Name of Clinical Guideline and Number
Clinical Guideline
Management of Renal Dialysis Patients at the Emergency
Department
Document Registration Number: Insert
Sites where Clinical Guideline applies
All Emergency departments within HNELHD
This Clinical Guideline applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
(If Yes to 2 and/or 3) Approval gained from the Children
Young People and Families Network on (insert date)
Target audience
All clinicians working in the Emergency Department and
the Nephrology Department in HNELHD, including
Doctors, Registered and Enrolled nurses and Managers
Description
The purpose of this guideline is to assist emergency
department staff to recognise the appropriate
management required for renal dialysis patients.
Comprehensive assessment can facilitate early
diagnosis and treatment. This guideline has been
developed to describe the minimum assessment
process required for a renal dialysis patient, to assist
ED clinicians in early clinical diagnosis and referrals to
the appropriate team for further treatment.
Keywords
Renal, Dialysis, Emergency Department, RenalCard
Replaces Existing Guideline?
Yes
Registration Numbers of Superseded
Documents
JHH Nephrology SWP G.3
Manning Nephrology MP-2011-81
HNEH G&P 10-01 Medical Responsibility for Dialysis
Dependant Patients Presenting to Rural Health
Facilities in the Peel, Mehi, McIntyre and Tablelands
Clusters
Related Legislation, Australian Standards, NSW Health Policy or Circular, EQuIP Criterion,
other HNE Health Documents, Professional Guidelines, Codes of Practice or Ethics:

EQuIP Criterion:

NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf

NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf

NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf

NSW Health Policy Directive PD 2008_009_Triage of Patients in NSW Emergency
Departments

NSW Health Guideline GL2005_026_Emergency Department-Notification of Specialist or
VMO Regarding admitted through the ED

Hunter New England Health Policy 02/28 Medical Responsibility for the Care of patients
Awaiting Transfer to another Healthcare Facility and /or who require Specialist Advice
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0009/40869/HNEH_07_03_Me
dical_responsibility_transfer_care.pdf
Version Number
Month and Year
Name of Clinical Guideline and Number
Position responsible for Clinical
Guideline Governance
HNELHD Renal Clinical Stream Leadership Group &
Emergency Clinical Stream Leadership Group
Clinical Guideline Contact Officer
Ginger Chu (Nephrology CNC); Diana Williamson
(Emergency CNC)
Contact Details
(02) 49048815; (02) 49855554
Date authorised
Authorising body
This Clinical Guideline contains advice
on therapeutics
No
Issue Date
Date for review
TRIM number
Version Number
Month and Year
Name of Clinical Guideline and Number
GLOSSARY
Acronym or Term
Definition
ED
Emergency Department
ESKD
End Stage kidney Disease
Fistula
The arteriovenous fistula is an internal access created by surgically joining an artery
to a vein to create a large blood vessel for haemodialysis access
Graft
The arteriovenous graft is created by surgically joining an artery and vein using the
saphenous vein or a synthetic material such as polytetrafluoroethylene (PTFE) for
haemodialysis access
RenalCard
An identification card contains the patient’s usual dialysis unit contact details and
how to access the renal guidelines and procedures.
FBC
Full Blood Count
UEC
Urea Electrolytes Creatinine
SAGO
Standardised Adult General Observation (Adult General Observation Chart
SMR110010
BACKGROUND
Dialysis is a treatment that removes metabolic waste products and restores fluid and electrolyte balance in
the patients’ blood. It is the main therapy component used to maintain patients with ESKD and has two
types: Haemodialysis & Peritoneal Dialysis
Appropriate Settings for Haemodialysis
“In Centre” haemodialysis units will always be located within the footprint of a major hospital, with a
high level of medical support in close proximity and a consultant Nephrologist. These units will provide
maintenance haemodialysis for:
• patients with ESKD whilst they are suffering from a significant acute medical or surgical illness, not
always directly related to Chronic Kidney Disease,
•
medically unstable chronic haemodialysis patients and also
• can provide staff and equipment for dialysis of critically ill patients in special care facilities such as
Intensive care / Acute care/ Coronary care units.
Dialysis patients who are hospital inpatients, will, in most cases, require dialysis in an ‘in-centre”
haemodialysis unit.
“Satellite facilities” can have various locations as they are specifically for medically stable chronic
haemodialysis patients who do not require clinical assessment (apart from usual dialysis practice
needs) prior to each dialysis session. Satellite dialysis units would not perform dialysis for patients who
had been assessed as medically unstable on dialysis by the treating on-call nephrologist in consultation
with the on-site Medical Officer and senior dialysis staff, as appropriate medical management is to
transfer such patients to a location with available “In Centre” facilities. Satellite units do not have
consultant Nephrologists within close proximity, do not provide an “on-call” or out of hours emergency
service, and due to a very high occupancy rate cannot usually provide emergency dialysis (within
hours).
“Home Haemodialysis” is available for physically and medically appropriate patients who successfully
complete home training program requirements and have a residence suitable to perform home
Version Number
Month and Year
Page 3
Name of Clinical Guideline and Number
haemodialysis. Most home haemodialysis patients with either technical or medical issues will require
support at either a satellite or “In Centre” facility for dialysis, depending on their medical condition.
GUIDELINE
The following points are the important guidelines to follow when reviewing a renal dialysis patient presenting
to an Emergency Department:

