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Housestaff/NP Guidebook
July 2014
UHN Division of
Nephrology
D
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INTRODUCTION
Welcome to Nephrology at the University Health Network. The Division of Nephrology is one of the largestNephrology programs in Canada, encompassing treatment of Chronic Kidney Disease (CKD) with dialysis andtransplantation, general nephrology, subspecialty clinics, teaching and research. There are a large number of activestaff nephrologists at the Toronto General, Toronto Western and affiliated hospitals.
Dr. Christopher Chan, Division Medical Director
Dr. Joanne Bargman, Medical Director, Peritoneal Dialysis; Education ChairDr. Chris Chan, Medical Director, Home HemodialysisDr. Vanita Jassal, Medical Director, TR Hemodialysis, ONeill Centre Peritoneal DialysisDr. Charmaine Lok, Medical Director, RMC and Hemodialysis Vascular Access ProgramDr. Robert Richardson, Medical Director, Hemodialysis Program
In-patient clinical services consist of a 9 bed In-patient Nephrology Ward, and the Multiorgan Transplant Unit.General Nephrology is carried out through our Consulting Teams. The service is always very busy, thereforerequires much organization and co-ordination. This guidebook focuses on your rotation in General Nephrology andis a guide to management of nephrology patients utilizing accepted protocols and useful suggestions.
Outpatient clinical services consist of Home Peritoneal Dialysis (PD), Outpatient Hemodialysis (HD), Home HD, Self-Care HD and Out-patient clinics including an active Renal Management Clinic. Additionally, we have a HD unit atToronto Rehab (TR) on University Ave., which provides HD for patients in rehab at TR and in chronic care at TRsBickle Centre facility at Dunn Ave, and we provide PD at ONeill Centre nursing home. Our Nephrology servicecovers all UHN sites as well as consultation for Mount Sinai and Womens CollegeHospitals. The philosophy ofcare is toward that of Living Well at Home, Self Management, and Home/self-care modalities of dialysis - PD, HDand Nocturnal HD.
During this rotation, you will have exposure to, and learn how to manage many of the following conditions: AcuteKidney Injury (AKI); chronic kidney disease (CKD); end-stage kidney disease (ESKD); an understanding ofdialysis - both HD and PD; hypertensive disorders; renal disorders of pregnancy; tubulointerstitial renaldiseases, cystic diseases and other hereditary disorders; glomerular and vascular diseases (including theglomerulonephritides, diabetic nephropathy, and atheroembolic disease); disorders of mineral metabolism,including nephrolithiasis and renal osteodystrophy; disorders of fluid, electrolyte, and acid-base regulation;disorders of drug metabolism and renal drug toxicity.
It is hoped that this Guidebook will assist you in the management of your patients and in your learning experience. Inan effort continually improve our service; we welcome feedback on this document.
Guidebook Editor:Diane Watson, Nurse [email protected](416) 340-4800 ext 8238Co-editor: Debra Appleton, [email protected](416) 340-4800 ext 8726
Contributors:
UHN Division of NephrologyUHN Renal PharmacistsUHN Nephrology Allied HealthDr. Stephen VasDr. David Mendelssohn
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]7/21/2019 UK_UHN_Man_2014
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TABLE OF CONTENTS
UHN DIVISION OF NEPHROLOGY ....................................................................................................................................... 1
INTRODUCTION ........................................................................................................................................................................ 2
NEPHROLOGY PROGRAM .................................................................................................................................................... 6
In-Patient Nephrology Ward.................................................................................................................................................. 6
MEDICAL COVERAGE .................................................................................................................................................................. 7
Red and Blue Teams Acute Care Teams:......................................................................................................................... 7
Yellow Team In Patient Ward Team and TWH Nephrology:.......................................................................................... 7ROUNDS ....................................................................................................................................................................................... 8
Sign-In Rounds ....................................................................................................................................................................... 8
Sign-out Sheets ....................................................................................................................................................................... 8
Patient Centred Care Rounds ................................................................................................................................................ 9
Teaching Rounds .................................................................................................................................................................... 9
Sign Out Rounds ..................................................................................................................................................................... 9
Ambulatory Care Clinics........................................................................................................................................................ 9
On Call .................................................................................................................................................................................. 10
Confidentiality ...................................................................................................................................................................... 10
NEPHROLOGY TEAM ................................................................................................................................................................. 10
Nursing Staff ......................................................................................................................................................................... 10
Renal Management Clinic (RMC) ....................................................................................................................................... 11
Consulting Nurse Practitioner (cNP) (currently on leave 2014) ....................................................................................... 14
Physiotherapy/Occupational Therapy ................................................................................................................................. 14
Renal Pharmacists ................................................................................................................................................................ 16
Vascular Access Coordinator .............................................................................................................................................. 16
PD Catheter Coordinator .................................................................................................................................................... 16Hemodialysis Units ............................................................................................................................................................... 17
Dialysis Start Unit12 ES Room 411. ph 4757.............................................................................................................. 17Toronto Rehab (TR).............................................................................................................................................................. 18
Physician Coverage for Hemodialysis Units ...................................................................................................................... 18
Peritoneal Dialysis Unit ....................................................................................................................................................... 19
Sheppard Centre/Sussex Centre Self Care Dialysis Units .................................................................................................. 19
Nutrition for Renal Patients ................................................................................................................................................. 20
Renal Social Work ................................................................................................................................................................ 21Discharges ............................................................................................................................................................................ 22
Renal Education Room ..........................................................................................................Error! Bookmark not defined.
Microscope Rooms ............................................................................................................................................................... 23
Bloodwork ............................................................................................................................................................................. 23
Allergies ................................................................................................................................................................................ 23
Medications ........................................................................................................................................................................... 23
Admissions Policy for Dialysis Patients .............................................................................................................................. 25
Management of HD Patients Referred to Emergency Department (ED) with Dialysis related Issues ............................ 26
Admissions from Toronto Western ...................................................................................................................................... 27
New Nephrology Patients..................................................................................................................................................... 27
Management of Patients with Kidney Transplant: ............................................................................................................. 27
Responsibilities of the Yellow Team Nephrology Fellows .................................................................................................. 28
HEMODIALYSIS ....................................................................................................................................................................... 32
ORDERING HEMODIALYSIS: ...................................................................................................................................................... 32
OTHER HEMODIALYSIS ORDERS ............................................................................................................................................... 35
Antibiotics ............................................................................................................................................................................. 35
Blood Transfusions ............................................................................................................................................................... 35
IV Iron ................................................................................................................................................................................... 35
DIALYSIS IN THE ICUAND "OFF-UNIT"-CRRT ....................................................................................................................... 37
Peritoneal Dialysis ............................................................................................................................................................... 37
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Sustained Low Efficiency Dialysis (SLED) ......................................................................................................................... 37Scheduling of SLED in ICUs .............................................................................................................................................. 38
Continuous renal replacement therapy (CRRT) ................................................................................................................. 41
CRRT - Guidelines for Doctors Orders ............................................................................................................................... 41
Problems with Continual Renal Replacement Therapies ................................................................................................... 43
VASCULAR ACCESS (VA)FOR HEMODIALYSIS ....................................................................................................................... 45Internal:................................................................................................................................................................................. 45
Central Venous Catheters (CVCs): ..................................................................................................................................... 45
INFECTIONGUIDELINES FOR VASCULAR ACCESS .................................................................................................................... 47
Hemodialysis Catheter Infection ......................................................................................................................................... 47
