PARKLAND MEMORIAL HOSPITAL (PMH) and ZALE LIPSHY UNIVERSITY (ZLU) HOSPITAL ACUTE DIALYSIS ROTATION
Service:
The acute dialysis rotation consists of one clinical fellow and one attending. The fellow is responsible for all inpatient dialysis. The patient population consists of chronic dialysis patients who dialyze at outside facilities and are admitted for a dialysis or non-dialysis related issue, chronic peritoneal dialysis patients, and unfunded patients who do not receive regular dialysis, but who are dialyzed on an emergent basis. There are also patients admitted from the clinic for elective dialysis initiation.
The fellow learns the techniques of continuous forms of renal replacement therapy and becomes skilled in the management of ICU patients with renal failure. The fellow becomes skilled in the placement of temporary access when necessary (Quinton catheter). The fellow also becomes skilled in the various techniques of peritoneal dialysis when this procedure is indicated.
Responsibilities:
The clinical fellow typically is assigned to this rotation 3-4 months during the 2 years of clinical training. The fellow will perform a history, physical examination, and review the relevant laboratory studies in each case consulted upon. The fellow will present the patient to an attending physician and, under their supervision, will formulate a diagnostic and treatment plan to include writing the daily dialysis orders. The consult fellow is not responsible for admitting or discharging the patients, all patients are admitted to another service (medical or surgical) and the renal fellow acts in a consultant capacity only. The fellow will coordinate outpatient placement with the help of the dialysis social worker and coordinate access placement with the help of the access nurse. The fellow will also evaluate all unfunded patients who present to the ER to determine if they require emergent HD.
Expectations:
A. During this rotation the fellow should become familiar and develop and understanding of the following disease processes and techniques. This familiarity and understanding will be obtained from attending required teaching conferences, daily attending rounds, renal clinic, and evaluating patients as a consultant.
-Acute renal failure
-Hypertensive disorders
-Indications for initiation of renal replacement therapy, both elective and emergent
-Evaluation and selection of patients for acute dialysis or continuous renal replacement therapies (CVVHDF)
-End-state renal disease
-Evaluation of end-stage renal disease patients for various therapies and their instruction regarding treatment options
-Understanding of the indications, contraindications, and complications of placement of peritoneal catheters
-Evaluation and management of medical complications in patients during and between dialysis and other extracorporeal therapies, including dialysis access, and an understanding of their pathogenesis and prevention
-An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient
-Disorders of drug metabolism
-Drug dosage modification during dialysis and other extracorporeal therapies
-The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis
-Understanding of how to manage complications of chronic angioaccess, such as thrombosis
-Technical expertise: peritoneal dialysis
-Technical expertise: placement of temporary vascular access for hemodialysis and related procedures
-Technical expertise: acute hemodialysis
-Technical expertise: continuous veno-venous hemodialfiltration
B. The fellow will also be expected to do the following:
-Evaluate all patients on service beginning with ICUs on a daily basis
-Write dialysis orders on all patients prior to initiation of treatment
-Write daily progress notes tailored to renal disease management
-Review all medications and dose adjust according to renal function
-Schedule and manage dialysis access problems
-Evaluate all ESRD patients in ED upon request
-Promptly notify attending after completing evaluation of all ED consults
-Place temporary venous access for dialysis as needed
-Contact (pager or voicemail) attending nephrologist for all ESRD patients admitted to PMH at time of admission and again at discharge
-Prescribe usual Kt/V for all maintenance ESRD or a minimum spKt/V = 1.2
-Update dialysis patient list in computer on a daily basis
-Read Daugirdas and Ing’s Handbook of Dialysis
-Coordinate inpatient and outpatient care of all ESRD patients
General Competencies:
During this rotation, trainees are expected to acquire and master the following core competencies:
A. Patient Care:
1. By demonstrating a compassionate, appropriate and effective care
2. By promoting health and general well being of the patients
3. By demonstrating satisfactory clinical competence in performing medical interviews, physical examinations, review of relevant data and procedural skills
4. By making diagnostic and therapeutic decisions based on available evidence, sound judgment and patient preferences
B. Medical Knowledge:
1. By demonstrating knowledge in established and evolving biomedical, clinical, epidemiological and social-behavioral sciences (as listed above)
2. By demonstrating the ability of applying this knowledge to patient care and understanding complex mechanisms of diseases
- By being highly resourceful in developing knowledge
C. Practice-Based Learning:
- By demonstrating improvement in patient care based on:
Evaluation of one’s own practice
Incorporation of feedback information into improvement activities
Appraisal and assimilation of scientific evidence
Effective utilization of technology to manage information for patient care and self-improvement
2. Examples of practice-based evaluations that can be performed during this rotation include, but are not limited to:
The use of erythropoietin in hospitalized ICU dialysis patients
The appropriateness of performing dialysis during late hours
The proper antibiotic dose adjustments in ESRD patients
The performance of urinalysis on every patient with acute renal failure
The complication rate of the placement of temporary vascular access for HD
The mean time allowed for a femoral temporary vascular access for HD to remain without exchange
D. Communication and Interpersonal Skills:
1. By demonstrating effective and humanistic information exchange with patients and their families and other health professionals
2. By demonstrating excellent listening, narrative and nonverbal skills
3. By demonstrating ability to educate and counsel patients, families and colleagues
E. Professionalism:
1. By demonstrating a commitment to carrying out professional responsibilities
- By adhering to ethical principles
- By exhibiting sensitivity to diverse patient population
4. By demonstrating respect, compassion, integrity and honesty
5. By consistently exhibiting role model and responsible behavior
- By willingly acknowledging errors
7. By consistently considering the needs of their patients, families and colleagues
F. Systems-Based Practice:
1. By demonstrating awareness of the larger context of health care systems.
- By demonstrating responsiveness to health care systems
3. By effectively utilizing system resources to provide care of optimal value
4. By effectively using systematic approaches to reduce errors and improve patient care
5. By enthusiastically assisting in developing systems’ improvement
