MANITOBA RENAL PROGRAM POLICY AND PROCEDURE MANUAL TABLE OF CONTENTS

Transcription

1 MANITOBA RENAL PROGRAM POLICY AND PROCEDURE MANUAL TABLE OF CONTENTS Introduction Code Administration Committee Manitoba Renal Program: Policy and Procedure Committee Terms of Reference Code MRP Policies and Procedures Dialyzers Providing Hemodialysis without Heparinization Dialysate Delivery Systems Use of Fresenius 2008K Delivery System Responding to Fresenius 2008K Blood Leak Alarms Fresenius 5008 ISO Ultrafiltration (Sequential Therapy) Fresenius 2008K Air Detector Alarm Troubleshooting Guide Use of Fresenius 5008 Delivery System Fresenius 5008 Air Detected Below the Venous Bubble Catcher Fresenius 5008 Blood Leak Alarms; responding to Changing the Extracorporeal circuit during hemodialysis treatment for the Fresenius 5008 delivery system Fresenius 5008 Recirculation of Extracorporeal Circuit with Normal Saline and with Blood Single Needle (Click-Clack) Hemodialysis for Fresenius 5008 Dialysis Delivery system Code Vascular Access Venipuncture of Arteriovenous Fistula/Graft Accessing and Locking Dialysis Central Venous Catheter (Anticoagulant/ Thrombolytic/Antibiotic Locking) Establishing and Maintaining Buttonhole Venipuncture Sites W:\P & P\Procedures\Table of Contents\Current\On Line Table of Contents july 2014.doc 1 of 5

2 Use of Tego Connectors with Hemodialysis Central Venous Catheters (CVC) Hemodialysis Central Line Dressing Change Fresenius 2008K Recirculation of Extracorporeal Blood Circuit AVF/AVG Vascular Access Assessment Obtaining Blood Specimens to Measure Adequacy of Dialysis Removal of Non-Tunnelled Hemodialysis Central Venous Catheters Alteplase for Clearing Hemodialysis Catheter Thrombosis using the Push (30 minute) Method Alteplase IV Infusion for Clearing Hemodialysis Catheter Thrombosis Local Centres: Antibiotic Lock Preparation Procedures for Hemodialysis Central Venous Catheters Collection of Blood Culture Specimen From a Hemodialysis Access Code Accessory Equipment Use of Neo-Stat/Neo-Stat Plus Dialysate Conductivity Meter A Use of BARD Dialysis Catheter Repair Kit B Use of Covidien Acute and Chronic Catheter Repair Kit: Palindrome Chronic Care and All Mahurkar Acute and Chronic Care Catheters Use of the HEMOdialert device with hemodialysis Use of DWA Continuous Concentrate Mixing System Code Water Treatment Use and Disinfection of Portable Reverse Osmosis System (Gambro WRO) Use of Lauer Aquaboss Eco RO Dia Reverse Osmosis System Use of Reverse Osmosis System via the Multi-Media Interface Nurse Remote Panel (Boundary Trails, Island Lake, Lake of the Woods District, Selkirk, and Swan Valley Health Centre) Code Standards of Care Obtaining Blood Sample for International Normalized Ratio from Central Venous Catheters Intradialytic Blood Product Administration Ordering & Returning Of Dialysis Supplies: Local Centres DRAFT Discharge Criteria for Hemodialysis Patients from the Dialysis Unit following Treatment Administration of Intradialytic Parenteral Nutrition to the Hemodialysis Patient Code Peritoneal Dialysis W:\P & P\Procedures\Table of Contents\Current\On Line Table of Contents july 2014.doc 2 of 5

3 Attachment of Minicap Extended Life PD Transfer Set to Peritoneal Catheter Changing Titanium Adaptor in a Peritoneal Catheter Instillation of Medication into Peritoneal Dialysis Solution a b Appendix A: Intraperitoneal Medication List Appendix B: IP KCl Application of Locking Cap to Peritoneal Catheter Peritoneal Catheter Flush a Appendix A: Decision Tree for Managing Contamination Peritoneal Exit Site Care a b Appendix A: Physician Management of Exit Site Infection Appendix B: Catheter Dressing Peritoneal Dialysis Bag Exchange Utilizing Twin Bag System a Appendix A: Decision Tree for Managing Contamination Home Choice Cycle Set-Up: Initiation of Cycling and End of Treatment (utilizing a luer lock cycle set) Peritoneal Catheter Irrigation Silver Nitrate Application Ascites drainage utilizing a Peritoneal Catheter Code MRP Standards and Protocols Code Standards Hemodialysis Treatment Record Standard a Appendix: Hemodialysis Treatment Record (Form #W-00411) Hemodialysis Flow Sheet Standard a Appendix: Hemodialysis Flow Sheet (Form #W-00417) Hemodialysis Nursing Kardex Standard Hemodialysis Signature Sheet Standard a Appendix: Hemodialysis Signature Sheet (Form #NS 00714) Hemodialysis Renal Medication Flow Sheet Standard a Appendix: Hemodialysis Renal Medication Flow Sheet (Form #85561) Hemodialysis Vascular Access Record Standard Standard for Completion of Cardiorenal/Ascites Peritoneal Dialysis Catheter Drainage Assessment Report W:\P & P\Procedures\Table of Contents\Current\On Line Table of Contents july 2014.doc 3 of 5

