South East Wales Critical Care Network, Welsh Renal Network and Renal Department, University Hospital of Wales.

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1 South East Wales Critical Care Network, Welsh Renal Network and Renal Department, University Hospital of Wales. Authors: David Heyburn, Zoe Goodacre, Matt Davies and Jack Parry-Jones Guidance for Referral and Transfer of Patients requiring acute Renal Replacement Therapy (RRT) in the Renal Unit, University Hospital of Wales. April 2011 Background The Renal Unit at the University Hospital of Wales provides the Acute Renal Service for South East Wales. Patients who are in single organ failure (Renal) should be referred to the SpR on-call for Renal Medicine via the UHW switch board (see below). If they are accepted, every effort should be made to transfer them within 24 hours of acceptance. Problems have arisen in the past due to patients, whilst waiting for a renal bed, then deteriorating and requiring acute Renal Replacement Therapy (RRT) in the DGH critical care unit, and also patients, with single organ failure, occupying critical care beds unnecessarily. Conversely, problems have also arisen when transferred patients have arrived with a greater degree of physiological derangement than the Renal ward is capable of delivering and who then require emergency Critical Care admission in UHW. Many of these problems may be avoided if a consistent and common system of referral and acceptance is followed. The South East Wales Critical Care Network, the Renal Network and the Renal Department in the University Hospital of Wales have agreed these guidelines to assist the adoption of best practice in referral and transfer of patients with acute renal failure. They also provide an audit trail and means of identifying the cost implication to the Critical Care Units and to the Renal service. This guidance is intended to apply to all patients throughout the hospitals general as well as Critical Care wards. 1

2 Table 1. Summary of where Acute Renal Replacement therapy should occur. Indication UHW Renal Ward Local Critical Care unit Single organ renal failure requiring RRT Respiratory FiO2 < 60% FiO2 > 60% Respiratory No NIV/CPAP requirement for 24 hours Cardiovascular No inotrope or pressor requirement Neurological GCS >12/15 GCS<12/15 2 or more organ failure including renal NIV/CPAP requirement the last 24 hours in Unstable haemodynamics requiring arterial line or on inotropes or pressor agents The Guidance 1. Who should be referred? 1.1. Any patient with acute renal failure of unknown aetiology may be referred but acceptance will usually be limited to stable Level 1 patients with single organ failure (i.e. renal failure alone). In general patients with 2 or more organ failure should have recovered from other organ failures and be stable i.e. to be in a condition whereby other organ functions are not likely to deteriorate requiring acute critical care There may be rare occasions e.g Pulmonary Renal sydromes requiring plasma pheresis, or renal biopsy, when patients are accepted who need a higher level of care. Please discuss such specific cases with one of the Consultant Renal physicians and with the on-call Consultant Intensivist in UHW (contact via UHW Switchboard). 2. What can the Renal Ward deal with? 2.1. Stable Level 1 patients plus renal failure O 2 therapy. FiO2 requirement <60% Complicated fluid balance 2.4. Central venous catheters 2.5. Confused patients provided transfer safe. 3. What are they unable to deal with? 3.1. Patients requiring level 2 care i.e 2 or more organ system failure CPAP/NIV or other advanced respiratory support. 2

