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Renal Resource Centre 37 Darling Point Poad, Darling Point, NSW 2027 AUSTRALIA Telephone: 61 2 9362 3995 9362 3121 Facsimile: 61 2 9362 4354 Freecall: 1800 257 189 Click here for our location map |
| Authors |
| Lesley Salem, Nephrology Nurse Practitioner |
| Barbara Harvie, Nephrology Nurse Practitioner |
| Co-author |
| Adrian King, Registered Nurse |
About the authors
Lesley Salem is Nephrology Nurse Practitioner, Lower Hunter New England Health Service. Lesley has worked as a renal nurse for twenty three years and holds qualifi cations in renal nursing, apheresis and in nursing science.
Barbara Harvie is Nephrology Nurse Practitioner, Greater Southern Area Health Service. Barbara has practised as a renal nurse for nearly twenty years, and holds qualifi cations in renal nursing, advanced practice and Nurse Practitioner.
Adrian King is a Registered Nurse at the Muswellbrook and Maitland Dialysis Units, Hunter New England Area Health Service. Adrian has practiced as a renal nurse for eight years and holds qualifi cations in renal nursing.
These management plans are aimed at achieving the best possible End Stage Kidney Disease (ESKD) care.
This document should not be viewed as a set of rules to be applied without the clinical input and discretion of the managing health professional. Each patient should be evaluated individually and a decision made as to appropriate management in order to achieve optimal clinical outcomes. Each area Health Service is responsible for ensuring the development of local protocols based on these management plans.
Area Health Services are also responsible for ensuring that all staff managing dialysis patients are educated in the use of locally developed wellness check management plans and protocols.
FOREWORD
INTRODUCTION
END STAGE KIDNEY DISEASE MANAGEMENT PLAN
ANAEMIA SURVEILLANCE
Pathophysiology
Surveillance flow chart
CALCIUM AND PHOSPHATE
SURVEILLANCE
Pathophysiology
Surveillance flow chart
IDEAL (DRY) WEIGHT SURVEILLANCE
Pathophysiology of fluid retention
Surveillance flow chart
ACCESS SURVEILLANCE
Manifestations and adverse events
Surveillance flow chart
APPENDICES
Medicare Benefits Schedule 2006
Acknowledgments
References
| Professor Ranjit Nanra |
| Nephrologist Hunter |
| New England Area Health Service |
| Greater Newcastle Sector |
It is important to have proper management plans that optimise health outcomes in patients with End-Stage Kidney Disease. Therefore, the development of these health management plans for kidney disease, in accordance with CARI guidelines, is a signifi cant step in the delivery of best practice health care in a collaborative manner.
As a Nephrologist, I support these management plans.
Prof Ranjit S Nanra
Associate Professor Rowan Walker
Chair, CARI Guidelines Steering Committee
CARI like other Clinical Practice Guideline Groups is keen to support endeavours aimed at improving patient outcomes. Thus the CARI organisation would support the broad thrust of the document ‘Australian Health Management Plan for End Stage Kidney Disease’ as a potentially useful tool for the implementation of important evidence-based clinical practice guidelines for patients on dialysis. It will be with considerable interest that the CARI & the nephrological community will wait for the impact of this document and other similar documents on the achievement of CARI targets and more importantly on any improvement in patient outcomes.
A/Prof Rowan Walker
On behalf of the CARI Steering Committee
.JPG)
This book has been supported by an unrestricted educational grant from Amgen.
aim
To enhance patient centred health promotion strategies in End
Stage Kidney Disease (ESKD) patients through a model of care
that utilises clinical nursing assessment (EN, RN, and CNS),
cost effective investigations, collaborative management (nursing,
medical, allied health) and education strategies drawn from
evidence based Australian Nephrology Guidelines (‘CARI’-Caring
for Australians with Renal Impairment). ESKD patients on dialysis
require a unifi ed surveillance management plan to maintain
their ‘wellness’. The management plans should provide an early
detection tool for the prevention of further complications resulting
from ESKD.
background
The number of Community and Centre (hospital) based dialysis
patients is increasing progressively. Nephrology Teams are
currently fi nding it diffi cult to address patients’ needs. Traditional
renal care is reactive, complication-managed rather than proactive.
By incorporating preventative management through health
promotion aimed at patient ‘wellness’ in this group of patients
with complex problems who require multidisciplinary input, many
adverse events could be prevented.
ESKD patients assume they should experience poor health and often the staff deem complications the patients experience as inevitable. There are preventative strategies available that could prevent many complications from occurring.
Limited numbers of specialised and experienced renal staff (nurses and nephrologists) has led to the introduction of changes to the nephrology workforce structure. This consists of skill and staff dilution with the addition of Enrolled Nurses, new graduate Nurses on rotation programs and non-renal trained nurses. Awareness and use of evidence based guidelines such as CARI and of cost effective, collaborative approaches to the management of kidney disease is lacking. The expertise needed for proactive treatment is limited.
