VETERANS ADMINISTRATION (VA) CHRONIC OUTPATIENT DIALYSIS ROTATION
Service
The VA Dialysis rotation is designed to give the fellows an outpatient dialysis experience. Thus, dialysis adequacy, anemia, calcium phosphorus management, nutrition and blood pressure/ dry weights are the focus of this rotation. The K/DOQI guidelines are used as a template for the care of patients. The VA outpatient unit is composed of 4 shifts with approximately 120 out patient hemodialysis patients. There are also 10-20 peritoneal dialyses patients in the Dallas VA system. All aspects of renal replacement therapy are provided including in-center hemodialysis, nocturnal hemodialysis, home hemodialysis, and peritoneal dialysis. In addition, Nephrologists in the section insert all peritoneal dialysis catheters and a significant fraction of permcatheters, opportunities that also will be available for the fellow. It is a hospital based unit directly adjacent to the offices of the members of the Nephrology section. Fellows and attending physicians work together in a geographically confined environment. The section currently has 5 full time 8/8ths positions for Nephrology and the acting chief of medicine is a Nephrologist as well.
Responsibilities
The fellow will manage the care of a single shift of dialysis patients (25 patients) while on this rotation. He/she will be responsible for all aspects of patient care under the supervision of a single attending physician. The clinical fellow typically is assigned to this rotation 3-4 months during the 2 years of clinical training. The resident will see the dialysis patient during each hemodialysis session and round with the attending physician weekly. The fellow will learn to place permcatheters and places peritoneal dialysis catheters and learn the technique of renal sonography. The fellow manages access problems and coordinates procedures with interventional radiology. The fellow writes medicine prescriptions as needed and writes new dialysis orders on each patient once per rotation.
Expectations
During this rotation the fellow is expected to acquire sufficient clinical expertise in the evaluation and management of the following disorders:
- chronic renal failure and its management by conservative methods, including nutritional management of uremia
- evaluation of ESRD patients for various forms of therapy and their instruction regarding treatment options
- evaluation and management of medical complications in patients during and between dialysis, including an understanding of the pathogenesis and prevention and treatment of dialysis access complications
- long-term follow-up of patients undergoing chronic dialysis, including the evaluation of dialysis prescription and assessment of adequacy of dialysis
- hypertension in ESRD patients
- disorders of mineral metabolism
- disorders of vitamin D, parathyroid hormone and renal osteodystrophy
- drug dosage modification during dialysis
- understanding of the principles and practice of PD, including the establishment of peritoneal access and how to choose appropriate catheters
- understanding of the technology of PD, including the use of various cyclers
- assessment of PD efficiency using the peritoneum equilibrium test
- understanding of how to write PD prescription and how to assess PD adequacy
- pharmacology of commonly used drugs, and the kinetics and dosage alteration with PD
- understanding of the complications of PD, including peritonitis and its treatment, exit site and tunnel infections and their managements, hernias, pleural effusions, and other less common complications and their management.
- understanding of the special nutritional requirements of the HD and PD patients.
- psychosocial and ethical issues of dialysis.
- end-of-life care and pain management in the care of patients undergoing chronic dialysis.
- Occupational Safety and Health Administration regulations and universal precautions of health-care workers
- Medical informatics and decision-making skills, including critical appraisal of the literature, clinical epidemiology and biostatistics.
- Quality assessment and improvement, risk management and cost-effective medicine, including the economic impact of medical decisions on patients and society and the need to be the primary advocate for patients’ needs.
- Clinical ethics, patient counseling, effective communication techniques for diverse population and end-of-life care.
In addition, during this rotation trainees gain the necessary knowledge and become familiar with the following procedures, including their indications, contraindications, complications and interpretation of results, as well as their cost-effectiveness and application to patient care:
- placement of internal jugular and femoral Quinton catheter placement
- permcatheters
- placement of peritoneal catheters
Research
The resident will also be exposed to and participate in research that is currently ongoing with respect to veterans with ESRD at the Dallas VA. Active protocols include such areas as gadolinium exposure, permcath infections, hepatitis B vaccination, cardiovascular disease, morbidity of hepatitis C and iron administration, anemia management, and renal osteodystropy. Databases exist within the section that include all chronic dialysis patients since 2001 and all permcath placements since 1999.
The resident will also be encouraged to participate in the Clinical Scholars Program at the Center for Biostatistics and Clinical Sciences at UT Southwestern headed by Dr. Milton Packer. This program funded by an NIH Multidisciplinary Research Career Development Program offers a wide variety of epidemiology and biostatistical classes that can either be audited or taken for credit including: biostatistics for the clinical sciences; mathematical biostatistics for the clinical investigator; clinical research design and analysis; clinical research management and leadership; clinical research protocol development; clinical research questions and methods; epidemiology for the clinical investigator; grant writing and funding strategies; effective data collection and management; clinical research from proposal to implementation; and research ethics in biomedical sciences. The resident will also be required to write at least one first author manuscript during the year under the supervision of one of the Nephrology division faculty that will be either a review article or pertain to original research they participated in.