Table 1. Definitions of Catheter-Related Infections........................................................................................................... 50Table 2. Culture and Sensitivity Follow-up ........................................................................................................................ 50
Table 3. Vancomycin Dosing in Hemodialysis ................................................................................................................... 52
AV Graft Infection ................................................................................................................................................................ 53
PLEASE RETURN THIS FORM TO CYNDI AT MORNING ROUNDS................................................................................................. 53
THROMBOSISGUIDELINES FOR VASCULAR ACCESS................................................................................................................ 53
Non-tunnelled Catheters: ..................................................................................................................................................... 53
Tunnelled Catheters: ............................................................................................................................................................ 54Accessing HD Catheters ...................................................................................................................................................... 54
Alteplase (Cathflow) (tPA) ................................................................................................................................................. 54
Native AV Fistulae: .............................................................................................................................................................. 55
AV Grafts: ............................................................................................................................................................................. 56
Removal of tunnelled cuffed hemodialysis catheter ............................................................................................................ 56
MANAGEMENT OF BLEEDING FROM HDCATHETER................................................................................................................ 58
ANTIBIOTIC PROPHYLAXIS FOR HEMODIALYSIS PATIENTS ..................................................................................................... 59Cystoscopy /GI ...................................................................................................................................................................... 59
Dental Procedures ................................................................................................................................................................ 59
PROPHYLAXIS FOR CONTRAST (DYE)ALLERGY ...................................................................................................................... 60
MANAGEMENT OF INTOXICATION ............................................................................................................................................ 60Methanol ............................................................................................................................................................................... 60
Ethylene Glycol ..................................................................................................................................................................... 61
Salicylates ............................................................................................................................................................................. 62
PERITONEAL DIALYSIS ....................................................................................................................................................... 62
HOME PERITONEALDIALYSIS UNIT ......................................................................................................................................... 62
Ordering Peritoneal Dialysis ............................................................................................................................................... 62Responsibilities of the Nephrology trainee .......................................................................................................................... 63
PERITONEALDIALYSIS CONNECTOLOGY ................................................................................................................................. 65
Peritoneal Dialysis Transfer Set .......................................................................................................................................... 65
PERITONEALDIALYSIS PRESCRIPTIONS.................................................................................................................................... 66
CAPD (Continuous Ambulatory Peritoneal Dialysis) ........................................................................................................ 66
CCPD (Continuous Cyclic Peritoneal Dialysis) and E-CCPD* (Enhanced CCPD)....................................................... 66NIPD (Nocturnal Intermittent Peritoneal Dialysis) ........................................................................................................... 67
IPD (Intermittent Peritoneal Dialysis) ................................................................................................................................ 68
Tidal Volume ......................................................................................................................................................................... 72
PERITONEALDIALYSIS SOLUTIONS .......................................................................................................................................... 73
Standard Solutions ................................................................................................................................................................ 73
Specialty Solutions ................................................................................................................................................................ 73
INTRAPERITONEAL (IP)MEDICATIONS ..................................................................................................................................... 74
Antibiotics ............................................................................................................................................................................. 74
Heparin ................................................................................................................................................................................. 74
Erythromycin ........................................................................................................................................................................ 75
Sodium Bicarbonate ............................................................................................................................................................. 75Metoclopramide (Maxeran) ................................................................................................................................................. 75
Potassium Chloride .............................................................................................................................................................. 75
Xylocaine without Epinephrine ............................................................................................................................................ 75
Tissue Plasminogen Activator (tPA)Alteplase(Cathflo) .............................................................................................. 75
Insulin Therapy in IPD ......................................................................................................................................................... 76
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Insulin Therapy in CCPD .................................................................................................................................................... 76PERITONEAL CATHETER INSERTION ......................................................................................................................................... 76
POST-OP CATHETER COMPLICATIONS .................................................................................................................................... 80
MANAGEMENT OF PDLEAKS ................................................................................................................................................... 81
Exit Site Leak ........................................................................................................................................................................ 81
Intra-Abdominal Leak/Hernia ............................................................................................................................................. 81Hydrothorax / Pleuroperitoneal Leak ................................................................................................................................. 82
PERITONITISGUIDELINES .......................................................................................................................................................... 82
Initial Assessment ................................................................................................................................................................. 83
Management ......................................................................................................................................................................... 83
Refractory Peritonitis ........................................................................................................................................................... 89ANTIBIOTIC PROPHYLAXIS AND PROCEDURE PREP FOR PDPATIENTS................................................................................... 91
Cardiac Catheterization / Angiogram -- Dye Exposure ..................................................................................................... 91
Cholangiogram ..................................................................................................................................................................... 91
Colonoscopy (Sigmoidoscopy/Proctoscopy) ....................................................................................................................... 91
CT Scan - Abdomen .............................................................................................................................................................. 92
Cystoscopy ............................................................................................................................................................................ 92
Echocardiogram ................................................................................................................................................................... 93
ERCP(Endoscopic Retrograde Cholangio Pancreatography)......................................................................................... 93Gastroscopy/Upper GI ......................................................................................................................................................... 93Gynecological procedures ................................................................................................................................................... 93
Iliac Dopplers ....................................................................................................................................................................... 93
Liver biopsy ........................................................................................................................................................................... 94
Stress Test ............................................................................................................................................................................. 94
Ultrasound - Abdominal, Thoracic, Pelvic ........................................................................................................................ 94X-RayChest, Abdomen, Pelvic ......................................................................................................................................... 94
OTHER PERITONEAL DIALYSIS ISSUES ..................................................................................................................................... 94
Hemoperitoneum .................................................................................................................................................................. 94
Assessment of Peritoneal Dialysis Prescription.................................................................................................................. 94
Iron Management in Peritoneal Dialysis ............................................................................................................................ 95
PD Exit Site Infection (ESI) ................................................................................................................................................. 96
KIDNEY BIOPSIES ................................................................................................................................................................... 97
Elective Kidney Biopsy: ....................................................................................................................................................... 97
Post Biopsy: .......................................................................................................................................................................... 99
Emergency and Transplant Biopsies: .................................................................................................................................. 99
