DaVITA OUTPATIENT PERITONEAL DIALYSIS ROTATION
Service:
The peritoneal dialysis rotation is an outpatient rotation that is located in the DaVita outpatient dialysis facility. The service consists of one fellow and one attending is devoted exclusively to peritoneal dialysis. The clinical experience will entail supervised involvement in decision-making for patients undergoing PD. This rotation provides a comprehensive and longitudinal clinical experience in the care of patients on peritoneal dialysis. The fellow will obtain an understanding of the principles and practice of peritoneal dialysis including the indications, contraindications, complications, cost-effectiveness, and application of PD to patient care (see topics below).
Responsibilities:
The fellow is assigned to this rotation 2-3 times during the two years of clinical training. During the rotation the fellows will attend the PD Clinic on Tuesday mornings and evaluate walk in patients on other weekdays. The fellow will attend the multidisciplinary care plan meeting and the CQI (continuous quality improvement) meetings that are held each month. The fellow is responsible for coordinating the care of PD patients admitted at PMH, ZLU and St. Paul University Hospital. During the rotation the fellow is expected to give a 30 minute talk on any topic related to PD to the members of the peritoneal dialysis staff.
Expectations:
A. During this rotation the fellow should become familiar and develop and understanding of the following topics related to PD:
1. Peritoneal physiology, including the concepts of small and middle molecule clearance and ultrafiltration
2. Evaluation and selection of patients for PD (CAPD, CCPD) and their instruction about treatment options
3. Assessing adequacy of peritoneal dialysis and implications of adequacy related to patient morbidity and mortality, transporter status, peritoneal equilibration tests, residual renal function, KDOQI standards; dialysis prescriptions and their modifications to achieve adequate dialysis
4. The short and long-term complications of peritoneal dialysis, including the pathogenesis and prevention of complications including but not limited to: peritonitis, catheter infections, leaks, hernias, sclerosing peritonitis, nutritional and metabolic issues, hemoperitoneum
5. Placement and maintenance of peritoneal catheters and available catheters for use and how to choose appropriate catheters; the appropriate radiologic procedures for evaluating PD catheters
6. Peritoneal dialysis solutions—composition, biocompatibility, side effects;
7. An understanding of the technology of peritoneal dialysis, including the use of automated cyclers (CCPD); principles of peritoneal biopsy
8. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis; drug dosage modification during peritoneal dialysis;
9. An understanding of the special nutritional requirements of patients undergoing peritoneal dialysis; urea kinetics and protein catabolic rates in PD patients; nutritional management of PD patients
10. The quality of life of patients on peritoneal dialysis; psychosocial and ethical issues in PD patients and their families
11. The function of the nephrologist in the collaborative practice of peritoneal dialysis including aspects of quality assurance in PD and the function of a Medical Director in PD programs
General competencies
A. Patient Care:
By the end of this rotation, fellows are expected to develop and demonstrate the following skills:
1. To select the proper candidate for Peritoneal Dialysis
2. To give a clear description of the available choices in renal replacement therapy to the patient including the pros and cons of each modality
3. To assist the patient in modality selection considering the individual patient’s medical and social circumstances
4. To write a PD prescription
5. To supervise patients PD training and have the confidence in solving the unusual and unexpected problems by using your commonsense, experience, medical knowledge and by seeking advice if needed
6. To provide continuous care for the PD patients according to the DOQI requirements and recommendations
7. To recognize the incident problems at an early stage and provide remedies for them before evolves into serious or unmanageable state
8. To diagnose and treat PD-associated infection versus surgical problems and managed common PD problems such as malnutrition and anemia
9. To demonstrate full understanding of the differences between various modalities of dialysis regarding their mechanisms, their advantage/disadvantages, clinical results of each modality, and their applicability under different circumstances
10. To analyze Dialysis Adequacy Tests, to understand the methods of optimization and the rationale behind these issues
11. To appreciate the importance of nutrition in dialysis patients survival, the basics of nutritional evaluation and correction of malnutrition in these patients
B. Medical Knowledge:
1. By the end of this rotation fellows are expected to demonstrate effective application of biomedical, clinical and social skills, and knowledge to the care of patients.
2. The fellow should demonstrate knowledge in established and evolving biomedical, clinical, epidemiological and social-behavioral sciences
3. The fellow should demonstrate the ability to apply this knowledge to patient care and understanding complex mechanisms of diseases
4. The fellow should being highly resourceful in developing knowledge
C. Practice-Based Learning:
By the end of this rotation, fellows are expected to develop and demonstrate the following skills:
1. To acknowledge our limited understanding of nature and limited knowledge of medicine in general
2. To recognize your limited experience in the field of PD, yet not be afraid of providing this kind of care and thus granting your ESRD patients the right to choose the dialysis modality that may serve them best. You should know that you are also legally bound to educate ESRD patients in the matter of modality choice on Renal Replacement therapy
3. To understand and apply clinical practice guidelines to the care of the PD patient
D. Communication and Interpersonal Skills:
By the end of this rotation, fellows are expected to develop and demonstrate the following skills:
1. To gain the trust of the End Stage Renal Disease patients through expression of empathy and compassion towards them, recognizing that they are passing through a very critical state, forced to experience a lifestyle change and uncertainty about their well-being. They may have to face many losses, i.e. jobs, spouses, or social status. Each one of these distresses requires tremendous physical and psychological endurance that they may be incapable of evoking in their unstable condition. Therefore, they may be angry, depressed, or confused. Patience, clarity, and sympathy exercised by the staff helps them in alleviation of their suffering. These qualities also inspire a spirit of cooperation between patients and staff, which facilitates the delivery of medical services. This positive interaction also generates a positive feedback on the outcome of their medical care.
2. To develop a rapport with the patients as their care enters the chronic phase, when the patients have to place trust in your judgment regarding the serious issue of their life and death.
E. Professionalism:
By the end of this rotation, fellows are expected to develop and demonstrate the following skills:
1. Demonstrate respect for your colleagues, supervisors, patients, and staff
2. Respect other physician’s opinions and not be afraid of asking for help and advice from more experienced staff members and other medical personnel involved in the case
3. Uphold ethical principles in your communications with patients
4. Understand the necessity of advanced directives and be able to handle the issues related to medical futility as well as dialysis withdrawal/withholding
F. Systems-Based Practice:
By the end of this rotation, fellows are expected to develop and demonstrate the following skills:
1. To develop a system of rapid contact for exchanging service with a Hemodialysis program which is ready to accept PD patients for emergency services and is willing to accept them for permanent modality change
2. To have surgical support for PD access management and emergency surgical events
3. To advise or direct special care that the PD patients need in the Emergency Room or during a course of hospitalization
4. To manage exclusively PD-related emergencies if possible in term of space and staff
5. To facilitate referrals and accommodate the routine health maintenance with other services as Gynecology, Ophthalmology, Podiatry, gastroenterology, and Mammography