4 a Appendix: Cardiorenal/Ascites Peritoneal Dialysis Catheter Drainage Assessment Report (Form #W-00471) Standard for Completion of Continuous Ambulatory Peritoneal Dialysis a Assessment Report Appendix: Continuous Ambulatory Peritoneal Dialysis Assessment Report (Form #W-00472) Documentation Standard - Manitoba Renal Program & Long Term Care Communication Record Form #W-00273, #WR-16, and # CL Code Protocols Vascular Access Protocol Human Leukocyte Antigen Antibody Testing Routine and Post Transfusion Protocol Adult Patient Screening and Vaccination Protocol for Hepatitis B and Hepatitis C a b c Appendix A: Algorithm for Hepatitis B Vaccination and Monitoring in Susceptible Patients Appendix B: Schedule for Routine Blood Testing for Hepatitis B and Hepatitis C Virus Infections Appendix C: How to Switch a Patient from one product to the other Initial and Monthly Lab Tests Protocol for Chronic Hemodialysis Patients Management of Hemodialysis Patients with Infectious Diseases Protocol including HBsAg Positive Patients Management of HBsAg Positive Hemodialysis Patients Screening of Dialysis Patients for Hepatitis B, MRSA and VRE Protocol when Travelling Continuous Ambulatory Peritoneal Dialysis Protocol a Appendix A: Fluid Management Guidelines Continuous Cycling Peritoneal Dialysis Protocol a Appendix A: Fluid Management Guidelines Peritonitis Protocol Care of Patient on Home Peritoneal Dialysis Protocol Care of Patient on Home Hemodialysis Protocol Care of Patient on Home Care Attendant Assisted Continuous Cycling Peritoneal Dialysis Protocol Protocol for Transfer of Patients between Dialysis Units and/or Sites within the Manitoba Renal Program a Appendix A: Transfer Checklist for dialysis patients transferring between Winnipeg units or sites W:\P & P\Procedures\Table of Contents\Current\On Line Table of Contents july 2014.doc 4 of 5

5 a b c Appendix A: Form #W Manitoba Renal Program Transfer of Patients Between Dialysis Units and or Sites within the Manitoba Renal Program Checklist Appendix B: Patient Transfer Letter Appendix C: Hemodialysis Patient Permanent Transfer Algorithm Protocol for Providing Acute/Emergent Dialysis Treatments Outside the Operating Hours of the Hemodialysis Units at SBH Protocol for Providing Acute/Emergent Hemodialysis Treatments Outside the Operating Hours of the Hemodialysis Units at HSC Addendum A: Addendum to Protocol for Providing Acute/Emergent Hemodialysis Treatments Outside the Operating Hours of the Hemodialysis Units at HSC Code Guidelines Guidelines for Heparinization during Hemodialysis Guidelines for the Prevention of Hypophasphatemia in Patients Receiving Nocturnal/Long Daily Hemodialysis Ordering & Returning Dialysis Supplies for Local Centre Dialysis Units Contacting a Patient who does not Attend a Hemodialysis Treatment Guidelines for Managing Hospitalized Hemodialysis Patients Form #W Guidelines for Patient Identification of Outpatients receiving services or procedures from the MB Renal Program Team DRAFT Guidelines for Medication Reconciliation a Guidelines for Medication Reconciliation Medication Change Form Guidelines for assessing, monitoring and documenting patient care pre, post and during the hemodialysis treatment Guidelines for assessing, documenting and verbally reporting patient care at the time of transfer from one health care provider to another Code Home Hemodialysis Bellco (Formula 2000) Delivery System; Use of Phosphate Additives for Hemodialysis Patients Calcium chloride additive for hemodialysis patients Changing the Dialyzer During Treatment with the Formula Delivery System Ordering Dialysis Supplies for Home Hemodialysis Patients a Appendix: Manitoba Renal Program Home Hemodialysis Script Order Form Use of the Horizon Mini E Centrifuge W:\P & P\Procedures\Table of Contents\Current\On Line Table of Contents july 2014.doc 5 of 5