Arranging Biopsy at Mount Sinai Hospital ....................................................................................................................... 100
TRANSPLANT ......................................................................................................................................................................... 101
TRANSPLANT ROTATION ......................................................................................................................................................... 101
Wards, ER and Admissions ............................................................................................................................................... 101
Order Entry and Documentation ...................................................................................................................................... 102
OTTR ................................................................................................................................................................................... 103
Rounds, Clinics, and Call Schedules................................................................................................................................ 104
IMMUNOSUPPRESSION FORNEW RENAL TRANSPLANT RECIPIENTS..................................................................................... 106Definitions of donors and recipients .................................................................................................................................. 106
Immunosuppression protocols ........................................................................................................................................... 107
Prophylaxis post-transplant ............................................................................................................................................... 109
Treatment of acute rejection .............................................................................................................................................. 110
PD Catheter Care after Renal Transplant ........................................................................................................................ 111
ISSUES FORNEPHROLOGYPATIENTS (NOT UNDER TRANSPLANT TEAM) .............................................................................. 112
Transplant Assessment ....................................................................................................................................................... 112
Management of Failed/Failing Transplant ....................................................................................................................... 113
RENAL PALLIATIVE CARE ............................................................................................................................................ 113
KIDNEY FAILURE - DEFINITIONS AND APPROACH ............................................................................................... 115
DEFINITIONS ............................................................................................................................................................................ 115STAGES OF CHRONIC KIDNEY DISEASE (CKD) ..................................................................................................................... 115
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Creatinine assa interference by glucose in hyperglycemia .............................................................................................. 117CREATININE ASSAY INTERFERENCE BY GLUCOSE IN HYPERGLYCEMIA................................................................................. 117
Care and referral of adult patients with reduced renal function...................................................................................... 118
MANAGEMENT OF CONTRASTNEPHROPATHY....................................................................................................................... 119
MEDICATIONS IN CKD ....................................................................................................................................................... 121
DOSE ADJUSTMENTS OF DRUGS FOR RENAL FAILURE............................................................................................................. 121
DOSE ADJUSTMENT FOR DIALYSIS .......................................................................................................................................... 121
COMMON PROBLEMS IN THE ESRDPOPULATION AND THEIR THERAPIES............................................................................. 121
Bleeding Complications ..................................................................................................................................................... 121
AnemiaErythropoiesis Stimulating Agents (ESAs) ...................................................................................................... 122Anemia Management Protocol for HD ............................................................................................................................. 122
Vitamin deficiency .............................................................................................................................................................. 128Hyperphosphatemia ........................................................................................................................................................... 128
Hypophosphatemia ............................................................................................................................................................. 129
Hypocalcemia/PTH ........................................................................................................................................................ 129Constipation ........................................................................................................................................................................ 130
Analgesia............................................................................................................................................................................. 131
OPIOID ANALGESIC COMPARISON CHART ............................................................................................................................. 131HS Sedation......................................................................................................................................................................... 132
Anti-seizure medications .................................................................................................................................................... 132
Table 7. VTE (DVT) Prophylaxis for Transplant and Nephrology .................................................................................. 133
APPROACH TO POST PARATHYROIDECTOMYMANAGEMENT............................................................................................... 134
Table 8. Drug Dosing for HD, CAPD and CRRT ............................................................................................................ 136
Table 9. Antibiotic Dosing in Renal Impairment .............................................................................................................. 147
ANTIBIOTIC DOSING GUIDELINES IN HEMODIALYSIS ............................................................................................................ 151
Table 10: Dosing Guidelines in Hemodialysis and CVVHD .......................................................................................... 152
Nephrogenic systemic fibrosis (NSF) and Gd-enhanced MRI ......................................................................................... 157
HOWTO ORDER CATHETER INSERTIONS,BIOPSY,DOPPLER,ANAESTHESIA........................................................................ 159
TELEPHONE DIRECTORY ................................................................................................................................................. 159
TORONTO &AREANEPHROLOGY .......................................................................................................................................... 162
CALENDARS OF WEEKLY ROUNDS - NEPHROLOGY ............................................................................................ 164
NEPHROLOGY PROGRAM
In-Patient Nephrology Ward
7CB 340-5330, 14-5330 Fax 340-4102Nine Nephrology beds - No in-patient Nephrology at TWH so all Nephrologyadmissions to TGH
Off service PD7CB pgr (416) 715-9232 or ph 5330. Fax orders to 340-4102
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Medical Coverage
Red and Blue Teams Acute Care Teams:
Acute Care Teams - AKI, undiagnosed renal failure, or kidney pts for variousother procedures e.g. biopsy, angioplasty.
Attending Staffperson - responsible for the team, patients and ITER forms.
Renal resident/fellow as team leader, co-ordinates the work of the team,assists in teaching, and aware of all pts on team.
Diane Watson, Nurse Practitioner (NP) ph 8238, pgr 790-7775 to consult onall new dialysis pts and assist with dialysis options, focussing on Homedialysis, out pt HD spots, palliative mgmt. (*Diane on leave, 2014, Contactduring leave is Anna Gozdzik Nurse Navigator ph 5129, Fax 416-340-4291foreducation; for dialysis spots, contact Hemodialysis Managers)
On call does consults at TGH, MSH, PMH and Womens College HospitalCovers ward issues in evenings & weekends
Kidney transplant patients are followed by kidney transplant service, otherorgan transplants with renal issues are seen by Nephrology. Patients with K-Ptransplants are seen by K-P service, if dialysis is needed, Renal TxP to see.
Womens College Hospital has no in-pt medicine beds, thus if necessary,admit to TG under Yellow Team and follow as a consult for Nephro issues.
DSU coverage on STAT holidays.
Yellow Team In Patient Ward Team and TWH Nephrology:
Attending Staffperson, Nurse Practitioner (NP), and 2 Renal Fellows Jovina Bachynski Nurse Practitioner ph 8501, pgr 790-7758 1 Fellow acts as team leader and is responsible for pts with acute/complex
medical issues, and is a medical resource to NP(see Responsibilites p 28 -29).
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NP is responsible for dialysis pts with uncomplicated illness, awaitingplacement, rehab, dialysis, vascular access/PD catheter issues, and palliativemanagement.
Individuals with AKI do NOT go to Yellow Team, but are admitted underMedicine with Acute team consult
May admit from ER between 08:00 to 16:00 for non-life threateningadmissions after triaged by On Call MD.
Transfers from other services or teams must be Staff to Staff, NOT thru NP. Staff and second Fellow cover Nephrology consults at TWH.
Rounds
Refer to Calendar of Weekly Rounds at end of Guidebook
Sign-In Rounds
Mon - Fri 08:00 sharp 8N-828.To co-ordinate patient care for each dayReview prev days admissions, consults, dialysis, elective admissions,vascular access issues
Very short (1 or 2 sentence) summary of admissions, consults and wardproblems - focus on major issues and dialysis needs
Weekends and holidays, meet team in am to plan the day.Consult teams to notify Yellow Team of patients potentially needing transferto In-Patient Nephrology unit. Staff to consult Yellow Team Staff.
All teams to notify Anna Gozdzik of patients starting dialysis in order tofacilitate education re dialysis modality. Contact the Hemodialysis Nurse
Managers for patients requiring chronic outpatient spots, both at UHN andalternate dialysis units
Sign-out Sheets
Very important but succinct communication tool. Assign your name to yourpatients, document code status, and update sign-outs daily. Avoid using today,
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tomorrow etc. Very short history and update of issues in point formnotnecessary to include ALL information and your thoughts, just important data.Document date of pts first HD, PD or SLED/CRRT. Identify issues for on-call tofollow up on for that night or weekend, then erase once done.
Patient Centred Care Rounds
Held for Yellow Team each Wednesday 10:00 in 7C Conference Room. Todiscuss pts medical/social issues and discharge plan.
Teaching Rounds
Mornings:Mon to Thurs 08:30-09:00, teaching rounds in the 8N-828 conference roomfollowing Sign-In. Nephrology Curriculum.Fri 08:30-09:30, Division Rounds 12NU 1276. In summer, each team presents atopic on a rotating basis. During year, staff and fellows prepare renal rounds.
Afternoons:Tues 12:30Dialysis Journal Club, 8N-828. Critical review of dialysis journal article
Wednesday - Astellas Conf Rm 11C 15:00-16:00 Education Rounds.16:00-17:00 City Wide Neph Rounds
Thursday 12:00-13:00 Home dialysis teaching 12N-1276
Renal Biopsy rounds 10 ES-316. Time to be decided. It is the responsibility of theteam who admitted the patient for biopsy to present the cases and leaddiscussion. Dr Rohan John, the pathologist will notify Dr. Reichs (3439) officeas to which patient to be presented and she will contact the team as early aspossible.
Sign Out Rounds
In-pts needing follow up and consults to be signed out to the On-Call nightly.Weekend signout Friday at 15:00 in the 8N-828 conference room.Prepare written sign-out sheets ~6 per team. Be brief on sign-out sheets.HD for the weekend and Monday morning should be arranged and HD and
PD orders written for your own patients before you leave on Friday.
Ambulatory Care Clinics
Housestaff may be scheduled to attend ambulatory care clinics in order tosee what is, in fact, the bulk of nephrology care delivery.
Clinics are held on 12-NU
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On Call
On-call schedule is posted on the ward and in the residents room.There is always Housestaff on first call, renal fellow on back-up, and staff
nephrologist on call
New consult pts remain with the team of junior housestaff on call.
Person on call is responsible for all in-patients and consults.Please date your consults, make your name legible and pager no.On-call room 12ES 402Dont leave valuables in the roomOn call to ensure that at least 1 HD pt has orders for following a.m. so HDnurse can start before sign-in.
