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KING FAISAL SPECIALIST HOSPITAL AND RESEARCH CENTRE                                

INTERNAL POLICY AND/OR PROCEDURE (IPP)

DEFINITION:

The mission and standard of care for hemodialysis at King Faisal Specialist Hospital and Research Centre.

EQUIPMENT/SUPPLIES:     None

REFERENCES:

IPP -  ACN-64-01-04

IPP – ACN-64-04-03

IPP – ACN-64-06-37

COMMENTS

1.  The goal of the hemodialysis program is to maintain the general health of the patient with end stage renal disease, who requires treatment in a tertiary care center, including renal transplantation. 

     The Hemodialysis program provides:

A.  Acute hemodialysis – only for patients admitted, pre-booked and hemodialysis emergency patients.

B.  Chronic hemodialysis – for long term (maintenance) hemodialysis patients with end stage renal disease who is (are)

      candidate(s) for renal transplantation.  Priority is given to those with living related donors.

C.  A professional staff to assist the patient with medical aspects of hemodialysis care and to support the patient and his

     family in health maintenance and rehabilitation during hemodialysis.

D.  Education Research and Quality Improvement in Health Care Delivery is promoted to improve patient care.

2.  Appropriateness of Care:

     The decision to initiate hemodialysis will be made by the Nephrologist after consultation with other members of the renal

     care   team.  It will be based on the general medical and psychosocial assessment of the individual patient’s need for

     renal replacement therapy.

     A.  The mode of hemodialysis (conventional hemodialysis, on-line hemodiafiltration, slow continuous hemofiltration,

          and continuous venovenous hemofiltration), is determined by the dialysis team.  This consists of the nephrologists,

          nurses, dietitian and social worker.

          Factors to be considered in the determination of the hemodialysis modality are:

          1.  The patient(s) medical condition

          2.  The resources available

          3.  The patient(s) physical, psychological and social condition.

3.  Quality Care:

     A.   Acute Hemodialysis

           1. Medical rounds by the nephrology team will be held daily and as needed for full care

               Of the acute patients.

      B.  Chronic Hemodialysis 

           1. The following clinical and biochemical parameters will be monitored in all patients Receiving long term

                Hemodialysis.                                                                                                                                                                   

                (a)  An “ideal dry weight” will be established

                (b)  Body weight pre and post Hemodialysis, blood pressure, temperature, pulse, and physical assessment

                      are monitored and recorded pre-dialysis, intra- dialysis and post-dialysis with each treatment.

                (c)  Weight loss during treatment is recorded at the conclusion of each treatment.

           (d)  Laboratory Testing:

                 1.  Monthly:  IP, FER, CBC, ACT’s, Renal Profile, Hepatic Profile are done.

                 2.  Quarterly: PTH, HP, HCV, CWL, And CBCD are done and the results recorded

                 3.  Semi-annually: HIV

                 4.  Annually:  HCV and hepatitis profiles are done on all reactive patients.

           (e)   Yearly:  physical examination, chest x ray, and EKG

            (f)  The specified Hemodialysis treatment parameters are stated in the physician’s standing orders

                  and renewed annually.

            (g)  Patient’s consent for Hemodialysis is obtained annually 

      C.  BI-monthly multi-disciplinary conference will be held to discuss and review all issues

      Pertaining to patient care.  Each patient will be reviewed in depth at least once a year.

Essential portions of each patient’s treatment plan will be reviewed at this meeting by the multidisciplinary team and such review documented (medical report) placed in the patient’s chart.  Treatment plans may be reviewed at any time on an immediate basis.

Factors to be assessed may include one or more of the following.  

