WAKE DIALYSIS CLINIC, INC.

POLICIES AND PROCEDURES

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The following policies, procedures, rules and regulations
contained in this manual have been reviewed and approved for
use by the medical director of the Wake Dialysis Clinic, Inc.

/et1 -atgil
eith Keen MD t/ Date
Medical Director
 WAKE DIALYSIS CENTER

This Regulation and Procedure Manual was reviewed and updated.

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 ANNUAL GOVERNING BODY REVIEW

POLICY: The Governing Body of Wake Dialysis Clinic, Inc. will meet annually for the
purpose of reviewing all policies and procedures. Minutes of this meeting will be
recorded and made available.
 TABLE OF CONTENTS

A. AIR EMBOLISM, TREATMENT

AIR REMOVAL FROM EXTRACORPOREAL SYSTEM
AMPHOTERICIN ADMINISTRATION
ANTIBIOTIC ADMINISTRATION

B. BATHROOM USE DURING HEMODIALYSIS TREATMENT

BATHROOM, CONSENT FOR DIALYSIS INTERRUPTION FOR USING
BLEEDING POST HEMODIALYSIS
BLOOD ADMINISTRATION - REACTION AND TREATMENT
BLOOD ADMINISTRATION - POST TRANSFUSION PT INSTRUCTIONS
BLOOD ADMINISTRATION - PT CONSENT FORM
BLOOD CULTURE - OBTAINING
BLOOD GLUCOSE DETERMINATION
BLOOD LEAK
BLOOD PRESSURE - TAKING AND RECORDING
BLOOD SAMPLES - COLLECTING
BLOOD TRANSFUSION ADMINISTRATION
BOMB THREAT

C. CALCIJEX PROTOCOL
CARDIAC/RESPIRATORY ARREST
CARDIAC/RESPIRATORY ARREST - CODE DRUGS
CENTRAL LINE CATHETER, REMOVAL OF
CHART ORGANIZATION
CLEANING OF BLOOD SPILLS IN THE HEMODIALYSIS UNIT
CLEANING OF CHEMICAL SPILLS IN THE HEMODIALYSIS UNIT
CLEANING OF MACHINE DRAIN BUCKET
CLEANING PATIENTS CHAIRS
CLOTTED DIALYZER
CONSENT FOR DESFEROXAMINE TREATMENT
CONSENT FOR HEMODIALYSIS
CONSENT FOR HIV BLOOD TEST
CONTROLLED SUBSTANCES - RECORDKEEPING
CRASH CART CHECK LIST
CULTURE AND SENSITIVITY OF WOUND OR EXIT SITE
 1

D. DENTAL CARE FOR HEMODIALYSIS PATIENTS

DESENSITIZING THE DIALYZER
DESFEROXAMINE ADMINISTRATION
DESFEROXAMINE CHALLENGE
DIALYSIS PROCEDURES
- MACHINE SET UP
- PRIMING THE REPROCESSED DIALYZER
- PRESSURE HOLDING TEST
- INITIATION OF DIALYSIS
- SODIUM VARIATION
- DISCONTINUING DIALYSIS
- SHUT DOWN - VINEGAR/ACID CLEAN PROGRAM
- SHUT DOWN - BLEACH
— DISASTER PLAN
DISCONTINUATION POLICY
DISCONTINUATION FORM
DISINFECTION OF EQUIPMENT - DAILY
DO NOT RESUSCITATE PROTOCOL
DRESSING CARE OF SUBCLAVIAN AND PERMACATH CATHETERS
DRY WEIGHT CALCULATION
DRY WEIGHT DETERMINATION

E. ELECTROCARDIOGRAM
.--EMERGENCY TERMINATION OF DIALYSIS
EPOGEN
EVACUATION ROUTES

F. - FIRE (SEE DISASTER PLAN)

FISTULA CARE
FISTULA EXERCISES

G. GRIEVANCE PROCEDURE

H. HANDWASHING
HEMATOCRIT
HEMODIALYSIS ADMISSION ORDERS
HEMODIALYSIS STANDARD ORDER FORM
HEPATITIS B VACCINE
HEPATITIS B VACCINE DECLINATION FORM
HIV - ANNUAL POLICY
HYPOTENSION DURING DIALYSIS
I. INCIDENT UNUSUAL
ADVERSE PATIENT OCCURRENCE/QUALITY IMPROVEMENT REPORT
INTRADIALYTIC PARENTERAL NUTRITION
INTRAMUSCULAR INJECTIONS
INTRAVENOUS MEDICATION VIA THE VENOUS DRIP CHAMBER
IRON DEXTRAN
IRON DEXTRAN ADMINISTRATION RECORD
IRON DEXTRAN CALCULATION SHEET
IRON DEXTRAN STANDING ORDER

K. KT/V

L. LAB STUDIES - PATIENTS

- MONTHLY
- QUARTERLY

M. MACHINE MALFUNCTION
- Equipment Problem Report
MEDICAL COMPLICATIONS DURING DIALYSIS
MEDICAL RECORDS
MEDICATIONS
-I.V., I.M. S.Q.
- P.O.
MONITORING GUIDELINES

