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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Virus, Haemodialysis Replaces Existing Guideline and Procedure and: Yes Registration Number(s) and/or name and of Superseded Documents: JHH Nephrology SWP N 2.2 JHH Nephrology SWP N 2.4 Relevant or related Documents, Legislation, Australian Standards, Guidelines etc: NSW Health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 Page 2 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 April 2012 Page 3 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 Page 4 Appendix 1 Adopted from the World Health Organization and Hand Hygiene Australia. Version One April 2012 Page 5