As a relatively new DON, I recently ran into the issue administration ordered we cut back on heparin (no maintenance dosing during tx) and to cut back on normal saline use. I'm told 1.5 liters per tx is too much. Reportedly the price of heparin and saline doubled (according to my last meeting with admin). We use Cobe3 and instructed to use the prime for recirc and to turn uf off to save 200ml per tx. I have no idea how to do this technically and I thought per CMS rules we had to follow manufactor recommendation for the dry packs we use (optiflux F160NR/F180NR)? Couldnt we be cited for this during surveyor observations? I'm having trouble with line clotting and diminished Kt/V's.I restarted a few of the maintenances as my patient comes first. I'm not sure how to approach this with my upper management as it definitely is affecting pt outcomes also. Therefore I had some extra lines used due to clotting in the chambers yet did save dialyzer and having to justify why we used 6 additional lines for the month. We are a relatively small clinic also with an average census of 26-28.

Hello New DON,
I work for a very large Dialysis provider and have also seen the effects of cutbacks in Heparin Dosing due to cost. We no longer follow Manufacturer's recommendations when priming the dialyzer and system with saline, also due to cost issues. Although in-house studies had been performed to "JUSTIFY" these changes, and to prove that after all these changes have been made, that it is still safe for the patient. The downside will always be that it is truly the patient that is paying the ultimate price. Clotted systems, clotting in dialyzers and drip chambers contribute not only to Anemia but additionally also to poor Adequacy. I always remind people that we are obligated to do what is "BEST FOR OUR PATIENTS". Saline flushes during treatment generally don't work - anyone that has tried it will pretty much agree, it is a bandaid that does not even work. Temporarily for about 1-2 minutes and as soon as one walks away from the dialysis delivery system the pressures begin to creep back up. High pressures, especially a high TMP can contribute to fibers breaking, Blood leaks and/or Pressure Fails on the Renatron Station. Once again if it happens during treatment, the already anemic patient looses more blood.
Medicare Regulations state that orders for patients must be based on an Individual Basis and we know that ONE FITS ALL heparin dosing certainly is not working.
I always try to treat patients with the best of care and think of them as though they are my Mother or Father. What kind of treatment would we like for our loved ones?

Italian Girl