Confidentiality
Please remember that all patient information is confidential. Shred old sign-out
sheets & consult notes (shredder in On Call and Sign-in room). Do NOT discusspatients on elevators or public areas. Do NOT use email for ANY patient infounless on UHN system or ONE pages (with patients consent). (NEVER utoronto,Hotmail, Yahoo, gmail etc)(UHN email Policy 1.40.014)
Nephrology Team
Nursing Staff
There is a nurse on Nephro assigned to PD each daypgr. 715-9232, ph 5330
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Renal Management Clinic (RMC)
Janice Ritchie, RN, MN, C Neph (C) Manager2399 pgr 416-790- 0007Evie Porter, RN, MN, C Neph(C) - 3588Maria Mendez, RN, BSc, C Neph (C) - 6053
Anna Gozdzik RN MN CNeph(C) -5129Diane Stoker B.Sc. Secretary - 6389 fax 4291Isolyn Samuels, Clerical 3056 fax: 4291
Clinics Monday, Tuesday ph 2860
Provides multidisciplinary care for patients diagnosed with CKD Stage 4 - 5.(Including failing kidney transplants and other transplant pts with CKD)
Educates patients about CKD and treatment options
Plan for transition to dialysis and/or Live Donor Transplant Arranges for dialysis access To refer patient to RMC, fill out RMC referral form and fax along with info to
340-4291Patients must be seen as an Outpatient by a Nephrologist forinitial workup of CKD before referral to RMC, even if seen as Inpatientconsult.May not get an appointment for up a month or more, pls ensurethey are stable enough to wait, if not, pls have them follow in nephrologistsoffice.
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Consulting Nurse Practitioner (cNP) (currently on leave 2014)
Diane Watson, RN(EC), MSc, C Neph (C) cNP8238 pgr 790-7775 fax: 4291(onleave 2014, contact Anna GozdzikMN, C Neph(C) for patient education; AngieChai ph 3992, pgr 790-6316 re: Geriatric Rehab; Fellows re; tunneled IJ line
catheters; Zita Abreu RN BScN C Neph(C) PD Co-ordinator re: exteriorization ofPD catheters)
cNP provides education/support for pts starting dialysis emergently Pls refer ANY new In-pt starting dialysis who will need long term dialysis Assists with coordinating out patient HD, PD, NHD, Geriatric rehab. Refers patients to outside centres for dialysis near their home Coordinates assigning dialysis out patient spots Assists with and teaches Fellows removal of tunnelled IJ catheters,
exteriorization of PD catheters Helps with referrals to rehab or placement
Nurse NavigatorAnna Gozdzik RN MN, C Neph (C) -5129; fax 4291
Provides education/support for pts starting dialysis emergently Pls refer ANY new In-pt starting dialysis who will need long term dialysis
Physiotherapy/Occupational Therapy
Tiffany Byndloss PTA/OTA pgr 719-3869Katherine Castrinos PT pgr 416-790-3903Sandeep Marwaha OT ext. 6754, pgr. 416 -790-4609
On In-Pt ward, HD, PD units.
Physios assist in rehabilitation needs and planning for discharge, or assessing forrehab hospital.
For Out-Patients:Outpatient Referrals for Physiotherapy (Exercise Programme in Hemodialysis)Order must be written in chart for PTCoverage for 1stand 2ndshift only, not for 3rd shift(Assessment for independent programme on special request)
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Criteria for referral
Medically stable, cleared for cardiovascular training Cognitively intactable to follow instructions, capacity for learning & carry over Motivated & interested in exercising during dialysis On hemodialysis for >3 months
Contraindications to the exercise program include: Poorly controlled blood pressureSBP>160, DBP >90, SBP
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Renal Pharmacists
Marisa Battistella, Pharm D. In Centre, Home HD: 3207 pgr 790-0793Ruchi Kumra PD: 6547 pgr 790-7790 (Coverage days: Monday, Wednesday, andThursday)
Stephanie Ong RMC: 6547 pgr 790-8466Claudia Summa-Sorgini: 6547 pg 416 790-8466
Annemarie Cesta: 6547 pg 416 790-8466
Resource for renal dosing and medication related questions specific tonephrology.Provide patient counselling and discharge medication education for admittedpatients.
Vascular Access Coordinator
Cyndi Bhola RN, MSc C Neph (C) - 3518 pg 790-5320Sally Lima, Medical Secretary 6993
Notify Cyndi for vascular access issuestunnelled central lineinsertion/removal, permanent vascular access creation or issues.
Housestaff to enter requests for tunnelled central lines in Electronic PatientRecord (EPR): Under Nephrology Order set: DiagnosticsAbd/Thoracic
Angio. Enter comment (reason for insertion/removal/guidewire change). Report all insertions/removals/changes/line sepsis to Cyndi at AM rounds.
PD Catheter Coordinator
Zita Abreu, RN, BScN C Neph (C) - 2358
Notify for PD catheter issuesinsertions, removals, manipulations Arranges PD cath insertions - laparascopic, bedside, radiologic or surgical Liaise for hemodialysis spots in Dialysis Start Unit
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Hemodialysis Units
Hemo West (HW) - 4072 fax 3084. Hemo East (HE)5707 fax 4892.Home HD 3736; fax 4379
Deloris Bennett, RN, BScN, HD Manager HW 6049Denise Williams, RN, MSc, C Neph (C), HD Manager HW 6305
Annellie Cristobal, RN, BSN, HD Manager, HE6908Kirsten Lewis RN, MSN, HD Manager, HE8502Janice Ritchie, RN, MN, Manager, Home HD2399 pg 416-790- 0007Debra Appleton, RN, MN, C Neph (C), APNE (Nurse Educator)8726Vanessa Godfrey, RN, MSc, C Neph (C) Advanced Practice Nurse Educator2051
HD Manager or charge nurse to be contacted for all pts requiring HD or anychanges for inpatients - attends AM sign-in rounds.
Use Standing order sheet for HD orders. Orders to be written for theweekend and Mon a.m., before leaving Friday, and for discharged new HDpts.
ALL patients starting HD MUST have Hgb, Creatinine, Urea, serumbicarbonate, Ca++, phosphate, albumin, PTH bloodwork done PRIOR tofirst dialysis. (Ontario Renal Reporting System guideline)
HD schedule for the day reviewed at morning sign-in Urgent HD after hours to be discussed with the renal fellow.
HD requests from other hospitals - call staff Nephrologist on call.Dependant upon status noted in Sign In morning meeting.
On call HD nurse for emergency dialysis after hours and Sundays throughlocating (to avoid hemodialysis on Sundays unless urgent.) CRRT (only atMount Sinai Hosp) and SLED should only be initiated during the day.
Dialysis Start Unit 12 ES Room 411. ph 4757
For any patient newly starting chronic dialysisHD or PD. Focus is modalityeducation and support for dialysis modality. Patient should be stable onhemodialysis, be deemed ready to go to an out-pt dialysis unit (although still maybe in-patient), be able to dialyze sitting up, and have a functioning vascularaccess (CVC or internal). PD requires a functional peritoneal catheter, althoughproblem solving for access is also mangaged in the DSU. Medical coverage is
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by Home Dialysis Fellow except for Stat Holidays covered by Consult team oncall.
Coordinated through Zita Abreu (2358) & Anna Gozdzik (5129)
Toronto Rehab (TR)
Natalie Stanton, RN, MN, HD Charge RN, 597-3422 ext. 3801 fax 977-8719In-Pt Unit, TR rehab 597-3422 ext 3018. In-Pt Unit, CCC 597-3422 ext 2235Dr. Vanita Jassal, TR Hemo Nephrologist - 3196, Angelique Chai RN MN C Neph(C) -3992; pager 416 790 6316
TGH runs the HD unit at TR for geriatric patients getting rehab at TR-rehab aswell as those who reside at TR-Complex Continuing Care (CCC) on Dunn Ave.Consider rehab for any HD patient >60 yrs if they have had a prolonged hospitalstay, are not managing at home, or need to learn energy conserving techniques.
Applications for rehab or CCC are through Social Worker. You would need to do
the Dialysis part of the application form for TR.
