A Costly Complication: Venous Needle Dislodgement

By Jane Hurst, RN, CLNC

We have seen amazing advances in medicine in the past 65 years. Diseases that would have been fatal in 1945 are now usually treatable and many are curable. More and more advances are made every day, but modern medicine can come with a hefty price tag. Treatments can be very expensive costing thousands if not hundreds of thousands of dollars. Specialized treatments, procedures, and medications can quickly add up to momentous amounts. In looking at the cost, it’s not just the price of the treatments. Patients may suffer, and new complications may occur due to the risks and side effects of the treatments themselves. A complication in medicine is an additional problem that arises following a procedure, treatment or illness and is secondary to it. A complication complicates the situation.¹

Every treatment and procedure has associated risks and complications. Complications may delay the recovery time for a patient, have an effect on the patient’s ability to recover from the primary illness, and could also result in death.

Creating a Balance

In order to better understand how certain inherent complications, such as venous needle dislodgement (VND) can be avoided, it helps to be aware of the safety measures that help guide medical treatment.

Maintaining a reasonable balance between safe, high-quality patient care and cost containment is a never ending balancing act. It requires a consolidated effort from the medical professionals, facilities, insurers, and the patient.

• The medical professionals are responsible for carrying out care that meets the acceptable guidelines, and providing assessments of the patients so complications may be identified and treated as necessary.
• The facility’s role is to ensure that the medical professional employed in the clinics are well trained and carry out safe patient care, according to policies and procedures. They also ensure that the facility’s professionals are trained on the safe use of the equipment.
• Insurance companies, many times in the form of managed care companies, contribute by setting forth their philosophy of providing the safest, highest quality healthcare while controlling costs.
• Patients are assuming an even larger role in their care. Patients are being educated about their diseases and treatments so they can assume an active role in their care.

Costs to provide the safest and highest quality of care are carefully calculated. Unexpected expenditures for complications arising from a treatment, or expenses related to liability issues can interrupt the delicate balancing act.

Focus on Safe, High Quality Care

In the early 1980s professional medical associations, as well as insurance companies and voluntary organizations began the process of identifying the best methods for treating diseases and illnesses consistently.²

By the late 1980s, the American Medical Association, working with medical specialty societies, launched a major initiative that signaled the endorsement of medical standard-setting by the organized medical profession.³ One of medicine’s goals was to raise the quality of patient care by developing written guidelines for the management of diseases and illnesses, as well as treatments and procedures. The collaborative effort resulted in the development of medical standards of care, which are in use today. Evidence-based medicine is also used in U.S. healthcare. It is best described as means integrating individual clinical expertise with the best available external clinical evidence from systematic research.⁴

Some of the goals of standards of care include: improving patient outcomes and quality of care, preventing duplication and overuse of services, controlling costs, and eliminating or reduce costly complications. Standards of care do not refer to one thing. There are several categories that fall under the term standard of care:

• Standards of quality: statements defining the minimal level of performance,
• Clinical practice guidelines: statements to assist practitioners in decision making
• Medical review: assesses the appropriateness of decisions, services, and outcomes
• Performance measures: monitors quality, practice guidelines, and medical review criteria

Dialysis

Dialysis is an example of a treatment that has dramatically changed the lives of people with renal failure. The short-term goal of dialysis is to correct fluid and electrolyte imbalances and remove toxins. Long-term goals include optimizing the patient’s functional status and blood pressure, preventing uremia, and improving the patient’s quality of life and survival.

Medical professionals and patients are constantly alert for possible complications that may occur as a result of the treatment before, during and after a dialysis. Because dialysis affects every system in the body, the list of potential complications is long. Some examples are: decreased blood pressure, cramps, increased temperature, heart irregularities, air embolism, infections, seizures, low oxygen level, and VND. Some complications are more common than others, and some pose a greater threat than others to the well-being of the patient.

VND

One of the most serious complications in dialysis is venous needle dislodgement. If the venous needle becomes dislodged or disconnected from the vascular access, large amounts of the patient’s blood may be pumped outside of the patient’s body in a matter of minutes. For instance, if a dialysis machine is set to pump the blood at 400 mL/min, the patient loses the equivalent of 13 ounces of blood (over 1 ½ cups) every minute. This can have tragic results if the dislodgement isn’t recognized immediately. Dialysis machines are required by law to have pressure alarms built into them that are set to be triggered if the pump pressure falls below a specified amount. Unfortunately, once the end of the needle is out of the patient’s access, and the blood is being pumped into the bed or chair, there is very little leeway in time before the patient experiences a massive hemorrhage or dies from exsanguination.

New information on the incidence of VND, based on recent statistics, indicates it occurs much more frequently than what was once thought. More than 200 needles dislodge everyday.5 More than two patients have a VND with a serious outcome everyday.6 More than two patients die every week due to VND.⁷

If dislodgement is recognized early, the patient may not lose enough blood to warrant any additional treatment; however, it is such a rapidly occurring incident that large amounts of blood may be lost very quickly if intervention isn’t begun almost immediately.