From: Deborah Brouwer

RE:  JCAHO National Patient Safety Goal #3 may have an adverse impact on inpatient dialysis units


Hypertonic Saline Solution

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established six national safety goals.  Goal # 3 has a very negative impact for any hemodialysis providers that fall under a hospital seeking re-accreditation. This will impact both acute and chronic hemodialysis units owned by a hospital.  The freestanding chain dialysis center will not be required to address this goal as it is a JCAHO goal, not a State Department of Health issue. 


2003 National Patient Safety Goals

Beginning Jan. 1, 2003, all JCAHO accredited health care organizations will be surveyed for implementation of the following recommendations-or acceptable alternatives-as appropriate to the services the organization provides. Alternatives must be at least as effective as the published recommendations in achieving the goals. Failure by an organization to implement any of the applicable recommendations (or an acceptable alternative) will result in a special Type I recommendation. Organizations are made aware of the requirements to meet the NPSG-related recommendations in the Accreditation Participation Requirements in the accreditation manual.

Goal # 3. Improve the safety of using high-alert medications.Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.

Standardize and limit the number of drug concentrations available in the organization.


 For the full text see the JCAHO web site at


Hypertonic Sodium Solution or Sodium Chloride concentrated 23.4% (4mEq/ml) is used routinely to prevent and treat hemodialysis related intradialytic hypotension and dialysis related cramps.  Intradialytic hypotension occurs in 20%-30%of dialysis sessions and has been linked to higher morbidity and possibly higher mortality.  Dialysis related cramps occurs in 5%-20% of dialysis sessions.  Medications used to treat cramps or hypotension in hemodialysis include normal saline solution (0.9%), hypertonic saline (23.4%), mannitol, dextrose solution (D50), or salt poor albumin.  The volume of normal saline solution is usually limited to 500cc's per dialysis session.  Mannitol and hypertonic saline solution are limited to two doses per session and are both a standard of care in most US hemodialysis units.  Salt poor albumin is not used routinely due to excessive cost of the product.  Dextrose solution has been replaced by mannitol in most dialysis units because it can be used with both diabetic and non-diabetic patients. Dialysis machine may have various options that can also be utilized to help prevent cramps and hypertension.  Ultrafiltration modeling, sodium modeling and dialysate temperature modeling are options, but not necessary available with all current hemodialysis machine in use today.  Extension of the patient's treatment time is another alternative to reduce the ultrafiltration rate for a specific dailysis session, but due to time and transportation issues, the dialysis unit can not always accommodate extended treatment times without advance notice.  Patients often present to the dialysis unit with an excessive weight gain and require dialysis without the option of extending the dialysis session time.  The National Kidney Foundation Kidney in 2000 updated the  Disease Outcomes Quality Initiative (K/DOQI) Guidelines for Hemodialysis Adequacy of Hemodialysis.  Guideline 15 reads:

Optimizing Patient Comfort and Adherence

Without compromising the delivered dose of hemodialysis, efforts should be undertaken to modify the hemodialysis prescription to prevent the occurrence of intradialytic symptoms that adversely affect patient comfort and adherence.


The hemodialysis patients that receive hemodialysis at a hospital based or owned dialysis unit face the loss of important drug to treat intradialytic hypotension or cramps. Patients that require an ambulance transport to dialysis are often required to be dialyzed in a hospital base unit and are commonly very debilitated and sick patients. The lack of hypertonic saline solution poses a higher risk of intradialytic complications to patients.  Patients that dialyze at a non-hospital, freestanding or chain dialysis unit can still continue to receive hypertonic saline solution for treatment of their intradialytic hypotension or cramps. This places an unfair burden on hospital based or owned dialysis units by preventing a standard of care medication to be given to their patients only. 


JACHO will allow a Request for Review of an Alternative Approach to a National Patient Safety Goal Recommendation ( The form can be downloaded from this link:


Due to the large number of dialysis units that will be effected by the new safety goal, an industry response to the goal as it applies to hemodialysis is necessary to keep this standard of care medication available to all dialysis patients.  Please help with this issue to ensure all dialysis patients can safely receive hypertonic saline solution for the treatment of intradialytic hypotension or cramps. 


If you can help with this issue, please contact:

                        Deborah Brouwer RN CNN or Terry Sherockman RN

                        Allegheny General Hospital

                        Division of Nephrology and Hypertension

                        320 East North Avenue

                        Pittsburgh, PA 15212

                        412-359-6703 (Deborah) 413-359-8698 (Terry)

                        dbrouwer &at& or tsherock &at&

                        <<email “at” signs removed to prevent spamming>>




William L. Henrich, MD, Up to Date Online 10.3, "Hemodialysis instability during hemodialysis: Overview."


Daugirdas J, Blake P, Ing T. Handbook of Dialysis 3rd edition Chapter 7 Complications During Hemodialysis.


National Kidney Foundation K/DOQI Guidelines 15 for Hemodialysis Adequacy,