharged with a post treatment weight > 1kg +/- their EDW, without notifying the CN.
- All DPC staff are recording each 30-minute safety check and that all entries onto the treatment record are legible.

The clinic manager will ensure compliance by direct review of the treatment records and through review of the charge nurse rounding tool. Additionally, as a member of the IDT and Total Quality Management (TQM) team, the CM will ensure compliance through review of the SBP tracking report and the Fluid Management Summary Report monthly prior to the TQM meeting where all outliers will be discussed and appropriate interventions taken to achieve goal, such as initiation of an individualized CA/POC by the IDT to establish goals and reasonable timelines in order for the patient to achieve their fluid management goals. The findings from the CM monitoring tool and CN rounding tool will also be reviewed at the monthly TQM meeting where additional action will be taken by the committee such as continuing the weekly CM monitoring and/or disciplinary action.