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Renal: Patient dependency rating in dialysis units HNELHD GandP…..
Guideline
Renal: Patient dependency rating in dialysis units
Sites where Guideline and Procedure applies:
All HNE Health facilities where a patient undergoes
haemodialysis
Target audience:
Nephrology clinical staff, who provide care to haemodialysis
patients.
Description:
This document comprises part of the clinical information
package for the care haemodialysis patients.
This Guideline and Procedure applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
Keywords:
Blood, Virus, Haemodialysis
Replaces Existing Guideline and Procedure
and:
Yes
Registration Number(s) and/or name and of
Superseded Documents:
JHH Nephrology SWP N 2.2
JHH Nephrology SWP N 2.4
Relevant or related Documents, Legislation, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Renal Services Plan 2007-2011
http://www.health.nsw.gov.au

HNELHD Renal Plan 2007-2011
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0009/42966/FORMATTEDRENAL_SERVI
CES_PLAN_Final_090807.pdf
Prerequisites (if required):
Nil
Guideline and Procedure
Note:
This document reflects what is currently regarded as safe standards of clinical
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace the
need for the application of clinical judgment in respect to each individual patient.
Date authorised:
Authorised by:
Renal Clinical Stream Leadership Group
Contact Person:
Kelly Adams, Renal Stream Coordinator
Contact Details:
4904 8800
This Guideline and
Procedure contains advice
on therapeutics
No
Date of Issue:
Review due date:
TRIM Number:
Version One
TBA
April 2012
OUTCOMES
1
Patients dependency is categorised and haemodialysis attended in the most appropriate clinical
area with adequate staffing levels
ABBREVIATIONS & GLOSSARY
ADL
Activities of Daily Living
PREAMBLE
“In Centre” haemodialysis units will always be located within the footprint of a major hospital, with a
high level of medical support in close proximity and a consultant Nephrologist. These units will
provide maintenance haemodialysis for patients with end stage kidney disease whilst they are;
suffering from a significant acute medical or surgical illness, not always directly related to Chronic
Kidney Disease, a medically unstable chronic haemodialysis patient and also can provide staff and
equipment for dialysis of critically ill patients in special care facilities such as Intensive care / Acute
care/ Coronary care units. Dialysis patients who are hospital inpatients, will, in most cases, require
dialysis in an ‘in-centre” haemodialysis unit.
“Satellite facilities” can have various locations as they are specifically for medically stable chronic
haemodialysis patients who usually do not require clinical assessment (apart from usual dialysis
practice needs) prior to each dialysis session. Satellite dialysis units would not usually perform
dialysis for patients who are concurrently hospital inpatients as appropriate medical management
is mostly to transfer such patients’ to a location with “In Centre” facilities. Satellite units do not have
a consultant Nephrologists within close proximity, do not provide an “on-call” or out of hours
emergency service, and due to a very high occupancy rate can not usually provide emergency
dialysis (within hours).
“Home Haemodialysis” is available for physically and medically appropriate patients who
successfully complete home training program requirements and have a residence suitable to
perform home haemodialysis. Most home haemodialysis patients with either technical or medical
issues will require transfer to a suitable “In Centre” facility or back to their home training unit for
dialysis.
PROCEDURE
In-centre and satellite haemodialysis facilities are not always as distinguishable as current
terminology might imply, especially in rural centres. Some very dependent patients are cared for in
satellite facilities, and some patients receiving care in hospital-based facilities are not high
dependency and could be cared for in a satellite facility, if it were accessible (NSW Renal Plan
2007).
The objective of a dependency criterion is to have a standard scale in which to assess patients of
dialysis units to ensure safe patient to staff ratio’s and to determine the distribution of patients from
each category level that can be accommodated on each shift.
Note: According to the Definition in the “Review of Maintenance Renal Dialysis Services in NSW” a
medically stable haemodialysis patient is: a patient in whom blood pressure and pulse rate can be
maintained within an optimal range during a routine haemodialysis procedure given the variables
involved in fluid and solute removal (NSW Renal Plan 2007).
