2019 Home Hemodialysis Standing Orders
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- Kory Doyle
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1 2019 Home Hemodialysis Standing Orders 1. Nutrition Standards of Care: A. Follow P&P Nutrition Standards of Care 2. Laboratory Tests: A. Drawn On Admission: 1. Renal Function Panel (BMP, PO 4 and Albumin) (ICD10 N18.6 & Diabetics E08.21 or Non- Diabetics R73.09) 2. Total Protein, Alkaline Phosphatase, ALT (ICD10 N18.6) 3. CBC with differential and platelets (ICD10 N18.6) 4. HBsAg, HBsAb, HBcAb, HCVAb (ICD10 N18.6) 5. Serum Aluminum (ICD10 N18.6) 6. Iron Studies (ICD10 N18.6) 7. Vitamin D-25 (ICD10 N18.6) 8. Intact PTH (ICD10 N18.6) B. New Patient Training Labs: 1. End of week 1, 3 and PRN: Renal Function Panel, Hgb, Kt/V (ICD10 N18.6, Z49.31 & Diabetics E08.21 or Non-Diabetics R73.09) C. Monthly Draws: 1. Renal Function Panel (ICD10 N18.6 & Diabetics E08.21 or Non-Diabetics R73.09) 2. Total Protein, Alkaline Phosphatase, ALT (ICD10 N18.6) 3. CBC with differential and platelets (ICD10 N18.6) 4. HBsAg (ICD10 N18.6) 5. Full Kt/V if patient is dialyzing 3 times a week (ICD10 Z49.31) 6. Standard Kt/V if dialyzing > 3 times a week (ICD10 Z49.31) 7. Intact PTH (ICD10 N25.81) if patient is on Sensipar D. Two (2) Weeks After Monthly Labs: 1. Hgb if receiving ESA therapy (ICD10 N18.6) E. Quarterly Labs: 1. Iron Studies (Jan, Apr, Jul, Oct) (ICD ) 2. Intact PTH (Feb, May, Aug, Nov) (ICD ) 3. Aluminum for patients with most recent aluminum levels > 30 or on aluminum containing phosphate binders (Feb, May, Aug, Nov) (ICD ) F. Annual Labs: 1. HBsAb, HCVAb (Jan) (ICD10 N18.6) 2. Vitamin D-25 (Jan) (ICD10 N18.6) 3. Aluminum (Jan) (ICD10 M83.9) G. PRN Lab Draws: 1. Blood Cultures (ICD10 A41.9) & Wound Cultures of access site (ICD10 T82.7XXA (initial), D (subsequent)or S (sequela)) a. Patient with a central venous catheter and a fever of >100.4⁰F or >38.0⁰C, draw two (2) sets of blood cultures from the access/bloodlines at least five (5) minutes apart. Notify MD. b. Patient with a fistula or graft and a fever of >100.4⁰F or >38.0⁰C, call MD for orders.
2 Page 2 of 5 c. Culture and Sensitivity on any drainage noted from a dialysis access site i. Specify Site ii. Contact MD prior to initiation of dialysis if access infection suspected. d. ALL CULTURES MUST BE DRAWN IN CENTER 2. HBsAb titer recheck 30 days after completion of Hepatitis B vaccination series (ICD10 N18.6) 3. Recheck labs and notify MD per P&P Critical Lab Notification to Nephrologist 4. Water and dialysate cultures, LAL, and colony counts from machine and water treatment: (ICD10 N18.6) a. PRN Nurse clinical suspicion 3. Water Testing: Initial Home Survey (Testing Done by Technical Services) Initial Home Treatment Done by RN) Quarterly Testing Done by Patient) Testing Schedule Annual Testing Done by Patient) New or Change in Water Source Done by Patient) Patients On Well Water Quarterly testing Done by Patient) (Raw Water) 4. Dialysis Adequacy: (Product Water) A. Notify MD if: 1. Kt/V < Standard Kt/V < 2.0 B. If Kt/V <1.2 or Std Kt/V < 2.0, recheck prior to end of current month (ICD10 Z49.31) C. Ultrafiltration rate may not exceed 13 ml/kg/hr without MD order 5. Medications: Oxygen and IV medications will NOT be given by patient or caregiver. Oxygen, SubQ and IV medications can only be given while in the Home Department or during an in-center treatment by a nurse. A. Epinephrine Auto Injector per P&P Anaphylaxis B. Benadryl 25 mg IV: 1. FOR ALLERGIC REACTIONS ONLY 2. Patients should not drive after dialysis after receiving these medications as their abilities may be hampered C. Ondansetron 4 mg PO PRN nausea or vomiting, may repeat once
3 Page 3 of 5 D. Acetaminophen 325 mg 1-2 PO every four (4) hours as needed for pain E. Nitroglycerin 0.4 mg SL PRN chest pain: 1. May repeat every five (5) minutes for up to 3 doses 2. Page MD after the first dose is given 3. DO NOT GIVE IF BP SYSTOLIC IS < 100 F. Glucose Tabs for Insulin Reaction (ICD10 E16.1): See P&P Hypoglycemia Management 1. Obtain chemstrip 2. For symptomatic hypoglycemia (chemstrip < 80), administer two (2) glucose tab PO 3. Recheck chemstrip every 15 minutes and repeat glucose tabs until symptoms resolve and chemstrip Page MD if more than four (4) glucose tabs are administered G. Dextrose 50% for Insulin Reaction (ICD10 E16.1): See P&P Hypoglycemia Management 1. For severe symptoms of hypoglycemia or chemstrip < 60, give Dextrose 50%, 50 ml (25 grams) IV push and page MD for further instructions 2. Continue to monitor chemstrips every 15 minutes until patient is stable or transferred to ER via Medics 3. May