Harbor:Scheduled dialysis patients in ED: Difference between revisions

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** Hep neg <30d … repeat q30d
** Hep neg <30d … repeat q30d


*ED
1) inpatient who was COVID (-) in house - no retest. 
** call from HD clerk to OCN
2) if previously COVID (+) and recovered per our EP, can go to the unit after discharge (coming in from home) – no retest
3) if ever develops new symptoms, must be dialyzed in ED unless, at least, tested and clinical determination made with results known
 
 
*ED Flow
** call from Dialysis Area Clerk to OCN
** OCN to place pre-arrival note
** OCN to place pre-arrival note
** Pt arrives with paper stating here for scheduled emergent HD
** Pt arrives with "dialysis ticket" (given by dialysis team prior to previous DC)stating here for scheduled emergent HD
** MSE - stable for HD
** MSE - "Pt here for emergent HD; no other medical concerns; hemodynamically stable for HD"
** USA takes to Transitional HD center
** ED/Transitional Dialysis Unit (5 West Room 10)
** ED/Transitional Dialysis Unit (5 West Room 10)
*** symptomatic/COVID positive/Hep B - A15, R19, G29, Tra1
*** symptomatic/COVID positive/Hep B - A15, R19, G29, Tra1
** after HD - DC from FT with HD instructions
** After dialysis completed, HD nurse to write brief note stating that session completed and patient is stable
***Perform documented dialysis treatment/documentation as ordered
***Perform documented post-treatment assessment and discharge education/instruction
***Place a procedure note in ORCHID post treatment
** after HD - DC from FT with "Hemodialysis" instructions
** if hemodynamically unstable after HD, return to ED for evaluation
 
*Dialysis nurses to request transport service to transport patient back to ER for patients completing dialysis if needed or for patients needing to return to ED for management.


*Patients empaneled to HD centers but new covid positive get admitted … may use transitional for this in the future
* If symptomatic can use 1-hr test to avoid admission
* Patients empaneled to HD centers but new covid positive get admitted … may use transitional for this in the future
 Referral document for scheduled for transitional dialysis service, notify Dialysis area staff of scheduled start date/time for transitional dialysis
 Transitional patients will be presented on consult service rounds to the Attending on consult service
• Post-discharge Responsibilities:
 Write transitional dialysis orders and evaluate patient at each outpatient treatment
 Review post-discharge ESRD-related laboratory test results and take appropriate action
 Request admission for any patient for whom the hospital has not secured placement with a chronic dialysis center by post-discharge day 28. The patient will be readmitted to the inpatient service for dialysis.
 Clinical Social Staff
 Inpatient Pre-discharge Responsibilities
 Assess patient’s insurance status and engage Patient Financial Services if patient needs to apply for Medi-Cal
 Perform documented psychosocial assessment of patient
 Provide patient with a list of chronic dialysis centers and obtain patients’ top 5 placement choices
 Dialysis Area Clerk
 Inpatient Pre-discharge Responsibilities
 Prepare placement paperwork and work to secure placement with a chronic dialysis center.
 Communicate with ED, SW, nephrology, primary medicine team, financial services to coordinate discharge
 Will provide “dialysis ticket” to primary nurse to be included in patient discharge paperwork/instructions. Nephrology consult service may also provide this information directly to patient
 Medical case worker/social work may provide backup as needed
 Keep track of number of days patient is in transitional dialysis
 Maintain a log of patients receiving outpatient treatment
 Post-discharge Responsibilities
 Follow up to secure placement with a chronic dialysis center.
 Review for transportation needs as necessary
 Dialysis clerk will continue placement work for both inpatients and transitional unit patients
 Patient Financial Services Workers staff
 Inpatient Pre-discharge Responsibilities:
 Assist patient with submission of Medi-Cal application
 Input Pending Medi-Cal Number into ORCHID chart
 Post-discharge Responsibilities:
 Follow up medical applications
 Nursing Department ED Nursing staff
 EMTALA Responsibilities:
 Document patient in the EMTALA-required Central Log (begun by Router Desk staff)
 Perform documented Nursing triage assessment including temperature check
 Engage ED provider to perform EMTALA-required medical screening evaluation
 Following completion of medical screening evaluation, arrange dialysis disposition as determined by ED provider either to dialysis within the ED physical space or to the ED/Transitional Dialysis Unit and notify Dialysis RN
 Emergency Medicine Physician and/or Nurse Practitioner staff
 EMTALA Responsibilities:
 Perform documented EMTALA-required medical screening evaluation, including need for emergent dialysis. Notify ED nurse of appropriate dialysis disposition – either within ED if COVID+ and/or Hepatitis B+, or to the ED/Transitional Dialysis Unit if COVID- and Hepatitis B-
 Unstable patients will return to ED for management
 ED staff will write the order to discharge the patient post dialysis treatment
 Nursing Department Dialysis RN staff
Staffed at a ratio not to exceed 2 patients to 1 Dialysis RN. At all times when patients are present in the ED/Transitional Dialysis Unit, there must always be 2 staff; the level of those 2 staff depend on the number of patients present. Patient care to be documented in ORCHID.
• Post-discharge Responsibilities
• Document that patient has a mask before entering 5w room 10
• Covid screening temperature check
 Perform documented pre-treatment nursing assessment
 Perform documented dialysis treatment/documentation as ordered
 Perform documented post-treatment assessment and discharge education/instruction
 Place a procedure note in ORCHID post treatment
 Dialysis Technician
 Perform documented water testing and equipment preventive maintenance and cleaning
Scheduling of treatments
 Nephrology
 Will provide instruction/referral to Transitional Dialysis
 Will communicate with Dialysis area clerk to notify the emergency room staff, hemodialysis nurses, PFS, and social worker of the outpatient
 Infection Prevention/Control
• Machine maintenance and water system disinfection will be continued per hospital HD policies
 Transportation
• ED/RME to arrange for transport from the ED/Transitional Dialysis  to 5W room 10
• Dialysis nurses to request transport service to transport patient back to ER for patients completing dialysis if needed or for patients needing to return to ED for management. Ambulatory patients may also walk down to the ED themselves




