Stopping Fistula Hemorrhage without Bleeding Time and Money – A Low Cost, Low Resource Hemodialysis Fistula Model for Emergency Medicine Residents
Correspondence should be addressed to Lacie Bailey, MD, MHPE, MS at labailey@mcw.edu
DOI: https://doi.org/10.5070/M5.52204
ABSTRACT:
Audience: This bleeding fistula model is designed to instruct emergency medicine residents and third- and fourth-year medical students on their emergency medicine rotation.
Introduction: The prevalence of end-stage renal disease (ESRD) has increased since 2001 (808,536 people in 2021 versus 409,226 in 2001).1 About 14% of the United States population has a decreased glomerular filtration rate (GFR), and the overall presence of ESRD in the population as of 2021 was 2,219 per million population.1 As of 2021, 87.7% of patients receiving dialysis were on hemodialysis.2 Around 60% of dialysis patients use a fistula for access.3 Patients with ESRD have a high emergency department utilization rate, and emergencies related to dialysis include hyperkalemia, volume overload, bleeding at the dialysis site, infection, aneurysm, and pseudoaneurysm .4-9 It is important for emergency medicine (EM) physicians to be able to intervene quickly on life-threatening complications related to dialysis, including vascular access hemorrhage. There are approximately 250 deaths related to vascular access hemorrhages yearly, and it accounts for 0.4% of deaths in patients on dialysis.4 Patients with an initial presentation of hemorrhage from their vascular access site are also at risk for re-bleeding, and 80% of patients with bleeding die at home.10 Due to the high acuity and low occurrence (HALO) of bleeding fistulas, procedural knowledge of hemorrhage control and a thorough understanding of dialysis-related complications is paramount for EM physicians.
Educational Objectives: After using the task trainer bleeding fistula model, learners will be able to: 1) identify vascular access hemorrhage as an emergency presentation in dialysis patients; 2) execute a stepwise approach to manage a bleeding fistula; 3) demonstrate effective hemorrhage control for a patient with uncontrolled bleeding from their fistula, including choice of appropriate suture material and suturing technique; and 4) discuss pitfalls of hemorrhage control in patients with fistulas, including risks of tourniquet use and complications related to clot formation at the fistula site.
Educational Methods: The novel bleeding fistula model was embedded within a high-fidelity simulation for learners as part of weekly EM resident didactics. Learners received a pre-brief session to the simulation case. They then participated in a simulation scenario using a high-fidelity manikin with the bleeding fistula model on the manikin’s arm. The bleeding fistula model allowed learners to progress through a stepwise approach to achieve hemorrhage control in a patient presenting with bleeding from a dialysis access site. After the simulation, learners participated in a simulation debrief, which included a procedural skills workshop.
Research Methods: This simulation scenario and model have been used in two academic year didactic sessions to collect learner data. Across the two years, a total of thirty-two learners consisting of fourth year medical students, post-graduate year 1 (PGY-1) and PGY-2 residents have participated in the high-fidelity simulation at a Society for Simulation in Healthcare (SSH) accredited, state-of-the-art simulation center. Learners performed a self-assessment survey using a three-point Likert scale after participating in the high-fidelity simulation case. A retrospective pre- and post-simulation survey was conducted. They answered survey questions related to their confidence of identification of a bleeding fistula and knowledge of treatment of a bleeding fistula before and after the simulation.
Results: Over two years of implementation, we had thirty-two learners participate in the simulation and use the model for demonstration of hemorrhage control of a bleeding fistula. Based on self-assessment, learners overall felt that their overall knowledge regarding hemodialysis access hemorrhage increased. Prior to the simulation, eighteen learners rated their confidence in identification of a bleeding fistula as “average,” and fourteen learners rated their confidence as “below average.” After participating in the simulation, seventeen learners rated their confidence in identifying a bleeding fistula as “above average,” and fifteen learners rated their confidence as “average.” Prior to the simulation, thirteen learners rated their knowledge of the management of bleeding fistulas as “average,” and nineteen learners rated their knowledge of the management as “below average.” After the simulation, eighteen learners rated their knowledge in the management of a bleeding fistula as “above average,” and fourteen rated their knowledge of the management as “average.”
In the composite score, learners self-reported knowledge and confidence in managing bleeding fistulas improved. The pre-simulation score had a mean of 2.17 and a median of 2.0, increasing to a post-simulation mean of 3.31 and a median of 3.0. This difference was statistically significant (p < 0.00001), indicating a robust improvement in learners perceived comfort and knowledge following participation in the bleeding fistula simulation, hands-on task trainer, and debriefing workshop.
Discussion: This novel fistula model helped residents practice a HALO procedure that closely simulated a real bleeding fistula. The model bled akin to a real fistula, with the ability to make the bleeding pulsatile and occlude with suturing, direct pressure, and tourniquet placement. In the literature review, there are no current simulation models or task trainers to get hands-on experience with management of hemodialysis access hemorrhage. This scenario tested resident knowledge of management of dialysis emergencies, and there was a good discussion regarding the subject. Residents stated that this simulation was helpful. They learned new information and were able to get hands-on practice to reinforce that knowledge through this activity and the use of the bleeding fistula model.
Topics: Dialysis, end stage renal disease, end stage renal disease complications, bleeding fistula, hemorrhage control, simulation, fistula model, HALO Procedure.
