KIMBERLEY RENAL SUPPORT SERVICE (KRSS)

The Role of Predialysis Coordinator

KRSS positions-where pre dialysis fits inReferral to the pre dialysis coordinatorSpecific tasks of the pre dialysis coordinatorPalliative approach model of careClose monitoringReporting and documentationEducation – Health providers & patients/familiesResources availablePre dialysis patient assessmentTreatment options availableVascular accessCommunication

OVERVIEW

TWO PRE DIALYSIS COORDINATORS

EAST KIMBERLEY – based in KununurraWEST KIMBERLEY – based in Broome

TRANSPLANTATION

DIALYSIS

HAEMODIALYSIS

PERITONEAL DIALYSIS

PALLIATIVE CARESTAGE 1 & 2 Proteinuria plus

eGFR 60+

(to determine eGFR over 60,

hand calculate GFR using Cockcroft-Gault formula)

STAGE 3

eGFR 30-59ml/minMODERATE

KIDNEY

DAMAGE

STAGE 5 eGFR <15

ml/min

FAILURE

STAGE 4 eGFR 15-29ml/minSEVEREKIDNEYDAMAGE

AMS Chronic Kidney Disease AHW

KRSS CKD Educator KRSS Pre Dialysis Coordinator

KRSS PD Educator

KRSS HD Educator

KIDNEY DISEASE PATHWAY & KIDNEY DISEASE PATHWAY & KIMBERLEY RENAL SUPPORT SERVICE KIMBERLEY RENAL SUPPORT SERVICE

POSITIONSPOSITIONS

All clinic staff

Kimberley Renal Support Service, KAMSC Developed by: Maree Wearne and Chrissy Fiegert Date: 18th December 2008

REFERRAL TO PRE DIALYSIS COORDINATOR

WheneGFR <30ml/minPer CKD protocol

Contact Pre dialysis coordinator:Phone 0400336069 or email predialysis@kamsc.org.au

SPECIFIC TASKS OF THE PRE DIALYSIS COORDINATOR

• Manage Referrals for pre dialysis • Coordination and communication of

patient care with health services• Monitor patients on MMEX data base in

stage 4 & 5 in conjunction with health services

• Education to health providers• Education and planning for patients and

families• Attend renal clinics• Organise and coordinate vascular access

surgery• Arrange case conferences &

multidisciplinary team meetings where required

PALLIATIVE APPROACH MODEL OF CARE

• People with chronic kidney disease have a life limiting illness. • The palliative approach is a holistic model of care that

supports the patient’s physical, psychological, social & spiritual wellbeing.

• A multidisciplinary team is utilised to provide holistic patient care.

CLOSE MONITORING

• Local health providers

should review patient monthly-

clinical review, BP, weight, UEC, eGFR, FBE, Fe studies, Ca, PO4, Albumin, PTH (All bloods cc KRSS)

• Pre dialysis coordinator

Provides support for local health providers

Monitors monthly bloods-

MMEX DB -stage 4 &5, plus buried PD tube patients

Reviews patient 6/12 – provides education

REPORTING AND DOCUMENTATION

• MMEX data base

• CKD summary sheet

• Family meeting form & Genogram

• Pre dialysis assessment form

• End of life wishes form

• RPH Transfer form

MMEX DATA BASE

• Data base used to monitor patients pathology results

• Cc pathology to KRSS

• All renal patients (KRSS) will have shared files with the patient’s primary health provider on MMEX in the future

• KRSS does not take the place of local health providers but works together to monitor and provide appropriate patient care

CKD SUMMARY SHEET

• The CKD Summary Sheet is being trialled

• The CKD summary sheet is used by health providers for patients with Stage 3 CKD and onwards, to summarise the patients current management.

• This sheet is kept in the front of the patients medical record once CKD is diagnosed. (It will eventually be superseded by MMEX).

FAMILY MEETING FORM & GENOGRAM

• The Family Meeting Form is used as a communication tool to track discussions on education, care planning and wishes between patient family and health providers.

• A copy of this form is kept in the patient medical record and uploaded onto MMEX.

•The Genogram documents the patients support network, it is completed by the patient with assistance from family and / or health providers. •A copy of the genogram is kept in the patient medical record and uploaded onto MMEX.

PRE DIALYSIS ASSESSMENT FORM

• The Pre Dialysis Assessment Form is used as a tool to assess the patient living environment, social situation and general health

• It is used to identify potential problems, or risks for commencing therapy

• A copy of this form is kept in the patient medical record and uploaded onto MMEX

END OF LIFE WISHES FORM

• The End Of Life Wishes Form is a tool used to document the ongoing discussions that occur regarding end of life care.

