MANITOBA RENAL PROGRAM

Transcription

1 MANITOBA RENAL PROGRAM POLICIES, PROCEDURES AND RESOURCES Current Number NEW Number Administration Manitoba Renal Program: Policy and Procedure Committee Terms of Reference Kidney Health HEMODIALYSIS Equipment Procedures Use of Fresenius 5008 Delivery System using 0.9% NaCl Fresenius 5008 Preparation for Hemodialysis using the ONLINEplus System Initiation and termination of Treatment using the Fresenius 5008 ONLINEplus System Converting to 0.9% NaCl bolus or NaCl reinfusion using the Fresenius 5008 ONLINEplus System Providing a bolus using the Fresenius 5008 ONLINEplus System Fresenius 5008 ISO Ultrafiltration (Sequential Therapy) 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 (0.9% NaCl set up) ONLINE Circulation of Bloodlines with Substituate After Blood Reinfusion Single Needle (Click-Clack) Hemodialysis for Fresenius 5008 Dialysis Delivery system Providing Hemodialysis without Heparinization X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 1 of 9

2 Intradialytic Blood Product Administration Calcium Chloride Additive for Hemodialysis Patients a a Attachment A: Calcium Chloride for Haemodialysis, CACL Administration of Intradialytic Parenteral Nutrition to the Hemodialysis Patient New a Appendix A Prevention and Treatment of Hypophosphatemia for Patients on Hemodialysis by utilizing phosphate additives Disinfection Policy- title to be finalized NEW Changing Dialysate Concentrate Providing Heparin Bolus During Hemodialysis Treatment Manually Opening Arterial Pressure Measurement Unit Emergency Reinfusion Procedure Using the Fresenius 5008 Manual Reinfusion in the Event of Power Failure and Empty Battery Vascular Access Venipuncture of Arteriovenous Fistula/Graft Under review Accessing and Locking Dialysis Central Venous Catheter (Anticoagulant/ Thrombolytic/Antibiotic Locking) Establishing and Maintaining Buttonhole Venipuncture Sites Use of Closed Needleless Access Device with Hemodialysis Central Venous Catheters (CVC) Hemodialysis Central Line Dressing Change AVF/AVG Vascular Access Assessment 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 Alteplase for Hemodialysis Central Venous Catheter (Dwell procedure) Local Centres: Antibiotic Lock Preparation Procedures for Hemodialysis Central Venous Catheters X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 2 of 9

3 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 Obtaining Blood Specimens Pre and Post Hemodialysis Collection of Blood Culture Specimen From a Hemodialysis Access a a Appendix A: Summary Poster Gold Standard Blood Cultures Obtaining Blood Sample for International Normalized Ratio (INR) from Central Venous Catheters Water Treatment Use of; Lauer Aquaboss EcoRO Dia II HT Reverse Osmosis System (RO). Health Sciences Centre Central Dialysis Unit, Sherbrook Dialysis Unit, St. Boniface Dialysis Unit, Seven Oaks Dialysis Unit, Pine Falls Dialysis Unit, Dauphin Dialysis Unit Fresenius AquaC UNO H Reverse Osmosis System; use of Use of Lauer Aquaboss Eco RO Dia Reverse Osmosis System Fresenius AquaUNO Reverse Osmosis System; use of 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) Peritoneal Dialysis Procedures Attachment of Minicap Extended Life PD Transfer Set to Peritoneal Catheter Changing Titanium Adapter in a Peritoneal Catheter Installation of Medications into Peritoneal Dialysis Solution a a Appendix A: Instillation of Medication into Peritoneal Dialysis Solution (IP Drugs Manual) b b Appendix B: IP KCl Application of Locking Cap to Peritoneal Catheter Peritoneal Catheter Flush Peritoneal Exit Site Care a a Appendix A: Physician Management of Exit Site Infection b b Appendix B: Peritoneal Catheter Exit Site Care X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 3 of 9