There is also a Day Hospital program which patients can attend 2 days per weekfor those needing some rehab, but not requiring in-hospital rehab.
Physician Coverage for Hemodialysis Units
MWF Hemo West Hemo East
1 Scholey Fenton
2 Pei Reich3 Richardson Chan
TTS
1 Richardson Lok2 Lok McQuillan3 Cherney Bargman
Nocturnal Dialysis (Incentre)MWF Richardson /Chan
TTSun Richardson /Chan
DSU and Home Dialysis (Home Hemo and HPDU)
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Home Dialysis Fellow Monday to Friday day shiftAfter Hours, Weekends and Stats by Consult Team on-call
Peritoneal Dialysis Unit
Home Peritoneal Dialysis Unit - HPDU 12ES 5672 fax 4169Janice Ritchie, Nurse Manager, RN, BScN C Neph (C) 2399 pgr 416-790- 0007Stefan Trohonel, Patient Care Co-ordinator, RN, MN, C Neph (C) ext 6285Zita Abreu, RN BScN, PD access coordinator - 2358
Peritoneal dialysis (PD) is an excellent choice for chronic dialysis, and allpatients should be assessed for ability to carry out PD, even if they requireacute dialysis. PD can be started very soon after the PD catheter isinserted, thus can be used acutely.
PD is available at TW, carried out by staff nurses on 8 Fell (see PeritonealDialysis section in this Guidebook). All patients on PD need dialysis orders. Pts usual orders may be faxed from
the HPDU (or in pm in HPDU chart via Security), but all acute pts needassessment.
ALL patients starting PD must have Hgb, Creatinine, Urea, serumbicarbonate, Ca++, phosphate, albumin, PTH bloodwork done PRIOR tofirst dialysis. (Ontario Renal Reporting System guideline)
Sheppard Centre/Sussex Centre Self Care Dialysis Units
Cathy Fulton, Manager, RN, BScN (416) 223-2013
Sheppard Ctr (Sheppard and Yonge) Ph (416) 223-2013 fax 223-3321Sussex Centre (Burnamthorpe Rd, Mississauga)
Ph (905)272-8334 fax(905)272-4534
Administered from UHN, the Sheppard and Sussex Centre Self Care dialysisunits offer self care HD 3x/week or short daily dialysis in a relaxed, quiet,
home-like environment. Patients come to TGH for clinic follow up, diagnostic tests, medical referralsand for other urgent medical care.
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Nutrition for Renal Patients
Nephrology Dietitians (RDs)
Jane Paterson, MSc, RD, Practice Leader & RMC 8591 pgr 719-3600Karla Dawdy, HBSc, RD (In-Pt, Pre-dialysis & Home HD) 4625 pgr 719-3114
Antonia Zettas, BSc, RD (PD & HD HE) 6530 pgr 790-4519Christine Nash, MSc(C) RD (PD & HD HE) 6272 pgr 790-4536Linda Cerullo, HBSc, RD, (HD HW & Kidney Tx) 4103 pgr 719-3249
The Nephrology Dietitians are available daytime hours MondayFriday.
When ordering diets: *Do not orderRenal Diet or Diabetic Renal Diet. There
are 4 Standard Renal diets at UHN to choose from.
Order one of the following Standard Diets:
Name of Diet Protein Phosphorus Potassium Salt FluidERI (Early RenalInsufficiency)
60g
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Inpatient Nephrology/ Inpatient Nephrology TransplantRDsThe inpatient Nephrology RDs will see all pts admitted to TGH who are followedby a UHN Nephrologist. All Nephrology Program Inpts are screened and
prioritized for care. Please consult the Inpt RD for all new pts to the UHN NephroProgram or for any pertinent nutrition issues, such as dysphagia, prolonged N/V,severe wt loss or gain, wounds, enteral feeding, TPN/IDPN, multiple foodallergies or any special nutritional needs for inpatient care.
Ambulatory Hemodialysis and Peritoneal Dialysis RDs(includes Nocturnal Hemodialysis and DSU)The Dietitians assess and educate all new HD and PD patients and provideongoing nutrition intervention/education for abnormal diet-related biochemistry,malnutrition, significant weight loss/gain, high IDWG/fluid overload, bloodpressure irregularities, GI disturbances, and enteral feeding/IDPN. Please notifythe appropriate RD as listed above with any nutrition concerns.
Pre-dialysis (Non-RMC) RDNutrition counseling appointments are available Tuesday afternoons by referralonly for any patient followed by a Nephrologist at UHN or Mt. Sinai. Referrals tobe faxed to 416-340-4291.
Renal Management Clinic (RMC) RD
All patients are assessed and followed by a NephrologyDietitian as part of themulti-disciplinary team upon referral to the RMC.
Complex Continuing Care Clinic (CCC) RDAll patients are assessed and followed by a Nephrology Dietitian as part of themulti-disciplinary team upon referral to the CCC Clinic
Renal Social Work
Zoe Levitt, MSW, 3618 pgr 719-2876
Melissa Rubin MSW, 6047 pgr 719-3731Michela Verdirame MSW, 3983 pgr 719-2812Torey Stronell 4768 pg 416-719-2668
Provide pre-dialysis patient and family education, counseling regardingadjustment to illness, treatment decision-making, family concerns, locating
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and arranging the resources necessary for an appropriate and timelydischarge.
Each Renal SW has a variety of areas of responsibility, please contactappropriate person:
Zoe Levitt:Renal Management clinics. Inpatients belonging to RMC clinicsand Hemo West. NEW Nephrology inpatients by last name: AL.
Melissa Rubin: Hemo East (all days all shifts). Inpatients belonging toHemo East. NEW Nephrology inpatients by last name: M- R
Michela Verdirame:Dialysis Start Unit, Peritoneal Dialysis and HomeHemodialysis. Inpatients belonging to PD and Home Hemo. NEWNephrology inpatients by last name: SZ.
Torey Stronell: Hemo West (all days all shifts).
Discharges
It is imperative that discharges are well planned due to the demand forbeds.
Ensure patients are ready for discharge - Homecare (CCAC)arrangements, particularly if on PD getting assisted PD, transportation fordialysis, discharge orders, and Rxs. Ensure that CCAC referral is done atleast 24 hours pre discharge. New HD pts to have first HD orders written.
Patients must be discharged by 11:00 AM
Complete on line Discharge Summaryfor all Yellow Team pts. (Foundunder Other tab on Pt care screen). Notify Nephrologist who follows pt.
Consult teams to prepare paper Discharge Summary to fax to dialysis unitor bring to morning report, and written HD orders for new patients.
Discharge summary MUSTinclude date of initial dialysis treatment, causeof renal failure, whether or not biopsy proven (where applicable), specifytype of diabetes and weight within the 1st month of treatment, also specifyany condition that would shorten life expectancy to less than 5 years.
Communicate with the patients primary nephrologist/nurse to update
about the patients hospital stay, changes in meds, and discharge plans.
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Microscope Rooms
12 NU clinic. Microscope, centrifuge, slides, sulphosalycilic acid etc to prepareand view urine. Please DISPOSE of urine, slides and pipettes etc., when
finished, and keep this room clean for the next person.
Contact Security for access after hours.
Bloodwork
Because Nephrology patients are anemic, order only necessary bloodwork,and remember to cancel orders for repeated BW
All pts, before starting dialysis or SLED/CRRT, must have Hgb, Cr, Urea,CBC, PTH, Ca, PO4, Bicarb, Alb (Ontario Renal Reporting System Guideline)
Check amount of BW ordered on consult pts and suggest less frequent BWunless clinical decisions rely on it, e.g. INRs
Remember, BW such as daily Cr on someone on chronic dialysis is nothelpful
HD pts can have bloodwork drawn in HD unit unless otherwise indicated.This should be specified on the HD Orders. If pt is at Mt Sinai and comesto TGH for dialysis, please order baseline and ongoing BW to be done on
EPR in HD.