• A copy of this form is kept in the patient medical record and uploaded onto MMEX.

• In the future we hope there will be an alert on MMEX when opening a patient file who has a completed form.

RPH TRANSFER FORM

• Royal Perth Hospital Transfer Form is a communication tool between services for smooth transition of patient transfer.

• This form can be filled in by local health providers in conjunction with KRSS team.

EDUCATION TO HEALTH PROVIDERS

• Education on structure and support of pre dialysis position

• Education on reporting and documentation

• Explain what education is provided to patients on the kidney care pathway and the treatment options

Educating on the resources available-KAMSC website

Protocols-vascular access

EDUCATION TO PATIENTS AND FAMILIES

• Education and information for patient and family about the kidney disease pathway care plan

• Education on the treatment options• Home visits & family meetings• Nephrology clinics• Vascular access surgery• Information on conservative care / palliative care

PATIENT RESOURCES

• Patient kidney education book

• Patient handout ‘kidney care booklet’

• Patient handout ‘medication booklet’

• Patient handout ‘KRSS brochure’

• Patient ‘dialysis options booklet’

• Show patients & family ‘family support DVD’

• NT treatment options

• Bessie’s story (Palliative care book)

PATIENT RESOURCES AVAILABLE

PRE DIALYSIS PATIENT ASSESSMENT

• Nephrologist review 3-6/12

• Pre dialysis assessment -Assess living environment, family & social situation & suitability for treatment options.

• Transplantation suitability discussed & workup is

coordinated by RPH

• Palliative Care Team prn, support the use of end of life wishes form

• Social worker – Broome / Perth (white goods, bed, electricity and telephone)

• Ensure HepB schedule has commenced and follow up with local health care providers

TREATMENT OPTIONS AVAILABLE

Haemodialysis – satellite, community or

home

TransplantationConservative management / Palliative

care

Peritoneal dialysis- CAPD or APD

Is the patient suitable for the

treatment options?

1.Is the patient compliant, do

they have co morbidities,

what is their age? 2.Do they have a

suitable abdomen, past abdominal

surgery?3. Do they have a house, a suitable environment, a carer, are they

literate, are they clinically stable?

Ect

REFERRAL FOR VASCULAR ACCESS

Pre dialysis coordinator will

• Monitor patients eGFR & creatinine closely-Communicate with health providers those patients with eGFR <20 (preparation for vascular access)

• Inform the health service of vascular access surgery (ie withhold clopidogrel, where, when, PATS)

• Coordinate planned access surgery in Broome/ Derby

• Explain access protocols to health providers

Vascular access

• Depending on pathology & symptoms - buried PD tube or externalised PD tube and fistula

• Fistula only if patient chooses & suitable for haemodialysis

PREPARING FOR VASCULAR ACCESS OR DIALYSIS

Coordinate vascular access clinic list in Broome / Derby / Perth• Communication with ACCHS, health providers, patient and

family• Ensure money, health cards, appointments, bloods, PATS,

accommodation,meet and greet, support person• Patient introduction to the PD training nurse

Coordinate Transfer to Perth / Broome for dialysis• As above• Transfer form completed and faxed (Address, end of life

wishes & genogram form)• Communication with family and KRSS team whilst patient in

Perth

eGFR

POST ACCESS

• Hospital , ACCHS, health care services and family members informed post surgery on return to community

• Discharge summary from hospital onto MMEX

• Management of patients with an externalized PD tube are transferred to the PD educator / trainer (to commence training & ongoing management)

• However all patients are monitored and managed by the local health providers in conjunction with the KRSS team

TRANSFER TO EDUCATOR /TRAINER WHEN TREATMENT BEGINS

Trainer

COMMUNICATION WITH HEALTH PROFESSIONALS

• Local health providers• GPs (medical staff)• Renal GP• KRSS team• Nephrologist• CKD coordinator• Palliative Care Team• Social worker• Dietitian• Podiatrist• Pharmacist• Perth Fresenius nurses PD

and HHD• RPH Anaemia coordinator• RPH Pre dialysis coordinator• RPH Transplant coordinator

KIMBERLEY RENAL SUPPORT SERVICE (KRSS)

Vision statement: A model of care in renal services,

working by and for the people of the Kimberley, to achieve equity, dignity and quality of life, respecting rights of individuals and communities to health and wellbeing of a level which is second to none.

Thank you