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


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

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