Revision as of 21:30, 6 July 2020

COVID Transitional Dialysis

  • Up to 30 days after hospital DC while awaiting transition to community dialysis centers; re-admit after day 28 if not transitioned
    • max 2 pt/shift, M/W/F, 8:30 a.m.-1230 p.m. and 1-30 p.m.-5:30 p.m.
      • repeat test every 7-10d at HD even if asymptomatic
    • COVID neg on admission - test q7d, Keck
    • recovered >10d no symptoms (do not re-test within 30d of last covid test) - upstairs … IPC expected practice coming soon
    • Symptomatic or /COVID positive - HD in ED
    • Hep neg <30d … repeat q30d

1) inpatient who was COVID (-) in house - no retest. 2) if previously COVID (+) and recovered per our EP, can go to the unit after discharge (coming in from home) – no retest 3) if ever develops new symptoms, must be dialyzed in ED unless, at least, tested and clinical determination made with results known


  • ED Flow
    • call from Dialysis Area Clerk to OCN
    • OCN to place pre-arrival note
    • Pt arrives with "dialysis ticket" (given by dialysis team prior to previous DC)stating here for scheduled emergent HD
    • MSE - "Pt here for emergent HD; no other medical concerns; hemodynamically stable for HD"
    • USA takes to Transitional HD center
    • ED/Transitional Dialysis Unit (5 West Room 10)
      • symptomatic/COVID positive/Hep B - A15, R19, G29, Tra1
    • After dialysis completed, HD nurse to write brief note stating that session completed and patient is stable
      • Perform documented dialysis treatment/documentation as ordered
      • Perform documented post-treatment assessment and discharge education/instruction
      • Place a procedure note in ORCHID post treatment
    • after HD - DC from FT with "Hemodialysis" instructions
    • if hemodynamically unstable after HD, return to ED for evaluation
  • Dialysis nurses to request transport service to transport patient back to ER for patients completing dialysis if needed or for patients needing to return to ED for management.
  • If symptomatic can use 1-hr test to avoid admission
  • Patients empaneled to HD centers but new covid positive get admitted … may use transitional for this in the future






OLD PROCESS from 12-2017

  1. The router will place them on the pre-arrivals each AM (M/W/F)
  2. HD times should be 5-9a and 930-130p
  3. They will receive a MSE at triage – if they decline the MSE and only want their scheduled HD, please document that “the patient declined a MSE and no emergent medical condition exists at this time” in the MSE note and we are done from the ED perspective
  4. If the patient appears unstable, please discuss with one of the AED attendings to determine if they need to be on an AED team or simply need dialysis with a call to the nephrologist for urgent evaluation.
  5. Once the MSE is performed, they will be taken to one of our HD rooms – preferentially Gold 29, then RME 19, then Acute 15 (likely a max of 2 rooms at a time).
  6. They will be cared for by the nephrologist (typically Dr. Anuja Shah) who will place the discharge orders (so these patients should NOT be placed on AED teams).
  7. If for some reason Dr. Shah is unable to evaluate the patient prior to discharge, the FastTrack NP (not resident) will briefly evaluate the patient when ready for discharge - documenting vitals, heart, lung, and lower extremity exam, and page Dr. Shah to clear for dispo and subsequently print the discharge instructions (“HEMODIALYSIS” patient education).
  8. The NP will forward the chart to Dr. Shah, not ED R4 or Attending.


See Also

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