1.  Compliance with the dialysis treatment regimen.

2.  Medical and psychological adjustment to Hemodialysis

3.  Teaching needs.

4.  Psychological issues related to the chronic disease process and/or treatment.

5.  Appropriateness/adequacy of treatment modality

6.  Alternate treatment possibilities

7.  Rehabilitation goals

8.  Quality of life

            9.  Need for referral to other resources of medical care.

       D.  Confidentiality and Privacy is maintained.  Contributing factors are:

 1.  Availability of curtains/private rooms.

 2.  Any change from routine procedure or environment are explained to avoid or reduce unnecessary anxiety.

 3.  Referral for spiritual, psychological, vocational and other counseling as needed.

 4.  Interventions and assessments are made in a manner to ensure maximum confidentiality

 5.  Information is given to patients to enhance involvement in decision making regarding his/her dialysis.    

        E.  Patient Education

 1.  Counseling and education regarding diet and dietary guidelines are available from the Dialysis Unit Dietitian

       and Nurse designated for dietary instruction.

  2.  A program of education for patients new to dialysis is maintained.

  3.  A program of educational review for patients on long-term dialysis is maintained.

  4.  Patients are instructed regarding procedures for termination of dialysis or evacuation in emergency

        situations.

   5.  An education program is established for each patient regarding his/her medications (dose, time, name of

        medication, action, side effects), vascular access care, and protection.

    F.  Vascular Access

   1.  Permanent vascular access is established promptly in all patients requiring long-term hemodialysis.

   2.  Request for vascular access is initiated by the Nephrologist and carried out by a qualified vascular surgeon.

   3.  Request for a new access site or surgical repair of failing or failed access sites are considered as

        emergencies in    patients already receiving dialysis.

   4.  The selection of the site for vascular access is made with due consideration for the maximum preservation

         of future sites for vascular access.

   5.  Initial, primary and secondary access failure rates are reviewed at least yearly.

   6.  Surveillance for hemodialysis access stenosis and corrective angioplasty surgery is done bi-annually or

        as needed.

4.  Safety 

     A.  On bi-monthly basis and as part of the function of the Hemodialysis Collaborative Practice Committee

          (a multidisciplinary group consisting of the Medical Director of the dialysis unit, the head nurse, nurses

          and biomedical personnel), review all technical, mechanical and safety aspects of treatment as they relate

          to Quality Improvement and Performance Improvement

     B.  The dialysis unit maintains the following safety standards within the patient care environment:

          1.  Electrical safety is maintained in accordance with general policies of the hospital.

          2.  Equipments are maintained in the proper operating condition when in used for patients’ treatment by

               the Hemodialysis staff.

  The Procedure includes:

   (a)  Disinfection of the hemodialysis machine with an approved disinfecting agent between each procedure

         and at the end of the day according to the manufacturer’s recommendation, the units guidelines and

         AAMI Standards.

  (b)  Cleaning of the exterior surfaces of the hemodialysis machines between treatments.

  (c)  Proper testing of dialysate solute composition prior to individual treatments.

  (d)  Proper testing for residual disinfectant in the dialysate circuit following the daily disinfecting procedure

        and prior to machine use is performed.

  (e)  Sterility of the blood circuit during equipment set-ups and operation is maintained.

  (f)  Blood born diseases precautions will be followed as outlined in the Dialysis Infectious Disease

        Control Policy.

  (g)  Emergency equipments will be readily available:

  1.  Emergency cart is available.  Daily documented inspection is performed

  2.  Oxygen and suction are available in good working condition

  3.  Hand crank for the roller blood pump is present on each dialysis machine if needed and personnel

       have knowledge of its use.

  4.  Personnel are knowledgeable of location and use of fire alarms, extinguishers and oxygen shut-off valve.

  (h)  Electrical/fire safety check-off are done during orientation and annually.

   (i)  A plan for emergency evacuation will be maintained.

C.  Mortality and morbidity are discussed in the Hemodialysis collaborative practice committee meetings. Identification and recurrence of persistent factors which affect patients care are documented.  Quality Improvement Programs are implemented as part of that committee’s function.

            1.  Education/Research/Quality Improvement:

          A.  Staffs are encouraged to attend in services/conferences related to Nephrology.

          B.  Staffs are encouraged to participate in surveys/education/research aimed at identifying/improving

                education of nurses and patients and improving the standards of health care delivery.

          C.  Staffs are encouraged to present at least one educational activity per year – a lecture or

               bulletin / poster board presentation

         D.  Support is given to staff to present clinical activities and research at in-services, grand rounds

              and in publishing articles related to Nephrology.

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