repeat 50% Dextrose, 50 ml (25 grams) IV push every 15 minutes if symptoms recur H. Heparin 5000 units/1 ml heparin lock for central venous catheters I. Alteplase (tpa, cathflo activase): 1. Follow Central Venous Catheter Protocols for indications and use 2. Alteplase can only be administered in-center J. Lidocaine 1% intradermal injection (up to 0.2ml) for local anesthesia at each cannulation site PRN K. Oxygen 2 L/min nasal cannula PRN dyspnea, chest pain or hypotension per P&P Administration of Oxygen L. Gentamicin 0.1% cream topical to central venous catheter exit site every hemodialysis treatment (ICD10 N18.6) 6. Vaccinations: A. Hepatitis B Vaccination (ICD10 Z23) per P&P Hepatitis B Prevention Program B. Seasonal Flu Vaccination (ICD10 Z23) per P&P Administration of the Seasonal Influenza Vaccine 1. Should be administered to all patients 18 years or older during the flu season (October-April) 2. Exceptions: a. Check package insert for contraindications b. MD stated contraindicated c. Patient refuses C. Pneumococcal Vaccination (ICD10 Z23) per P&P Administration of the Pneumococcal Vaccines PCV13 and PPSV23 7. Bone Disease Management Protocol: A. For dosing of oral calcium medications and phosphate binders follow P&P Calcium and Phosphorus Management 8. Anemia Management: A. For dosing of ESA (ICD10 D63.1) and IV Iron (ICD10 D50.9) see Home Anemia Management P&P
4 Page 4 of 5 9. Heparinization: A. NxStage Short Daily Dialysis: 1. If Patient is transferring from in-center, bolus dose = initial prime + 50% of the total hourly dose. 2. No hourly heparin in Short Daily Dialysis 3. Dose not to exceed 7500 units without Medical Director review B. Extended Dialysis: 1. Start with prime of 2000 units and 500 units/hr. 2. Adjust per clearance of dialyzer and lines and bleeding time post dialysis 3. Adjust prime first, then hourly 4. Notify MD of Changes C. Duration of bleeding after the removal of needles post dialysis should be within 10 minutes. If it is longer, heparin dose may need adjustment. D. With excess bleeding despite Heparin decrease, evaluate access for stenosis prior to further dose adjustment. 10. Dialysis Access: A. Maintain adequate blood flow rate (BFR): 1. Minimum BFR of 200ml/min up to maximum ordered BFR, but limited by arterial pressures NEVER to exceed -240 mmhg and venous pressures NEVER to exceed +240 mmhg. Adjust BFR as needed to stay within pressure limits. 2. Notify MD if unable to maintain blood flow rate 200 ml/min B. Recirculation Studies (ICD10 N18.6 or as indicated by MD) to be drawn per P&P Drawing Recirculation Studies for a Hemodialysis Access if: 1. Arterial pressure is -10 mmhg x1 at a 200 ml/min BFR 2. Venous pressure is 140 mmhg x3 consecutive treatments at a 200 ml/min BFR 3. Notify MD if: a. AV Fistula Recirculation > 10% b. AV Graft Recirculation >15% 11. Nursing: A. During NxStage training, patient will dialyze 5 days a week unless otherwise ordered B. Ok for patient to miss one run for 1 st home supply delivery C. Hypovolemia/Hypotension: 1. Administer 0.9% Normal Saline IV in 100 ml increments up to 500 ml PRN 2. Page MD if more than 500 ml is needed D. Unstable Medical Condition: 1. Dialysis may be postponed or terminated at the discretion of the nurse if the patient is deemed to be medically unstable 2. Page MD immediately E. Hypertension (Systolic Blood Pressure >200 or Diastolic Blood Pressure >120): 1. Do not initiate dialysis 2. Page MD for instructions F. Tachycardia (Pulse > 120): 1. Do not initiate dialysis G. Page MD for instructions H. Use Low Dose Heparin per P&P Anticoagulation Protocol and page MD if:
5 Page 5 of 5 1. Evidence of recent fall 2. Same day surgery 3. Dental visit 4. Epistaxis 5. Suspected pericarditis 12. Emergency Dialysis Orders: A. In a declared emergency (earthquake, fire, flood, power-outage, etc.) where routine dialysis treatment cannot be performed the following adjustments to the dialysis prescription may be made in an in-center setting: 1. Dialyzer: F160NRe (if not available, F180NRe may be substituted) 2. Dialysate: Per patient s prescription. If this is not available, the default dialysate will be K2.0/Ca Heparinization (unless no heparin ordered): 1000 units prime and 500 units hourly, off 1 hour (leave heparin on entire treatment for catheters) with Normal Saline Flushes PRN for clotting 4. Time: Maximum feasible up to prescribed time depending on the nature of the emergency 5. MD will be notified if adjustments are made to the patient s dialysate or time Nephrologist Name: Signature: Date: See Electronic Signature in the EMR system
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