Sustainability sessions at the Association of Renal Technologists Conference 2018

Hello! People are asking about what examples I talked about at the Association of Renal Technologists meeting last month... I mainly reminded everyone about examples from the case library at http://map.sustainablehealthcare.org.uk/green-nephrology-projects as well as some from http://greendialysis.org (in Australia). 

Fraser did a follow up workshop session where he got everyone to consider whether their unit already does/could do actions under the following headings:

Thermal disinfection of dialysis machines:

1. Set equipment disinfection policy to post patient use and manufacturers recommended time period only. Eliminating unnecessary routine cycles
2. Set equipment disinfection policy to once daily with a rinse between patient use 

Thermal Disinfection of central water systems:

1. Reduce frequency of thermal disinfection regime:
2. Only disinfect systems when elevated TVC or Endotoxin counts are recorded?

RO reject water recovery:

1. Collect RO reject water for use in other areas of the hospital
2. Collect reject water and recover a percentage to be fed back to the inlet of the RO 

Acid distribution:

1. Switch to dilution ratio of 1:44 if using 1:34
2. Collect residual acid from canisters post dialysis to be used for subsequent sessions  
3. Retrofit central acid distribution systems into HD units
4. Install central dry powder mix systems

Dialysis fluid flow:

1. Set dialysis fluid flow based on a factor of the effective blood flow rate. 1.2 for HDF, 1.5 for HD 

Recycling:

1. Cardboard
2. Plastic
3. Installation of baling machines to help with collecting recyclable waste

Remote Access:

1. Regular home therapy patient monitoring 
2. Remote nephrologist consultation, transplant follow up, dietetic clinics etc.
3. Home patient technical support
4. Remote logging of equipment

Following the meeting, we are keen to explore what might be possible in terms of pushing some of these actions nationally. A good place to start would be the phase-out of 1:34 acid concentrate, since all machines can be configured to use the higher dilution ratio, 1:44, which means smaller volumes, less transport…

It would be great to hear from others on any progress being made in your units on any of the above, or ideas for how we can accelerate things.

Hi and thanks!

I would like to know some more about the point n°2 :"Collect residual acid from canisters post dialysis to be used for subsequent sessions " ..... it's something which is in on my mind since a long time, but easier to be said than to be done: it's clearly written :"single use" on the bags, but still it's always clean and sometimes even an half of the bag is thrown away! You know some centre in which this procedure is used? can you produce a written procedure?

thanks, and forgive my not-perfect English!

Hi Silvia, this is practiced at a number of units in the UK after thorough risk assessment and putting careful procedures in place, mainly by protecting the acid can from contamination by using protective caps through which the acid intake passes.

You have to be aware that you are taking responsibility for using the product on more than one patient, however when the risks are assessed properly and mitigating processes are put in place UK renal services have been able to reduce this waste. 

I've attached a link to a document that may be useful

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/743416/Single-use_medical_devices_implications_and_consequences_of_reuse.pdf

Thanks again Frances,

I've read the arcticle but ... it doesn't incourage to reuse any of the disposables we use, neither acid concentrate bags or bicarbonate cartridge. so, if I understood: it's a procedure many centres do, but there is nothing written or officially declared, since this (very clear!) document says the opposite?

Hi Silvia,

The document from the UK MHRA states that products which are intended to be used once by the manufacturer are clearly labelled as such as there can be risks associated with reusing these products. In the case of acid concentrate, the product is "used" when it is drawn into a dialysis machine and mixed in order to make a dialysis solution. This is then passed through a diayser in order to treat a patient. There are obvious risks in trying to reuse the product in this circumstance, and no one is suggesting we collect spent dialysis fluid to be reused.

In collecting the "unused" acid concentrate we are not infringing this guidance. We are effectivly using all the product once instead of wasting large quantities of it. The potential risk in this process is around environmental contamination of the unused product, which is addressed by protecting the acid can with caps during treatment and careful procedures for collection and storage.    

just to make it more interesting ... I attached three of our bags leaflets ... the third one is in Italian and means: "single-use AND single patient"

Hi Silvia,  maybe there is something missing in the translation but i would say it's a distinct difference!

I'm not aware of any national or international body with a written and approved procedure for this. It would be for you and your clinical/operational leadership to write your own procedure, based on local conditions and indentified risks.

To me the biggest risk is that an un-qualified member of staff does it and pours the remnants of 1 formulation into a different can formulation or even worse something that isn't even HD concentrate e.g. bleach, 50% citric acid, peracetic acid. I've only ever heard anecdotal evidence of this happening a couple of times but neither of them were documented.

If they triggered a ph alarm it would stop the machine but if not the consequences could be fatal.

To me the can is the single use item not the contents or the patient otherwise we would still be able to re-use dialysers (on the same patient) which is what would save the enormous amount of waste plastics i.e. a 12 fold reduction in dialyser waste .

Best regards,

Chris Pearson 

Director Sales and Marketing 

Health Tec Medical Ltd