4 c c Appendix C: Peritoneal Dialysis Exit Site Intraperitoneal tpa for Obstructed Peritoneal Dialysis Catheters Peritoneal Dialysis Bag Exchange Utilizing Twin Bag System b a Appendix A: W00353 CAPD Flow Sheet Home Choice Pro Cycler Set-Up: Initiation of Cycling and End of Treatment utilizing a luer lock cycler set (software version 10.4) a a Appendix A: W00354 Automated Peritoneal Dialysis Record Peritoneal Catheter Irrigation Silver Nitrate Application Measuring Peritoneal Dialysis Adequacy: KT/V Collection a a Appendix A: Incremental PD Protocol Ascites drainage utilizing a Peritoneal Catheter Collection Of Peritoneal Dialysis Effluent from a Peritoneal Dialysis Drain/Sample for Peritonitis Investigation a a Appendix A: Site Specific Requisitions b b Appendix B: Decision Tree for obtaining Peritoneal Effluent Sample Peritoneal Equilibration Test (PET) a a Appendix A: PET (Peritoneal Equilibration Test) Collection Sheet W Home Hemodialysis Procedures - General Use of the Horizon Mini E Centrifuge NXSTAGE NEW NxStage Ordering Supplies NEW Nxstage Installing PAK NEW NxStage Adjusting the Temp of the PAK NEW NxStage Changing SAK Type NEW NxStage Draining a SAK NEW NxStage Initiation and Discontinuation of Dialysis NEW NxStage Instillation of New Dialysate SAK NEW NxStage Setup of Cycler X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 4 of 9

5 NEW NxStage Testing Chloramines NEW NxStage Boil Water Advisory BELLCO Bellco (Formula 2000) Delivery System; Use of Single Needle Double Pump on the Formula Ordering Dialysis Supplies for Home Hemodialysis Patients a a Appendix: Manitoba Renal Program Home Hemodialysis Script Order Form Documentation Standards and Forms Manitoba Renal Program - General Renal Health/Hemodialysis Nursing Kardex Standard a a Appendix A: Renal Patient Kardex (form #W-00195A) b b Appendix B: Hemodialysis Patient Kardex (form #W-00195B) * * c Appendix C PD Kardex Documentation Standard for use of Form W-00665A, Initial Skin and Wound Assessment Flow Sheet and Form W-00665B, Subsequent Skin and Wound Assessment Flow Sheet Hemodialysis A Hemodialysis Treatment Record Standard (For Fresenius 5008 Delivery System) a Aa Appendix A: Hemodialysis Treatment Record for Fresenius 5008 (form #1592) b B Hemodialysis Treatment Record Standard - HSC c Bb Appendix B: Form W HSC Hemodialysis Treatment Record Hemodialysis Flow Sheet Standard (for Fresenius 5008) a a Appendix A: Hemodialysis Flow Sheet (Form #W-1593) Hemodialysis Signature Sheet Standard a a Appendix A: Hemodialysis Signature Sheet (Form #NS 00714) b Hemodialysis Renal Medication Flow Sheet Standard (ekhr) Hemodialysis Renal Medication Flow Sheet Standard (non ekhr) a Appendix: Hemodialysis Renal Medication Flow Sheet (Form NS01708) X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 5 of 9

6 Documentation Standard - Manitoba Renal Program & Long Term Care Communication Record a Documentation Standard - Manitoba Renal Program & Long Term Care Communication Record Form #W b DLC Manitoba Renal Program & Long Term Care Communication Record #WR c RHC Manitoba Renal Program & Long Term Care Communication Record # CL Peritoneal Dialysis Standard for Completion of Cardiorenal/Ascites Peritoneal Dialysis Catheter Drainage Assessment Report a a Appendix: Cardiorenal/Ascites Peritoneal Dialysis Catheter Drainage Assessment Report (Form #W-00471) Standard for Completion of Continuous Ambulatory Peritoneal Dialysis Assessment Report b a Appendix: Continuous Ambulatory Peritoneal Dialysis Assessment Report (Form #W ) Working Alone Standard for Peritoneal Dialysis Community Care (PDCC) a b a b Peritoneal Dialysis Community Care Reporting form for missing employee Emergency Contact Information form Moved to HC page under new clinical guidelines tab Stepwise Approach to Uremic Pruritus Appendix: Hydroxyzine (Atarax ) and Risk of QT Interval Prolongation and Torsades de Pointes Protocols Manitoba Renal Program General Human Leukocyte Antigen Antibody Testing Routine and Post Transfusion Protocol Adult Patient Screening and Vaccination Protocol for Hepatitis B and Hepatitis C a a Appendix A: Algorithm for Hepatitis B Vaccination and Monitoring in Susceptible Patients b b Appendix B: Schedule for Routine Blood Testing for Hepatitis B and Hepatitis C Virus Infections c c Appendix C: How to Switch a Patient from one product to the other e MRP HIV Testing Letter Protocol for Transfer of Patients between Dialysis Units and/or Sites within the Manitoba Renal Program a a Appendix A: Transfer Checklist for dialysis patients transferring between Winnipeg units or sites a ai Appendix A: Form #W Manitoba Renal Program Transfer of Patients Between Dialysis Units and or Sites within the Manitoba Renal Program Checklist X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 6 of 9

