Lifesaving power of preparedness in dialysis units

Article information

Korean J Nephrol. 2025;.j.krcp.25.169

Publication date (electronic) : 2025 September 19

doi : https://doi.org/10.23876/j.krcp.25.169

Kyung Don Yoo^,1,2,3

¹Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea

²Basic-Clinical Convergence Research Institute, University of Ulsan, Ulsan, Republic of Korea

³Disaster Preparedness and Response Committee, The Korean Society of Nephrology, Seoul, Republic of Korea

Correspondence: Kyung Don Yoo Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 25 Daehakbyeongwon-ro, Dong-gu, Ulsan 44033, Republic of Korea. E-mail: ykd9062@gmail.com, ykd9062@uuh.ulsan.kr

Received 2025 May 31; Accepted 2025 June 23.

Patients undergoing hemodialysis are particularly vulnerable to intradialytic emergency situations. The consequences of sudden cardiac arrest in a dialysis center can be dire if facilities and staff are unprepared [1–3]. Real-world evidence comes from a Korean nationwide cohort study by Park et al. [4] that examined the impact of emergency equipment preparedness on the survival of patients undergoing hemodialysis. For 34,950 patients, facilities were classified based on the availability of five key emergency items: an oxygen cylinder, suction device, intubation kit, electrocardiogram (ECG) monitoring, and defibrillator. A total of 4.8% of patients were maintained on dialysis in units lacking at least one of these critical items, and over a follow-up of 4.5 years, patients in the well-equipped units had significantly better survival. Preparedness for all recommended emergency equipment was associated with a 13% lower risk of mortality (adjusted hazard ratio, 0.87; p = 0.004) [4], indicating that a fully equipped dialysis unit can improve patient survival. This provides real-world evidence that having the right tools at hand during a dialysis emergency can save lives.

The incidence of sudden cardiac death in dialysis patients is reported that 50 per 1,000 patient-years, more than 25-fold higher than that in the general population [5,6]. In-center intradialytic cardiac arrests are uncommon on a per-treatment basis—approximately one event per 100 patient-years of dialysis; however, they carry extremely high immediate mortality rates [2]. Previous studies have not always shown clear benefits of specific interventions in dialysis clinics. A United States study reported that simply placing automated external defibrillators (AEDs) in outpatient dialysis centers did not significantly improve cardiac arrest outcomes [7]; survival at 30 days and 1 year after in-center cardiac arrest was not affected by the presence of an AED. This nationwide Korean data in the study by Park et al. [4] looks at a broader bundle of emergency preparedness, not just AEDs in isolation and long-term outcomes; the findings suggest a meaningful benefit. This underscores that comprehensive preparedness, which includes the full kit of resuscitative equipment and, presumably, staff trained to use it, makes a difference in real-world settings. Intradialytic arrest typically presents as the sudden collapse or unresponsiveness of a patient during a dialysis session. Often, there are no prodromal symptoms; there are warning signs immediately before the arrest, such as acute dizziness, chest pain, palpitations, or undetectable blood pressure with severe hypotension; however, these can be missed if the patient is not under close observation. Dialysis staff may initially believe that a patient has fallen asleep, leading to critical delays in recognition [1]. On initial assessment, most intradialytic arrests were found to have pulseless electrical activity (PEA) or asystole. Continuous ECG monitoring is not routine in outpatient dialysis clinics; however, studies with implantable loop recorders and reports of resuscitation events have shown that bradyarrhythmias are more common than ventricular fibrillation in these arrests [8]. PEA may result from profound hypotension or electrolyte-induced electromechanical dissociation, whereas asystole may result from hyperkalemia or extreme ischemia. Ventricular tachycardia or fibrillation occurs especially in patients with underlying ischemic cardiomyopathy [8]. Among facilities lacking emergency equipment, defibrillators represent the most frequently missing items, accounting for 62.9% of equipment deficits [4]. The critical role of rapid defibrillation in managing intradialytic cardiac arrest is well documented, with survival rates diminishing substantially for every minute that defibrillation is delayed. Ensuring the availability of defibrillators in hemodialysis units must be prioritized as an urgent patient safety measure. Consequently, dialysis staff are trained to respond to standard basic and advanced cardiac life support protocols. When a cardiac arrest is recognized, the bloodlines are typically clamped and disconnected quickly to allow cardiopulmonary resuscitation (CPR) access and avoid blood loss; the patient is laid flat and often moved from the dialysis chair to the floor before CPR is initiated and a defibrillator is applied. According to survey data, dialysis unit first responders sometimes face ambiguity about whether to start CPR in a chair or move the patient to the floor; roughly half of events involve CPR initiation in the dialysis chair, with the other half initiating CPR after moving the patient [1]. The clinical reality is that prevention and early intervention, such as treating arrhythmias or hypotension before full intradialytic arrest, are far more likely to save lives than resuscitation after an arrest has occurred. Therefore, dialysis staff must receive regular, structured training in the use of emergency equipment and protocols, which aligns with the findings of a recent systematic review highlighting the benefit of interactive and multicomponent interventions in improving the ability of both healthcare staff and patients to effectively recognize and respond to life-threatening emergencies [9].

In South Korea, emergency equipment availability is systematically assessed at the national level through the Health Insurance Review and Assessment (HIRA) dialysis quality evaluation program. One significant contribution of the recent study by Park et al. [4] is its demonstration of the real-world clinical value of the national assessment criterion. Their findings explicitly showed that dialysis clinics that were fully compliant with the HIRA emergency equipment standards significantly improved patient outcomes. Previous research by the same group also highlighted the strong correlation between dialysis facility star ratings in the HIRA assessment and patient survival, further underscoring the crucial role of systematic quality management [10]. Dialysis facilities rated one or two stars had notably higher proportions of missing emergency equipment, demonstrating a gap in compliance with preparedness standards among lower-rated institutions [4]. Despite these national efforts, gaps in compliance persist. Approximately 5% of Korean dialysis patients still receive care in facilities that lack emergency preparedness. Such variability highlights the need for rigorous adherence to national standards and consistent quality control across all dialysis centers. Table 1 summarizes and compares key emergency preparedness measures across dialysis facilities in Korea, Japan, the United States, and the Philippines, highlighting differences in national regulations and their practical implementations.

Table 1.

International comparison of emergency preparedness measures in dialysis units

An important caveat in interpreting the findings of Park et al. [4] is that the analysis included only dialysis centers evaluated by the national HIRA system, excluding facilities such as nursing hospitals that predominantly provide dialysis for severely ill hospitalized patients. Since 2023, the HIRA dialysis quality evaluation has been expanded to include these nursing hospitals, and future research should closely examine whether similar positive outcomes are observed in this high-risk patient population.

Emergency preparedness in dialysis units is essential to protect patients and effectively manage medical emergencies during dialysis sessions. Park et al. [4] demonstrated that comprehensive emergency equipment preparedness significantly improved patient survival. Furthermore, dialysis units should be encouraged and incentivized to participate in national quality assessments to achieve higher standards. Ultimately, genuine preparedness requires more than equipment availability; regular staff training and drills are necessary to ensure rapid and competent responses to emergencies, thereby directly enhancing patient survival outcomes.