VA Clinics
While rotating at the VA the fellow will also attend the PMH continuity clinic. In addition the fellow attends the following VA clinics
A. Renal stone and glomerulonephritis clinic (Tuesday afternoon)
The clinic will allow the fellow to become familiar with evaluation of metabolic stone disease, learn how to prevent it, and learn radiology of stone disease. The Fellow will see patients with kidney stones and present them to the attending physician. Key literature will be reviewed as well as current guidelines for stone disease management. The case mix of diseases include: calcium oxalate and calcium phosphate stones, uric acid stones, struvite stones, renal tubular acidosis, medullary sponge kidney, primary hyperparathyroidism, enteric hyperoxaluria, urinary tract infections, acute urolithiasis.
This clinic will also consist of patients with various forms of primary and secondary glomerulonephritis. Examples of the case mix include Lupus nephritis, ANCA-associated glomerulonephritis, post-streptococcal glomerulonephritis, and infectious related glomerulonephritis.
- General renal clinic (Wednesday morning)
This clinic provides fellows with an opportunity to serve as outpatient nephrology consultants on a diverse patient population in an urban VA hospital. The clinic provides extensive exposure to a wide variety of renal diseases and hypertension as well as related diseases. The clinic provides fellows with a continuity experience while rotating at the VA. Fellows present all patients to an attending and receive direct feedback.
There is a complete range of kidney diseases represented in this clinic with the most common disorders being diabetic nephropathy, chronic kidney disease stages 3-5, hypertension associated with CKD, and chronic tubulointerstitial diseases. A small number of renal transplant patients are also followed in this clinic. Much time is spent helping patients choose a dialysis modality and preparing patients for dialysis. This consists of interdisciplinary discussions with social workers and nutritionists.
VA Conferences
While rotating at the VA the fellow will attend the following conferences:
- Renal Journal Club (each Friday)
- Renal biopsy conference (every 4th Friday)
C. Monday Renal grand rounds and Thursday Basic Science conference which occur at UTSWMC are transmitted live to the renal office for the fellows rotating at the VA. This transmission allows for full interaction such as questions and answers to take place.
General competencies
Patient Care:
By the end of this rotation, the fellows is expected to develop and demonstrate the following skills:
A. Take a relevant history regarding patient responses to hemodialysis
- Be able to evaluate dialysis and ultrafiltration adequacy
- Be able to manage dialysis-related hypotension
D. Be able to respond to fever and treat catheter-related infections
- Be able to initiate hemodialysis in a new patient
E. Serve as the primary care provider for a cohort of patients receiving chronic outpatient hemodialysis
F. Be able to assess and treat secondary hyperparathyroidism and understand the K/DOQI guidelines
G. Be able to assess the function of the hemodialysis access using physical examination and radiologic studies
H. Be able to manage chronic hypertension in the hemodialysis patient
I. Be familiar with the K/DOQI guidelines and protocols for management of anemia
Medical Knowledge:
The fellow is expected to acquire and master the core competency of medical knowledge:
A. By demonstrating knowledge in established and evolving biomedical, clinical, epidemiological and social-behavioral sciences (as listed above)
B. By demonstrating the ability of applying this knowledge to patient care and understanding complex mechanisms of diseases
- By being highly resourceful in developing knowledge
Practice-Based Learning:
By the end of this rotation, the fellow is expected to develop and demonstrate the following skills:
- Identify and review one’s own errors in management
B. Teach about errors in management (both one’s own, and those of others) with tact
- Disclose errors to patients when appropriate
D. Apply scientific evidence from the literature to one’s own patients and distinguish evidence-based medicine from opinion
Examples of practice-based evaluations that can be performed during this rotation include, but are not limited to the proper adjustment of erythropoietin dosing in dialysis patients, proper adjustment of vitamin D dosing in dialysis patients, participation at the CQI meetings
Communications and Interpersonal Skills:
By the end of this rotation, the fellow is expected to develop and demonstrate the following skills:
A. Be able to tell patients and family members about the initiation of the dialysis procedure
B. Obtain informed consent from patients for the hemodialysis procedure
C. Be able to interact with vascular radiology and vascular surgery in the management of the dialysis access
D. Explain to dialysis patients the important aspects of nutritional management
E. Discuss implications of interdialytic weight gain with patients
F. Work as part of the interdisciplinary team of nurses, nurse practitioner, surgeons, psychologists in caring for dialysis patients
G. Discuss end-of-life issues and advanced directives with patients and family members
H. Serve as a resource for first year fellows, providing them with appropriate advice regarding the management of hemodialysis patients
Professionalism:
By the end of this rotation, all fellows are expected to develop and demonstrate the following skills:
A. Demonstrate respect for other services, patients, and staff
B. Maintain a focus on excellent patient care, and the patient’s needs
- Model professional behavior for the service
D. Uphold basic ethical principles, especially as related to advanced directives, medical futility, the withdrawal/withholding of life-sustaining treatments
Systems-Based Practice:
By the end of this rotation, the fellow is expected to develop and demonstrate the following skills:
A. Understand how nephrologists interact with general internal medicine, cardiology, radiology, infectious disease, and anesthesiology services
B. Be able to coordinate care of individual patients with other members of the health care team
C. Be able to call on system resources such as ethics consults and risk management when appropriate
D. Be able to perform responsibilities in reporting of dialysis data (medical evidence forms, death forms) to VA Central Office, ESRD networks and CMS when required
E. Participate in the development of performance improvement project.
