Harbor:Scheduled dialysis patients in ED
Dialysis patients with COVID Symptoms
- Patients with assigned dialysis centers exhibiting symptoms or with a new COVID diagnosis
- Contact their dialysis center immediately to see if they can be placed in the COVID HD cohort
- If they cannot cohort:
- Consult nephrology to begin contingency planning
- During daytime hours, SW may be able to assist (there is one HD social worker)
- If patient just had HD, can send outpt test to MLK or Keck with ~24 hour TAT
- If Pt requires HD in <24 hours, patient may need ED dialysis
- If nephrology feels admission is warranted for HD, then rapid COVID test may be ordered (Dr. Mahajan 6/2020)
- If rapid test is negative, they can be discharged (and go back to their dialysis unit)
- If positive, will be needed for admission
- Drs. Chappell & Shah (Nephrology) 7/2020
- Consult nephrology to begin contingency planning
- If they cannot cohort:
- Contact their dialysis center immediately to see if they can be placed in the COVID HD cohort
COVID Transitional Dialysis
- Up to 30 days after hospital DC while awaiting transition to community dialysis centers; re-admit if not transitioned after 28 days
- max 2 pt/shift, M/W/F, 8:30 a.m.-1230 p.m. and 1-30 p.m.-5:30 p.m.
- COVID Testing (Per Dr. Zangwill 7/6/2020)
- Inpatients who were COVID (-) while admitted --> no re-test.
- If previously COVID (+) and recovered (asymptomatic >10 days) per our EP, can go to the unit after discharge –-> no re-test
- Patient develops new symptoms: must be dialyzed in ED until COVID test negative or asymptomatic >10 days
- HepB SAg must be negative within the past 30d; must repeat every 30 days
- Symptomatic or /COVID positive or HepB positive - HD in ED
- 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 Dialysis Unit (5 West Room 10) if COVID and Hep B negative
- Label as AD1 or AD3 on the tracking board in FirstNet
- Symptomatic/COVID positive/Hep B - A15, R19, Tra1
- Patients getting dialyzed in the AED will be placed on teams; the team ONLY places DC order (no note necessary)
- Post Dialysis
- After dialysis completed, HD nurse documents:
- Dialysis treatment performed as ordered
- Post-treatment assessment and discharge education/instruction
- A procedure note in ORCHID post treatment
- Dialysis nurses request transport service to take patient back to AED Triage (reassessment RN)
- Available provider discharges from triage or FT with "Hemodialysis" instructions
- if hemodynamically unstable after HD, return to ED for evaluation
- After dialysis completed, HD nurse documents:
OLD PROCESS from 12-2017
- The router will place them on the pre-arrivals each AM (M/W/F)
- HD times should be 5-9a and 930-130p
- 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
- 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.
- 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).
- 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).
- 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).
- The NP will forward the chart to Dr. Shah, not ED R4 or Attending.