To ensure maintenance of high standards of collaborative renal care that includes health promotion, appropriate assessment, investigations, multidisciplinary management and education based on evidence based medicine within this changing workforce, a cost effective, unifi ed approach is needed. There are no universal assessment tools for renal staff to provide a guide for clinical assessment in health promotion and prevention strategies
Response
In response to the shortage of specialised renal staff, we are
seeing a change to the workforce structure within Nephrology
Departments. The services of Nurse Practitioners, Enrolled Nurses,
fi rst and second year graduate Registered nurses on rotation
programs, and non-renal trained Registered Nurses are now being
engaged.
Whilst the quality of care is high, there is a lack of awareness of treatment targets and knowledge of cost-effective investigations. Proactive targeted treatment requires expertise to avoid overinvestigating and although nurses cannot formally request investigations, they can infl uence and prompt decision-making. A tool specifi c to health promotion in ESKD patients would assist in guiding the process of biological and haematological investigations as well as vascular access surveillance and maintenance of an ideal dry weight.
To ensure that the standard of care is maintained with the changing workforce, a unifi ed and cost effective, evidence based approach to investigative strategies for the dialysis patients is essential.
Solution
A tool that provides a guide for assessment, investigation,
management and education for anaemia management, calcium
and phosphate management, vascular access management and
dry weight assessment has been developed by adapting CARI
guidelines into cost effective approaches for ‘wellness check’
management plans. These plans;
Management plans
These management plans are a guide to a health check rather
than a reactive approach to care. They demonstrate a cost effective
approach, will allow the detection of complications earlier and
therefore ensure appropriate treatment is delivered in advance of
complications.
Using the fl ow charts
The fl ow charts are preceded by a brief overview of cause and
effect. They provide a guide to the process of surveillance,
questioning, examination, investigations and management that
should/could occur in the routine practice of health promotion in
dialysis patients. Any strategy for the care of dialysis patients is a
collaborative process that engages the nurse, nephrologist, medical
team, GP and allied health team.
The management tool affords guidance for a consistent and ongoing comprehensive assessment of the patient with kidney disease whether or not they have commenced kidney replacement therapy.
Included in the fl ow charts is the management strategy for nurses. This is to engage dialysis nurses (whether they are the patients primary nurse or not) in health promotion strategies that are within nurses’ scope of practice and knowledge.
N.B: These fl ow charts do not cover all ESKD complications that can occur.
KEY for surveillance flow charts
http://www9.health.gov.au/mbs/search
| Pathology test | Item no. | Fee | Description |
| Haematology | |||
| Haemoglobin | 65060 | 7.95 | Haemoglobin, erythrocyte sedimentation rate, blood viscosity - 1 or more tests |
| Full blood count | 65070 | 17.20 | Erythrocyte count, haematocrit, haemoglobin, calculation or measurement of red cell index or indices, platelet count, leucocyte count and manual or instrument generated differential count |
| Biochemistry | |||
| 1 test from list (eg glucose, ionised calcium) | 66500 | 9.75 | Quantitation in serum, plasma, urine or other body fluid of: acetoacetate, acid phosphatase, alanine aminotransferase, albumin, alkaline phosphatase, ammonia, amylase, aspartate aminotransferase, betahydroxybutyrate, bicarbonate, bilirubin (total), bilirubin (any fractions), C-reactive protein, calcium (total or corrected for albumin), chloride, creatine kinase, creatinine, gamma glutamyl transferase, globulin, glucose, lactate, lactate dehydrogenase, lipase, magnesium, phosphate, potassium, pyruvate, sodium, total protein, urate or urea |
| 2 tests from list (eg Calcium and Phosphate) | 66503 | 11.75 | |
| 3 tests | 66506 | 13.75 | |
| 4 tests (eg liver function tests) | 66509 | 15.75 | |
| 5 tests (eg Urea and eletrolytes) | 66512 | 17.80 | |
| 6 or more tests | 66515 | 19.80 | |
| Vitamin D | 66608 | 41.70 | Vitamin D or D fractions - 1 or more tests |