Allergies
Please remember to document allergies on Doctors Orders forms, andcheck Allergies when ordering medications.
Medications
Renal pts often require alterations in dosing of medications due to renal
failure and/or dialysis. Consult renal pharmacist if there are questions redosing beyond described in this Guidebook
When admitting a patient, call the appropriate Hemo Unit or HPDU to havethem fax medication and dialysis orders.
Remember to order Aranesp/Eprex and Venofer, HD pts may not includethese as meds that they are on, as they are given in HD
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All pts to be vaccinated for Pneumococcus, Influenza, Hepatitis andTetanus per protocols, documented in HD and PD charts.
See sections "Common Drugs Used in ESRD" and "Drug Dosing for HD,CAPD and CRRT".
Ontario Drug Coverage Overview for CKD Patients
Types of Coverage:1) Cash2) 3rdparty insurance (through employment, Blue Cross, Liberty Health)3) Ontario Drug Benefit (ODB)
Ontario Drug Benefit(ODB)Eligibility65 years old or olderReceiving services from Home Care (CCAC) programResidents of long term care facilities or Homes for Special CareEligible under the Trillium Drug ProgramReceiving benefits from Ont Works, Ont Disability Support Program (ODSB) or socialassistance
What is covered?Formulary medications - Follow the Ontario Drug Benefit FormularyLimited Use Products - Covered when patient meets listed criteria-Must put Limited Use code on actual prescription
Exceptional Access Program (formerly Section 8) approved meds (see below)
Exceptional Access Program (formerly Section 8)A source of payment that can be applied for when no formulary alternative is available orsuitable
Application requires Individual Clinical ReviewMeds that are not listed in ODB formulary or which fall under limited use criteriaPhysician is making special request for coverageGuided by DQTC and other expert medical advisers to review individual requests
What do I need to request for Exceptional Access Program review?Prescribers informationPatient demographics including OHIP numberRequested drug (generic name, brand name, dosage strength and drug identification number)Detailed summary of conditionIf the patient has taken the drug, provide objective evidence of efficacy (lab results, diagnostictests, culture and sensitivity reports, etc.)
Additional information regarding previous therapy, contraindications to formulary medications,concomitant drug therapy
Desired outcome with requested drug
Before I send out a Exceptional Access Program request, Check: Is the patient covered by ODB? Has the patient tried medications covered by ODB?
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Do I have all the necessary background information to support using this request? (lab results,diagnosis, response to treatment)- FAX: (416) 327-8123 or (416) 327-7526
- Follow up information PHONE: 416-327-8109If in doubt, please page renal pharmacist at 790-7790 or HD pharmacist 790-0793.
Admissions Policy for Dialysis Patients
Patient Destination
These guidelines refer to patients with ESRD who are on some form of chronicrenal replacement therapy, or are pre-dialysis, and require in-patient care.This does no t refer to patients seen on the consu lt service or those with
renal transplantation .
The following tables indicate what clinical problems (in the ESRD patient)would be directed toward General Internal Medicine, General Surgery, andNephrology respectively:
N.B. If there is a concern as to which service the patient should beadmitted, residents are instructed to contact the STAFF physiciansimmediately and allow them to make the decision.
General InternalMedicine
General Surgery (or appropriatesub-specialty)
Cellulitis Abdominal PainSurgical Abdomen, peritonitis innon-PD pts
Pneumonia Cholecystitis Pulmonary Embolus Gallstone pancreatitis DVT Bowel Obstruction Unstable Angina Unstable GI bleed Non-Q MI Post-operative complications Cardiac Dysrhythmias (non CCU) Arterial thrombosis (vascular service) PVD & complications Gangrene requiring amputation (vascular service) TIA/CVA Fractures (orthopedic service) Seizures GI Bleed Acute Renal FailureNephrology
Dialysis Access Issues
Creation of access (PD or HD) Infection Thrombosis
Radiologic/Surgical Revision Sepsis related to Access
Peritonitis (in PD patients)
Inadequacy of Dialysis
Urgent Dialysis in a Dialysis or pre-dialysis Patient
Volume Overload Electrolyte Emergency i.e Potassium
Awaiting out-patient Dialysis spotDialysis patients admitted to other services who are palliative, rehabilitating, or awaiting placement to
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long-term care facility.
Management of HD Patients Referred to Emergency Department
(ED) with Dialysis related Issues
This protocol was arrived at between the Depts of Nephrology and of EmergencyMedicine to expedite the care of patients who suffer complications whileundergoing hemodialysis (HD)and are deemed to be in need of assessment.
If such a patient is identified in a hemodialysis unit the following should occur:
1. If the patients condition warrants admission (eg: line sepsis, deterioration incardiovascular status, decreased LOC, etc), then the Staff Nephrologist orNephrology Fellow will contact the resident on-call for the appropriate service,depending on the patients presenting problem (refer to the attached protocol),who will then arrange direct admission to hospital. This may be a Nephrologybed, in the case of dialysis-related issues, or a GIM or Surgical bed, in the case ofnon-renal issues. In the absence of beds in the appropriate service the patientwill then be transported to the ED to be admitted to the appropriate service andconsulted on by the Renal Team as needed.
2. If the patients condition or deterioration in the hemodialysis unit does notimmediately demonstrate the need for admission, then it will be the expectationthat the Staff or the Fellow will verbally directly communicate with the physician inthe ED on-call for that time period, and that individual will communicate thereason for referral to the ED, any pertinent past medical history, as well as thegoal of the referral. The name and MRN of the patient will be communicated tothe ED physician or the nurse in charge in verbal or written form.
3. Patients referred from the HD Unit are quite complex with respect to theirpathology. When they are referred to the ED they often present complex andtime consuming diagnostic and therapeutic dilemmas. It will be the expectationthat the physicians in the ED can call the resident on-call for the Renal Serviceand use the Residents advice in the management of this patient.
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If a patient is accepted by the Renal service from another
institution then the Resident who has accepted the case will
communicate this and any other pertinent information to the
Charge Nurse verbally. If the department is in a bed crisis,
attempts will be made to admit the patient straight to the floor.
Admissions from Toronto Western
There are no in-patient Nephro beds at TW, thus patients coming to TW Emergmust be assessed, and a note written by the Nephro resident on call at TW. If thept requires a Nephro admission, the TG staff/fellow is to be notified and acceptthe patient in transfer. If the patient has medical issues, as outlined in theprevious table, they would be admitted to the appropriate service at TW andfollowed in consult by the TW Nephrology resident. HD and CAPD/CCPD (cycler
dialysis) are available at TW.
New Nephrology Patients
Any patient "new" to Nephrology coming through Emergency should be stabilizedand upon discharge, referred to a Nephrologist in their area.
ALL patients starting dialysis (HD or PD) MUSThave Hgb, Creatinine, Urea,bicarbonate, Ca++, phosphate, albumin, PTH bloodwork done PRIOR to first
dialysis. (Ontario Renal Reporting System guideline). Specify and document anycondition that would shorten life expectancy to less than 5 years.
Notify Diane Watson, NP (currently on leave) (14-8238) of patients new todialysis, likely needing long term dialysis, who require education, dialysis modalityoptions, or an out pt HD spot. While Diane on leave, contact Anna Gozdzik foreducational needs; contact Hemodialysis Managers for outpatient dialysis spots.
Management of Patients with Kidney Transplant:
Kidney transplant patients are admitted under the Kidney Transplant service. Kidney-pancreas patients are admitted under the Pancreas Transplant
Service; in special circumstances Transplant Nephrology may be asked toconsult for K-P patients (usually when dialysis is required)
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The Kidney Transplant Service also follows all kidney transplant patientsadmitted to another service, including patients at PMH or Mt. Sinai; patients atthe Western are followed by the Nephrology fellow covering the Western, withadvice from Kidney Transplant as needed.