N. NUTRITION SERVICES

0. OBSERVATIONS DURING DIALYSIS

P. PATIENT CARE EVALUATION

PATIENT INSTRUCTION SHEET
PATIENT LONG TERM CARE PLANS
-LONG TERM TREATMENT PLAN
-INITIAL SOCIAL WORK ASSESSMENT
PERMACATH CATHETER-INITIATION
PERMACATH CATHETER-DISCONTINUATION
PHARMACEUTICAL POLICIES
PHYSICIAN ORDERS
POLICY BOOK REVIEW
3K+ POTASSIUM BATH
POWER FAILURE -PT CARE
POST EXPOSURE PROCEDURE (INCLUDING NEEDLE STICKS)
PRE/POST/PRE
R. RECIRCULATION PROCEDURE
RECIRCULATION FORMULA PROCEDURE
REMOVAL OF PERMACATH CATHETERS
REMOVAL OF SUBCLAVIAN CATHETERS
RIGHTS AND RESPONSIBILITIES - PATIENT

S. SEIZURE PRECAUTIONS
SIGN-OFF DIALYSIS SHEET PATIENT
STAPLE REMOVAL
SUBCLAVIAN CATHETERS - INITIATION
SUBCLAVIAN CATHETERS - DISCONTINUING
SUBCLAVIAN CATHETERS - PATIENT INSTRUCTIONS
SUBCLAVIAN CATHETERS - TROUBLESHOOTING
SUBCLAVIAN/PERM CATH DRESSING CHANGE
SUTURE REMOVAL

T. T-LYMPHOCYTE HELPER CELLS

TRANSFER OF MEDICAL RECORDS
TRANSIENT DIALYSIS
- CRITERIA
- REQUEST FORM

TRANSIENT DIALYSIS PAYMENT POLICY

TRANSPLANTATION POLICY
TRANSPLANT EVALUATION REFERRAL FORM
TROUBLESHOOTING HEMODIALYSIS

U. OF GOAL CALCULATION
UROKINASE

V. VENIPUNCTURE
VENIPUNCTURE FOR OBTAINING PERIPHERAL BLOOD SPECIMEN
VENOUS DIALYSIS PRESSURE
 TREATMENT OF AN AIR EMBOLISM

POLICY: Upon discovery of an air embolism the patient will be treated according to the
following medical procedure.

PROCEDURE:

1. Upon discovery of air,. turn the blood pump off and clamp the venous blood line and
venous .fistula needle.
2. Turn patient on their left side with their head down for 20-30 minutes.
3. Clamp and disconnect blood lines to prevent further introduction of air.
4. Administer oxygen per nasal cannula at 2-10 L/minute.
5. Maintain blood access with normal saline drip.
6. Connect patient to cardiac monitor and be prepared for cardiopulmonary arrest.
7. Notify physician immediately.
8. Initiate air removal procedure to eliminate air from the extracorporeal system for possible
return of blood to the patient.

PREVENTION OF:

1. Double clamp all IV fluid tubing when fluid is not being administered.
2. Careful inspection of tubing for cracks.
3. Proper use of Machine Air Detector.
 REMOVAL OF AIR IN EXTRACORPOREAL SYSTEM

POLICY: Micro air emboli will be removed from the extracorporeal system to
prevent introduction of air into the patient's bloodstream.

EQUIPMENT: 2 - 10 cc syringes filled with saline

1 - blood line connection adapter

PROCEDURE:

1. Turn the blood pump off.

2. Disconnect the patient by clamping the arterial blood line and arterial needle line.
Disconnect the lines and connect the end cap.
3. Then, clamp the venous blood line and venous needle line and disconnect.
4. Connect the arterial blood line and the venous blood lines using end caps or similar
connection device.
5. Open saline line.
6. Unclamp arterial and venous bloodlines.
7. Turn the blood pump on and set at 100 ml/min. Begin recirculation.
8. Flush both arterial and venous fistula needles with 5-10 cc saline.
9. Flip dialyzer over, venous end up.
10. Continue to recirculate the blood with the saline line open until circuit is free of air.

When the circuit is free of air, then;

1. Turn the blood pump off.

2. Clamp saline line.
3. Clamp the venous and arterial bloodlines and separate.
4. Reconnect venous and arterial bloodlines to the venous and arterial fistula needles. Secure
the bloodline connections with leur-locks.
5. Unclamp the arterial and venous bloodlines.
6. Resume dialysis, being sure that all monitors and alarm parameters are properly activated
and set.
7. Document all occurrences on flow sheet.
 AMPHOTERICIN ADMINISTRATION

POLICY: To provide a uniform treatment for Candida Peritonitis.

EQUIPMENT: Amphotericin
Tylenol
Hydrocortisone 75
Benadryl 25
D5W 100 or 250
IV Set
2 - 3cc Syringes
1 - 10cc Syringe

PROCEDURE:

Every Treatment:
2 Tylenol one hour before Dialysis
Hydrocortisone 75 mg. IV push at beginning of Dialysis
Benadryl 25 mg. IV at beginning of Dialysis

First Treatment:
1 mg. Amphotericin in 100 cc's D5W, give over one hour.