| Beta 2 microglobulin | 66629 | 19.90 | Quantitation in serum, urine or other body fluids - 1 or more tests |
| Serum B12 | 66599 | 24.35 | Serum B12 or red cell folate and, if required, serum folate (Item is subject to rule 23) |
| Iron studies | 66596 | 36.70 | Quantitation of: (a) serum iron; (b)transferrin or iron binding capacity; and (c) ferritin |
| Lipids (fasting) | 66539 | 31.15 | Patient who: (a) has a serum cholesterol level >5.5mmol/L; or (b) has a fasting serum triglyceride level > 2.0 mmol/L; or (c) is on a lipid lowering drug prescribed by a medical practitioner; each episode to a maximum of 4 episodes in a 12 month period (Item is subject to rule 9) |
| HbA1C | 66551 | 17.10 | Quantitation of glycosylated haemoglobin performed in the management of established diabetes - each test to a maximum of 4 tests in a 12 month period |
| Beta-2 microglobulin | 66629 | 20.50 | Quantitation in serum, urine or other body fluids: - 1 or more tests |
| PTH ( 1 test) | 66695 | 30.70 | Quantitation of hormones and hormone binding proteins - ACTH, aldosterone, androstenedione, C-peptide, calcitonin, cortisol, cyclic AMP, DHEAS, 11-deoxycortisol, dihydrotestosterone, FSH, gastrin, glucagon, growth hormone, hydroxyprogesterone, insulin, LH, oestradiol, oestrone, progesterone, prolactin, PTH, renin, sex hormone binding globulin, somatomedin C(IGF-1), free or total testosterone, urine steroid fraction or fractions, vasoactive intestinal peptide, vasopressin (ADH) |
| Homocysteine | 66752 | 25.10 | Quantitation of citrate, oxalate, total free fatty acids or amino acids including cysteine, homocysteine, cystine and hydroxyproline |
| Virology screen | |||
| Hepatitis screen | 69462 | 29.45 | Determination of immune status to Hepatitis B and testing for Hepatitis C, including: (a) Hepatitis C antibody test; and (b)Hepatitis B core antibody test or Hepatitis B surface antibody test |
| Other | |||
| Pap smear | 17.80 | ||
| Microalbuminuria | 19.90 | Microalbumin in proven diabetes mellitus - quantitation in urine - 1 or more tests | |
| PSA (1 test) | 66656 | 20.50 | 20.50 Prostate specifi c antigen - quantitation in the monitoring of previously diagnosed prostatic disease |
Hunter New England Area Health Service
Leanne Avis. Team Leader, Wansey Dialysis Centre
Liza Charman. Endorsed EN
Margarite Cooper. EN Maitland Dialysis Centre
Jennifer Cousins. Team Leader Peritoneal Dialysis
Christine Cranson. Acting Coordinator Hunter Renal Resource Centre
Patrice Dobbs. NUM I Maitland Dialysis Centre
Kathie Donn. RN Wansey Dialysis Centre
Gemma Fogarty RN Maitland Dialysis Centre
Jeannette Gaetgens, Anaemia Coordinator, John Hunter Hospital
Dr Alastair Gillies. Director of Nephrology John Hunter Hospital
Marilyn Kelly. RN Wansey Dialysis Centre
Sue Kennedy. Centre Dialysis Unit John Hunter Hospital
Kaz Knutson. NUM Taree Community Dialysis Unit
Noelene Lake. Team Leader Home Training Unit Wansey Dialysis Centre
Sally Milson - Hawke NUM Centre Dialysis & Transport, John Hunter Hospital
Dr Trevor Mallard, 2005 Renal Registrar, John Hunter Hospital
Prof. Ranjit Nanra Nephrologist John Hunter Hospital
Leanne O’Grady. Renal CNC Taree
Carmel Peek. Service Manager, Department of Medicine, John Hunter Hospital.
Petra Salna. NUM H3, Nephrology/Gastric
Christine Shannon. RN, Singleton Dialysis Unit
Susan Sheehan. Anaemia Coordinator John Hunter Hospital
Sara Spiers. EN Maitland Dialysis Centre
Lorraine Thornton. Acting NUM II Centre Dialysis & Transplant, John Hunter Hospital
Dr Paul Trevillian. Nephrologist John Hunter Hospital
External Reviewers
Catharine Death. Acting NUM Renal/Transplant Ward Westmead Hospital, WSAHS
Denise Campbell CARI Guidelines Steering Committee member
Jill Farquhar Nephrology Nurse Practitioner Westmead Childrens Hospital
Deirdre Featherstonhaugh. CARI Guidelines Steering Committee member, VIC
Kathy Kable. Transplant NP Westmead Hospital, WSAHS
Denise O’Shaughnessy. Manager Renal Resource Centre, NSCCAHS
A/Prof Rowan Walker. Chairman, CARI Guidelines Steering Committee, VIC
Thank you to Patrick Coleman from Advanced Nephrology Nursing Staff
Agar, J. (2003). Nephrology for Tiny Tots. 3rd edition.Amgen
CARI guidelines online. www.cari.org.au
Northern Territory Chronic Disease Management Plan. 2004.
Medicare Benefi ts Schedule http://www9.health.gov.au/mbs/search (accessed 28.3.06)
RENAL RESOURCE CENTRE
37 Darling Point Road, Darling Point NSW 2027
Telephone: (02) 9362 3995 or (02) 9362 3121
Facsimile: (02) 9362 4354
Toll Free: 1800 257 189
Web: www.renalresource.com
Renal Resource Centre