Kidney transplant patients needing dialysis:
For Kidney transplant patients requiring hemodialysis, the Transplant Fellow isresponsible for the dialysis orders, and for all aspects of patient care.
For Peritoneal Dialysis, call the PD nurse on 7B (5330) Pgr 715-9232, and faxorders to 340-4102.
During the weekdays, Transplant Fellow may call Hemo West (4072) toarrange hemodialysis. Kindly inform Nephrology on call as a courtesy, so thatthey are aware of who needs dialysis.
After hours, and weekends, Transplant Fellow must call Nephrologyhousestaff on call to triage the patient, as the Nephrology service is aware of
the numbers of patients needing acute dialysis. The Nephrology housestaffwill then call in the HD nurse to do the dialysis, but will NOT do a consultthisis for triage only. Please be prepared to discuss the urgency for dialysis, aspatients needing dialysis immediately prior to transplant surgery will haverelative priority. If necessary, the second on-call nurse can be called in toperform the dialysis.
Hemodialysis nurses will liaise with the Transplant Fellow for orders, patientissues etc, once the triage has been done. Name and pager number shouldbe written clearly on the Hemo orders on the Doctors orders sheet.
Responsibilities of the Yellow Team Nephrology Fellows
The Yellow Team consists of Nephrology Fellows and a Nurse Practitioner (NP). One fellowcovers Toronto Western (TW) for consults, and another covers Toronto General (TG) in patientnephrology with the NP. The focus of the TG rotation is to manage chronic dialysis patientswith dialysis-related medical issues, such as peritonitis and vascular access problems, and tolearn about managing issues such as palliative care in Nephrology. The focus at TW is toprovide consultation, AKI, CKD, electrolyte disorders, and care of patients on dialysis requiringother services such as orthopedics and neurology, housed at TW.
Inpatient (TG) Responsibilities
Yellow Team fellow is the Inpatient Nephrology team leader, and the physician ultimatelyresponsible to know about day to day care of all Yellow Team patients including thoseassigned to the NP.
Yellow Team fellow reports to Staff Nephrologist.
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Patients are divided between the Fellow and NP according to medical acuity and division oflabour. Assign yourself to your patients names on the White boardon 7B. Assign yourselfto your patients on the Sign-Out sheet in EPR.
Attend Sign In rounds each morning TG 8NU-828 @ 0800. Be aware of when yourpatients need dialysis, and ensure that they are scheduled, and orders are written.
Assess each assigned patient and determine needsmedical, psych/social, physio,nutrition. For dialysis pts, Target weight, dialysis treatment, lab results and meds should bereviewed.
New admissions assigned to Fellow are to be seen and assessed; and medications,bloodwork etc ordered in EPR by the Fellow.
For a new admission, call the HD or PD unit for the dialysis orders and medication record,including immunization if needed. Remember that patients may not have Aranesp, Eprex orIV iron written in their own list of medications.
Advise the patients usual nephrologist so that they are aware of pts admission. A full clinical note should be written for each patient to include history, physical assessment,
medication changes, dialysis, plan, consults required and diagnostic tests planned. A shortnote with updates should be written daily and include assessment and plans.
Discussions with patients and their families are very important, and if required, you can setup a family meeting for major issues such as code status, disposition etc. As appropriate,
family meetings include the staff MD, SW, physios, dietitian and RNs as needed. Generally, after Sign in rounds, see all of your assigned patients then meet with NP to
review other patients with her, and assist with medical issues.
Lead rounds with staff nephrologist to review issues and plans for each patient. Beprepared to have evidence-based rationale for treatment plans.
Update Sign out sheet on EPR each day with plans and salient issues for patient. Be brief.Outline for On Call person any issues that need follow up by them.
Consults
When making an elective referral to a consult, call 3155 Locating, to page service and
document in the chart the issues to be dealt with.
Admitting/Transferring Patients
For bed flow and advice on admitting directly to the floor, speak withSusan Kiernan(Nurse Manager) or Tatiana Pires (PCC) or charge nurse for the day, who will get approvalfrom the appropriate administrative personnel. Complete the Admission Request Form forpatients requiring pre-planned admission (to request the bed, on Hospitral intranet, go todepartments, select nursing, select nursing practice areas, select7B and enter
Admission Request Form to complete information. Please check on the isolation status ofthe patient before asking for bed in case isolation is required. If a bed is available, you will
also have to call Admitting TGH (3921) with pts name, MRN, diagnosis, admitting doctorand bed allocation. Otherwise direct referring team to send patient to ER.
For transfers from other hospitals, centres without dialysis take immediate priority. UHNpatients at a hospital with dialysis facilities will be transferred based on bed availability. Torequest a nephrology bed, complete the Hospital Transfer Request Form (On Hospitalintranet, go to departments, select nursing, select nursing practice areas, select 7B and
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then enter the Hospital Transfer Request form and complete). If a UHN patient is atanother hospital with dialysis, and if bed available can try to arrange transfer asabove. Ensure patient is medically stable for transfer directly to a ward bed.
Discharging Patients
It is essential that discharges are well planned and comprehensive so that patients are able tomanage and do not require early re-admission. Identify a discharge date well ahead of time, in
consultation with patient and family.
Assess patient for issues required for discharge, such as transportation, prescriptions,rehabilitation, dialysis requirements, and ambulation. Assess if the patient might need rehab,(and refer to TR-rehab), or an Alternate level of Care (nursing home or chronic care placement).
When pt is ready for discharge, ensure that the following are in place:
Prescriptions Discharge Summaryhelpful to start writing it in EPR on admission and update throughout
patients stay. Be sure to review all medications prior to discharge with the assistance ofpharmacist, and note any changes or new medications in the Discharge Summary.
Notification to Dialysis Unit and patients nephrologist (verbal or UHN email) of patientsdischarge, and issues to follow up on. New patients to have initial dialysis orders sent todialysis unit.
Follow up appointments. Referral letters written and faxed as required. Include issues for GP or specific MD to follow up on, in D/C Summary Homecare (CCAC) referral if needed, particularly if they need home assistance for PDat
least 24 hrs before planned discharge
Wheeltrans/transportation to dialysis (if not in place, discuss with family and SW)
Home Care (CCAC)
If an individual needs assistance at home, complete CCAC referral on lineat least 24 hrs priorto discharge. May ask for assistance from Ward Discharge Co-ordinators or CCAC co-ordinators. Clearly state what assistance is needed, e.g. dressing changes, insulin injections,physiotherapy, personal support worker (PSW) etc. Complete all sections of the form. If anindividual needs HomePlus, ie assistance with PD at home, please make sure there is at least72 hrs lead time, and contact HPDU as well.
Rehab
If a patient is unable to ambulate or mobilize with an assistive device, consider rehabilitation atTR-rehab if they are >60, or alternate rehab facility if
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removal orderin EPR. Contact the appropriate nursing staff member re: the changes (maybe Nurse Manager, Patient Care Co-ordinator or designate.
Code Status
It is very important to establish code (CPR, no-CPR) status of our patients. This conversationshould be handled with great empathy but present a realistic view and likelihood of survival.Document code status on the Doctors Orders and Sign-out sheet, and document discussion inthe Clinical notes.
CCOT (Critical Care Outreach Team)
The team is available to review patients who are taking a turn for the worse, e.g. with refractorydecreased BP or O2sats, decreased LOC. They will provide assessment and advice and if ptneeds ICU transfer, will recommend and assist with the process. Call through Locating 3155.
Weekly Interprofessional Patient Centred Care Rounds
Wednesday at 0930: 7C-746. Be prepared to give short presentation of each patient andcurrent plans. Discuss plans with team membersPhysio, Pharmacist, NuTRtionist, SocialWorker, OT, RNs, etc. Focus on what patient needs to have in place for treatment anddischarge.
Friday Sign-out
Bring 5 edited and updated signover forms, to assist staff in knowing status and whom tocontact. Review only patients whom you want the weekend team to see or follow up.
