Harbor:Scheduled dialysis patients in ED

  • The dialysis clerk will provide a lit of patient for the following day; the OCN will place them on the pre-arrival list each AM (M/W/F)
  • HD times should be 5-9a and 930-130p
  • Patients should 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 is here for dialysis; the patient is hemodynamically stable and no EMC (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 (HTN will resolve with HD).
  • If symptomatic/COVID +ve OR Hep B +ve, HD will occur in ED - G29>R19>A15>Tra1
    • Hep B Surface Antigen must be negative within the past 30d; must repeat every 30 days
    • Patients getting dialyzed in the AED will be placed on teams; the team ONLY places DC order (no note necessary)
  • For all other SCHEDULED HD patients, the RME USA will take the patient to the Transitional Dialysis Unit (5 West Room 10)
    • Label as AD1 or AD3 on the tracking board in FirstNet
  • 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
      • if hemodynamically unstable after HD, return to ED for evaluation
    • Dialysis nurses request transport service to take patient back to AED Triage (reassessment RN)
  • Discharge
    • These patients are 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 "Hemodialysis" patient education and appointment time as listed in the nephrology note (if not already done by nephrology)
    • The NP will forward the chart to Dr. Shah, not ED R4 or Attending.

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

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 Dialysis social worker)
        • If patient just had HD, can send outpt COVID test
        • If Pt requires HD in <24 hours, patient may need ED dialysis
          • If rapid test is negative, they can be discharged (and go back to their dialysis unit)
          • If positive, discuss admission with nephrology if unable to go back to their HD center (requires admission q30 days to enter the COVID transitional dialysis pathway)
        • Drs. Chappell & Shah (Nephrology) 7/2020

See Also