Second Treatment:
10 mg. Amphotericin in 250 cc's D5W, give over 3 hours.

Third Treatment:
20 mg. Amphotericin, give over 3 hours.

Fourth Treatment:
30 mg. Amphotericin, give over 3 hours, then 30 mg. IV over 3 hours, then for
12 more treatments.

Drug needs to be covered during administration, as it is light sensitive.

STANDING ORDER FOR USE BY:

,
J. Keith Keener, MD Mark Rothman, MD

Leland E. Garrett Jr., MD Michael Monahan, MD

 ANTIBIOTIC ADMINISTRATION

PURPOSE: Since renal failure increases susceptibility to infection. Dialysis Patient's

frequently require intervention of antimicrobial agents.

Some commonly used antibiotics:

1. Gentamycin
2. Vancomycin

Antimicrobials act by:

A. Inhibiting bacterial cell wall synthesis
B. Altering permeability of cell membranes
C. Altering nucleic acid moleculization, inhibiting protein synthesis by altering cell
membranes.

GENTAMYCIN: (Aminoglycosides)
1. Rule out allergy to drug.
2. Draw up ordered dose and dilute into 100 cc's of N/S or D5W. It may be diluted
into 50-200 cc's of either N/S or D5W.
3. Infuse during last 20-30 minutes, not before, as this drug is removed with
dialysis.
4. Always draw lab cultures, if ordered, before infusion of drug

USUAL DOSAGE: 60-120 mg

Used for gram negative infections. (See package insert for specifics).

ADVERSE REACTION:
A. Neurotoxicity: Both vestibular and auditory branches of the 8th cranial nerve
may be effected (especially in Patient's with renal failure). Dizziness, vertigo,
tinnitus, roaring in ears and hearing loss. Dehydration may increase toxicity.

B. Peripheral neuropathy or encephalopathy, numbness, tingling of skin, muscle

twitching, convulsions.

C. Other: Respiratory depression, lethargy, confusion, depression and visual

disturbances.

VANCOMYCIN:
Used in gram positive infections. (See package insert for more specifics) and in Patient’s
who have allergy to Penicillin.

1. Rule out allergy to drug.

2. Reconstitute drug:
A. 10 ml Sterile H2O to 500 mg vial
20 ml Sterile H2O to the I gram vial
After reconstitution, drug maybe stored in refrigerator for 14 days without
 significant loss of potency.
3. Reconstituted solutions of 500 mg. Vancomycin must be further diluted with at
least 100 cc's of diluent.
4. Visually inspect for particulate matter and discoloration.
5. 1 gram reconstituted vials must be diluted in at least 200 ml. of diluent.
6. This drug should be administered over a period of at least 60 minutes. Can be
diluted in either N/S or D5W.

ADVERSE REACTIONS:
Anaphylactic reaction may occur during infusion.
The following symptoms may occur with rapid infustion: hypotension, wheezing,
dyspnea, urticaria or pruritis, flushing of upper body (red neck), or pain and muscle
spasm of chest and back. These reactions usually resolve within 20 minutes, but may
persist for several hours.
 BATHROOM USE DURING HEMODIALYSIS TREATMENT

POLICY: To insure Patient safety, Patients are discouraged to use Bathroom

Facilities during their treatment.

EQUIPMENT:
1. Bedpan and toilet paper.
2. Privacy Screens.
3. Consent for interruption.

PROCEDURE:
1. If patient verbalizes need to use Bathroom
A. Offer bed pan with Privacy Screen.
B. Encourage use of Bed pan before all else, explain safety factors involved
with procedure.
1. Loss of dialysis time.
2. Blood pressure instability may occur resulting in dizziness,
possible fainting.
3. Possibility of needle dislodgement.

If patient insists on discontinuing treatment temporarily to use Bathroom

Facilities:
A. Have Patient sign Consent Form/Liability Form.
B. Return blood to Patient.
C. Recirculate system.
D. Place sterile syringe on each fistula needle.
E. Check Patient's V.S. and assure stability.
F. Tape securely.
G. Escort Patient to Bathroom. Explain use of emergency signal.
H. Assist Patient in returning to Dialysis Area.
I. Check Blood Pressure.
J. Restart dialysis with arterial line, placing venous line in bucket. When
blood reaches venous chamber connect venous line to Patient. Add extra
N/S (200 cc's) to Patients fluid removal goal.
K. If Patient is hypotensive when returning to chair, infuse
N/S prime to Patient to enhance Blood Pressure.
L. Enter episode on Flow Sheet.
 WAKE DIALYSIS CLINIC, INC.

CONSENT FOR DIALYSIS INTERRUPTION FOR USING BATHROOM

I acknowledge that I have been offered privacy curtains and assistance using the bed pan during my
Hemodialysis Treatment. I have been made aware of the risks and complications associated with
stopping dialysis to go to the Bathroom and I understand that stopping my treatment to go to the
Bathroom is against medical advice.

I still choose to interrupt my treatment to go to the Bathroom and I will not hold Wake Dialysis
Clinic liable for any adverse complications that may result.

Patient's Signature Date

Witness Date

Patients Name Chart Number