3 3.3. Arterial line monitoring required Patients who are unconscious or severely obtunded (GCS<12) 3.5. Patients potentially needing or already receiving inotropic and/or vasoconstrictor support Patient s with a tracheostomy. 4. How do you refer a patient? 4.1. To refer a patient contact the SpR on call for renal medicine by bleep at UHW (switchboard ask for Renal SpR on-call). The renal team do not demand consultant-toconsultant referral If you need to discuss the case with the Renal Consultant on call contact via the UHW switchboard (as above). 5. Role of Local Critical Care Unit in Dealing with Unstable Patients 5.1. Patients who require more than single organ failure should be managed in their local critical care unit, and cannot be accepted into the ward on the Renal Unit at UHW Any acute presentation of renal failure where there is haemodynamic instability, severe respiratory compromise including volume overload with a FiO2 requirement >60% or CPAP/NIV requirement, or acute hyperkalaemia (K > 6.0mmol/l) should be stabilised prior to transfer to the Renal Unit. This may require Critical Care admission and CVVHF Patients who have recovered from multiple organ failure but who require ongoing renal support should be transferred to the Renal Unit when they are stable and not likely to deteriorate and require further critical care. 6. Patient preparation for transfer and escorts 6.1. Serum potassium must be at a safe level. (ideally <6.0mmol/l, unless hyperkalaemia long standing) 6.2. The escort will usually be a nurse with experience of highly dependent patients If the patient is hyperkalaemic and referral is urgent and essential a doctor with the appropriate knowledge and experience must also accompany the patient. 3

4 6.4. Send all of the notes, charts and scans etc. If the patient is complex please send all of the actual notes and XRs etc. If the patient is more acute (and thus with less documents), photocopies will suffice As with all transfers, excellent and full communication is vital. Patients transferred require current transfer documentation to be filled in by transferring and receiving team Please let the Renal Ward (B5) know in advance if there are any specific nursing requirements e.g. profiling beds, air mattress, which need to be ordered by the ward in advance. 7. Infection Control 7.1. Colonisation or infection with, e.g. MRSA, C.Diff, VRE, does not preclude admission, but this must be discussed with the renal unit. The patient will need ideally to be accommodated in a side room. 8. Standards/audit 8.1. The renal unit should receive all accepted patients within 24h of acceptance of the referral. Failure to achieve this should be audited by the Renal Service along with time from referral to acceptance of all patients Referrals of single organ failure (renal) from general wards may have to be transferred to their own hospital s ICU for CVVHF as a holding measure. This has financial and capacity implications for critical care. The financial and capacity issues should be audited by the Critical Care Units, with data collated by the Critical Care Network Patients accepted but waiting to go onto a dialysis programme, or on one but requiring in-patient dialysis and who then require CVVHF in a critical care unit due to lack of capacity in the Renal Service should be identified separately. This should be audited by the Renal Service and Renal Network. 4

5 Table 2. Indications for Acute Renal Replacement Therapy. 1. Hyperkalaemia not responding to medical therapy 2. Severe metabolic acidosis 3. Volume overload not responsive to diuresis. 4. Some forms of poisoning discuss with toxicology. Medical treatment for Hyperkalaemia 1. Glucose plus insulin see local guidelines. 2. Salbutamol nebulisers 3. Correction of metabolic acidosis with Bicarbonate 4. Calcium resonium oral or rectal administration 5

6 Flow Chart for the Referral, and acceptance of patients requiring Acute Renal Replacement therapy in South East Wales. Pathway by Critical Care and Renal Networks and by the Renal Directorate, UHW Renal Failure requiring Renal Replacement therapy for Hyperkalaemia, Volume overload, severe metabolic acidosis, and some forms of poisoning Single organ failure (Renal) Stable cardiovascular system, oxygen requirement < 60%, no requirement for CPAP/NIV for 24 hours, GCS > 12, no tracheostomy Renal failure + another organ failure, unstable haemodynamics requiring arterial line monitoring and inotrope or pressor requirement, CPAP/NIV required in the last 24hrs, GCS <12 Too unstable for Renal ward Discuss with local Critical Care admission for RRT and supportive care UHW switch board ( ) ask for on-call Renal SpR On-going single organ renal failure in Critical Care Unit but now otherwise stable for 24 hours Accepted by Renal Spr transfer to UHW Renal within 24 hours Level 2 or level 3 patients requiring the direct clinical input of the renal service e.g Pulmonary renal syndromes requiring plasmaphoresis, should be referred to the Renal service via the Renal SpR, and to the Consultant Intensivist at UHW contactable via switchboard ( ) 6