Consult (TW) Fellow Responsibilities
Present consults at Sign-In at TG 8NU-828 @ 0800. If unable to attend, advise InpatientFellow of consults for previous day.
Review all patients on Signout sheet, updating as required. Meet with Staff at theirconvenience, to review patients issues and plans.
Remember to review meds and bloodwork for each patient and ensure that they areappropriate for renal patients (ie avoid frequent bloodwork and ensure medications arerenally dosed and appropriate.
If already a dialysis patient, call their dialysis unit - HD or PD for most recent dialysis orders,medications and history. Remember that patients may not have Aranesp, Eprex or IV ironwritten in their own list of medications.
Document renal issues, progress and plans on Clinical notes in patients chart, writeNephrology suggestions on Doctors Order sheets in chart. Upon discharge, fill out Nephrology Discharge Summary and new HD orders and fax to the
dialysis unit or bring to Sign-In the following morning and give to appropriate Nurse Manager
Communicate with patients nephrologist to update about the patients hospital stay anddischarge plans.
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HEMODIALYSIS
Hemo West (HW) Hemo Unit: 4072. Fax 3084
Hemo East (HE) Hemo Unit: 5707 Fax 4892Hours 07:30-23:00 Mon-Sat,3 shifts of pts each day. Nocturnal hemodialysis is also done as a fourthshift in the Hemo West unit, with the shift running from 2230 until 0630.For
emergency dialysis at TGH, MSH, PMH, contact Hemo West chargenurse Monday to Friday and Saturday until 2230. For emergency dialysisat TGH, MSH, and PMH on Saturday 2230 until Sunday at 2230, contactthe on-call nurse through Locating. For emergency dialysis at TWH,contact Hemo East charge nurse Monday to Saturday from 0730 until2230. After 2230, contact the on-call nurse through Locating. Contactthrough Locating.
Initiation of a new hemo patient whether acute or chronic must be inconsultation with a staff Nephrologist, with a catheter in place and verifiedradiographically.
ALL patients starting HD must have Hgb, Creatinine, Urea, serum bicarbonate,Ca++, phosphate, albumin, PTH bloodwork done PRIOR to first dialysis. (OntarioRenal Reporting System guideline)
Ordering Hemodialysis:
Use Hemodialysis Orders Sheet. Write the orders a day ahead ifpossible. Call the HD unit as soon as you know that an inpatient will
require dialysis. When ordering medications which need to be given at dialysis, remember
to specify with dialysis when ordering on computer, or on MD orders.
Filling out Hemodialysis orders sheet:
1. Daily - - all acute or unstable pts, evaluate pt prior to each Rx.Chronic" - stable chronic pts.
2. DialyzerFor acutes-order Xenium 210. The standard for chronic HD pts is F80 which
is reused using heat reprocessing. Note: there is no reuse for patients withHIV, hepatitis B.
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3. Method"Conventional" refers to intermittent HD. HD time includes solute removal +ultrafiltration (UF). Can also have isolated UF if pt very volume overloaded -may permit a greater rate of fluid removal with less hemodynamic compromise.Increase dialysis hours until PRU (Percent Reduction of Urea) (adequacy) is>65%
PRU = Pre Urea - Post Urea x 100
Pre Urea
4. DialysateSodium: standard is 138 mM. May order Na+"Ramping" for pts withintradialytic hypotension or cramping - e.g. Na 145 1st hr, 140 2ndhr, 137 3rdhr,135 4thhr, ordered in consultation with fellow or staff. However is now stronglydiscouraged for most patients.
Potassium: 1.0, 2.0, 3.0 mmol/L available. Goal is predialysis K+4.0-5.5, postdialysis K+3-3.5. (to guesstimate: 7pts K+= dialysate K+). Standard is 2.0.
Calcium: standard is 1.5 mM. Also 1.25 and 1.00 mM available forhypercalcemia and 1.75 mM available for hypocalcemia.
Bicarbonate is the standard buffer - 35 and 40 mmol/L are available.
Phosphate: Patients on HD or SLED may develop hypophosphatemia. Oneway of correcting this is to add Fleet phosphate enema (concentrated sodiumphosphate) to the acid concentrate. 100 mL of Fleet enema contains
approximately 175 mmol of phosphatewhich gets diluted 1:45 by thedialysis machine.There are 2 sizes of acid jugs, 5.0 and 4.5 L - determine from the nurse whichsize is being used, it does not change the final concentration.
For 4.5 or 5.0 L acid jugs:Amount of Fleet enema Final Dialysate Concentration
120 mL 1.0 mmol/L95 mL 0.8 mmol/L47 mL 0.4 mmol/L
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5. Target weight (TW) and fluid removal.TW = pts euvolemic weight at the end of dialysis - ie. no peripheral orpulmonary edema, normal JVP, normal BP, and no s/s ECFV depletion -cramps, dizziness, orthostatic hypotension
Stable patients: establish TW by physical exam with reference to patient'scurrent weight; hemo nurses determine amount of fluid to remove using the
predialysis and target weight.
Acute In patients: Inpatients are ill and are often losing flesh weight and requirefrequent assessment and TW adjustment or they may become hypertensive andvolume overloaded. In pts who cannot be weighed, you may prescribe "fluidremoval goal" in liters. Pts to be assessed pre and post dialysis to ascertainappropriate fluid removal.
6. HeparinizationRegular heparinization = 1000u bolus and 1000u/hr.Tight = 0 bolus, 500 u/hrNo heparin = 0 bolus, 0 infusion, N/S flushes or Bioflow - use for patients withbleeding, coagulopathy, pre/post surgery, and HIT+. The risk of tight or noheparinization is dialyser clotting (blood loss). Need to balance risk of bleedingto risk of clotting system.
7. Blood Flow (Qb)Standard is Maximize at RN discretion, up to 400 mL/min Generally slowerQb's for first few runs to avoid dialysis disequilibrium (e.g. 250 mL/min).
8. BP maintenanceStandard is saline. In some ICU pts already on inotropes, dopamine mayoccasionally be used.
9. BloodworkMonthly Routine - only for chronic outpts; "other" includes any blood tests to bedone before or after dialysis. Blood is taken from the dialysis access, saving avenipuncture. Only order NECESSARY bloodwork, as dialysis pts areanemic.
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Other Hemodialysis orders
Antibiotics
Some IV antibiotics are to be given post dialysis, and may be giventhrough the dialysis machine, the HD doses are noted in the UHN
Guidelines for Antimicrobial use.
Blood Transfusions
Blood TransfusionsC&T prior to, and give during HD to allow removal offluid volume and K+.
Pts must sign a consent form for blood transfusion, explained by andsigned by MD, try to get consent for 1 year.
IV Iron
Iron sucrose is the standard intravenous iron preparation . Other preparationsincluding iron dextran or sodium ferric gluconate complex (Ferrlecit ) may beordered for patients who are allergic to or intolerant of Venofer.Dose - IV IronSucrose (Venofer) - 100 mg IV with HD x 10 consecutive HD's. Maintenancedose 100 mg IV 1 -2/month.
Dose - IV Iron Dextran - Test dose 25 mg IV with HD, with MD present. If noproblems, 75 mg IV then 100 mg x next 9 HD's (rarely used).
Have Benadryl 50 mg, Solumedrol 100 mg & Adrenalin 1:1000 .3-.5 mL on
hand when administering iron dextran.
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Dialysis in the ICU and "off-unit" - CRRT
Patients in the ICU, CCU and Off unit reviewed at AM report ICU pts often hemodynamically unstable, with large obligate fluid input, on
inotropes, with co-morbid conditions, which complicate their dialysis.
Conventional HD can worsen hemodynamic instability. SLED and CRRT -Continuous Renal Replacement Therapies - are slower and gentler than
conventional HD. ALL patients sta