Dependency 1 - 1:5 patient to staff ratio
Self care – able to dialyse without assistance. The criteria for these patients include:
a) Independent with ADLs
b) There is not an unstable medical condition e.g. unstable diabetes
c) Are independent in all dialysis procedures,
d) Have the ability to problem solve dialysis related problems
Version 1.3
April 2012
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Dependency 2 - 1:5 patient to staff ratio
Self care – able to dialyse without assistance. The criteria for these patients include:
a) Independent with ADLs
b) There is not an unstable medical condition e.g. unstable diabetes
c) Are self-sufficient in all dialysis procedures, using nursing staff as they would a home dialyser
helper
d) Have the ability to problem solve dialysis related problems
Dependency 3 - 1:5 patient to staff ratio
Minimal assistance required with dialysis procedure. The criteria for these patients include:
a) Independent with ADLs
b) There is not an unstable medical condition e.g. unstable diabetes
c) Has the ability to attend most of the dialysis process but requires assistance with one or more
of the following procedures e.g. cannulation, problem solving, discontinuing and commencing
dialysis
Dependency 4
- 1:5 patient to staff ratio
Does not perform any of the dialysis procedure but is independent in self care activities. The
criteria for these patients include:
a) Independent with ADLs
b) There is not an unstable medical condition
c) Can complete simple tasks e.g. BP, weigh, hold off a cannulation site, and might set out
dressing pack.
Dependency 5 - 1:4 patient to staff ratio
Patient requires assistance from staff for all aspects of dialysis treatment and some self care
activities.
a) The patient is usually medically stable but are at risk of becoming unstable due to co-morbid
conditions.
b) Requires assistance in some ADLs (e.g. mobilising, toileting)
c) Patient requires assistance or supervision in all aspects of treatment (e.g. Holding off,
weighing).
Dependency 6 - 1:3 patient to staff ratio
Patient is totally dependent on staff for all aspects of dialysis treatment and majority of self care
activities. The criteria include:
a) Total nursing intervention for dialysis treatment: unable to hold off, may not alert staff to change
in condition.
b) Patient is unable to perform basic self care activities: mobilising, sitting up in chair.
c) Patient is sometimes medically unstable during dialysis the treatment.
d) Patients who have extremely challenging behaviors that require frequent supervision or support
before, during and after dialysis, may also fall into this category
e) Infection control requirements requiring higher nursing care needs e.g. high shedding VRE
Version 1.3
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Dependency 7 - 1:1 patient to staff ratio
Patient criteria include:
a) Requires specialist/intensive nursing intervention for dialysis treatment
b) Patient is medically unstable during dialysis treatment
c) Requires constant nursing and medical intervention for unstable co morbid condition
d) Cared for in the ‘in-centre’ environment
Dependency 8 - 1:1 patient to staff ratio
Patient criteria include:
a) Requires specialist /intensive nursing intervention for dialysis treatment
b) Patient is medically unstable during dialysis treatment
c) Requires constant nursing and medical intervention for unstable co-morbid condition
d) Patient requires medical support within an ‘intensive care’ environment
Suitability Criteria for Satellite Units
When considering transfer from an In-centre facility to a satellite facility or acceptance of temporary
(eg holiday) patients directly into a satellite facility the following criteria should be met
-
-
A dependency rating of 5 or less
A well functioning vascular access
Patients (as required) should have received first dose of intravenous iron medications and
have ongoing ESA's organized and charted
A medical assessment including current fluid assessment and medication review
(particularly antihypertensives) that indicates that the patient will be stable on the dialysis
treatment and will not require frequent medical reviews (more frequently then monthly)
Dialysis prescription ordered
Transport arrangements known.
APPENDICES
Appendix 1 - Five Moments for Hand Hygiene
REFERENCES
HNELHD Renal Plan 2007-2011
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0009/42966/FORMATTEDRENAL_SERVICES_
PLAN_Final_090807.pdf
NSW Health Renal Services Plan 2007-2011
http://www.health.nsw.gov.au
Western Australia Health Department Renal Plan 2010 – 2021
http://www.wacountry.health.wa.gov.au/fileadmin/sections/publications/Publications_by_topic_type/Service_
Plans/WACHS_SP_Renal_Dialysis2010-2021.pdf
Version 1.3
April 2012
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Appendix 1
Adopted from the World Health Organization and Hand Hygiene Australia.
Version One
April 2012
Page 5