7 b b Appendix B: Patient Transfer Letter c c Appendix C: Hemodialysis Patient Permanent Transfer Algorithm Hemodialysis 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 Protocol when Travelling Initial and Monthly Lab Tests Protocol for Chronic Hemodialysis Patients a a Appendix A: Dialysis Panel HSC and LRHU b b Appendix B: Dialysis Panel SOH c c Appendix C: Dialysis Panel SBH d d Appendix D: Dialysis Panel Brandon Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis Protocol a a Appendix A: Fluid Management Guidelines b b Appendix B: CAPD Flow Sheet (Form #W-00353) Continuous Cycling Peritoneal Dialysis Protocol a a Appendix A: Fluid Management Guidelines b b Appendix B: Automated Peritoneal Dialysis Record (Form #W-00354) Peritonitis Protocol Care of Patient on Home Peritoneal Dialysis Protocol *NEW Peritoneal Dialysis Contamination Protocol *NEW a Appendix A W Physician Order Sheet Peritoneal Dialysis Empiric Treatment of Peritoneal Dialysis Related Peritonitis *NEW b Appendix B W Part 1 Determining Peritonitis in Rural Patients *NEW c Appendix C W Part 2 Collection of Peritoneal Effluent in Rural Settings *NEW d Appendix D W Part 3 Guideline for Empiric Antibiotic Treatment Guidelines for Rural Outpatients with Peritonitis *NEW e Appendix E W Physician s Order Sheet Peritoneal Dialysis OUTPATIENTS Confirmed Pathogen Peritonitis X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 7 of 9

8 *NEW f Appendix F W Physician s Order Sheet Peritoneal Dialysis OUTPATIENTS Exit Site/Tunnel Infections and Wet Contamination *NEW g Appendix G Decision Tree for Managing Contamination Initial and Monthly Lab Tests Protocol for patients receiving Chronic Peritoneal Dialysis a a Appendix A SOH PD bloodwork panel b b Appendix B SBH PD bloodwork panel Home Hemodialysis Care of Patient on Home Hemodialysis Protocol Guidelines Manitoba Renal Program General Guidelines for Patient Identification of Outpatients receiving services or procedures from the MB Renal Program Team DRAFT Guidelines for Medication Reconciliation a a Appendix A: Guidelines for Medication Reconciliation Medication Change Form b b Appendix B: Guidelines for Medication Reconciliation Medication Card c c Appendix C: MRP Medication Change Form (letter) Guidelines for assessing, documenting and verbally reporting patient care at the time of transfer from one health care provider to another a a Appendix A: Manitoba Renal Program Health Information Transfer Tool Hemodialysis Guidelines for Heparinization during Hemodialysis Ordering & Returning Dialysis Supplies for Local Centre Dialysis Units a a Appendix LC: Exchange Cart and Forms/Labels Discharge Criteria for Hemodialysis Patients from the Dialysis Unit following Treatment Contacting a Patient who does not Attend a Hemodialysis Treatment Jan Guidelines for Managing Hospitalized Hemodialysis Patients (Form #W-00346) X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 8 of 9

9 Guidelines for assessing, monitoring and documenting patient care pre, post and during the hemodialysis treatment a a Appendix A: Guidelines for the Treatment of Intradialytic Hypotension b b Appendix B: Guidelines for the Treatment of Post Hemodialysis Hypotension Providing Acute/Emergent Hemodialysis Treatments outside the Operating Hours of the Hemodialysis Units at the Health Sciences Centre a a Appendix A: HSC Guidelines On-Call ( ) Providing Acute/Emergent Hemodialysis Treatments outside the Operating Hours of the Hemodialysis Units at SBH Hemodialysis Performed in Emergency Department and ICU Units at Seven Oaks Hospital (7N ) APRIL Peritoneal Dialysis Guideline for care of the In-Centre Peritoneal Dialysis Patient a Appendix A Checklist for Managing hospitalized Peritoneal Dialysis Patient - draft X:\HSC\SHARED\MRP\MRP_P&P\Procedures WEB copies only\table of Contents April 2018.doc 9 of 9