Conduct triage on arrival including a full set of vital sign observations, documented on the SAGO
chart. (Note: Avoid taking blood pressure on the fistula/graft arm).

Follow Adult Sepsis Pathway if temperature >38 (Follow:
http://www.cec.health.nsw.gov.au/__documents/programs/sepsis/sepsis_pathway_final_3_may_201
1_adult.pdf)

Obtain blood samples including UEC and FBC from the non-fistula/graft arm

Review patients’ fistula/graft by assessing thrill and bruit. If unable to detect thrill and bruit, an urgent
surgical review is required.

Ask the patient for their “RenalCard” (see appendix1) to obtain dialysis information

If the patient requires peritoneal dialysis, and has presented to John Hunter Emergency Department,
follow local clinical guideline: Management of patients with Peritoneal Dialysis in the John Hunter
Emergency Department (GNAH: 0239). Or for Peritonitis treatment follow area guideline:
Management of Peritoneal Dialysis Related Peritonitis (HNEH G& P 10_36)

All acutely unwell renal patients should be considered for urgent transfer to the nearest hospital with
an acute in-patient dialysis service, after discussing the presentation with the on duty Nephrologist. If
the presenting problem is dialysis related, the Nephrologist can recommend initial treatment, as well
as coordinating rapid transfer to specialist dialysis areas thus avoiding further waits at the receiving
hospital ED, where such resources may be unavailable.
Specialist units that provide acute dialysis are: John Hunter Hospital,
Manning Rural referral Hospital (Taree) or Tamworth Rural Referral Hospital.
For patients presenting to rural Health facilities in the Peel, Mehi, McIntyre and Tablelands clusters the
Medical officer on duty / Senior Registered Nurse at the facility is to contact the Nephrologist “On Call” via:

Tamworth Rural Referral Hospital switch board staff – 02 67677700 and ask for the Nephrologist “On
call” to be paged.

If the Nephrologist “On Call” is unavailable or not responding contact Dr Stephen May – 0407
293253.

If neither the local Nephrologist “On call” or Dr Stephen May is available then contact the
Nephrologist “On call” at John Hunter Hospital via switchboard staff – 02 49213000, then page.
IMPLEMENTATION PLAN
This guideline is to be communicated across HNELHD via clinical network/stream and clinicians. Stream
leaders and managers are also responsible to communicate this CG with their staff via meetings, emails and
newsletters.
EVALUATION PLAN
IIMS monitoring of adverse outcomes
CONSULTATION WITH KEY STAKEHOLDERS
Version Number
Month and Year
Page 4
Name of Clinical Guideline and Number
Emergency network and stream
Nephrology network and stream
APPENDICES
1. RenalCard
REFERENCES
Hunter New England Health Policy 02/28 Medical Responsibility for the Care of patients Awaiting Transfer to
another Healthcare Facility and /or who require Specialist Advice
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0009/40869/HNEH_07_03_Medical_responsibilit
y_transfer_care.pdf
NSW Renal Dialysis Service Plan to 2011 http://www.health.nsw.gov.au
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
Version Number
Month and Year
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Name of Clinical Guideline and Number
Appendix 1
I AM A RENAL DIALYSIS PATIENT
OF THE
PLACE PATIENT ID STICKER HERE
WANSEY DIALYSIS
UNIT
FOR INFORMATION ON MY
DIALYSIS PLAN OF CARE PLEASE
CALL 02 49048800 BETWEEN
7AM – 9.30PM MONDAY TO
SATURDAY
PLEASE BE AWARE THAT MY DIALYSIS ACCESS
(E.G. PERMCATH, AVF, AVG OR PERITONEAL CATHETER)
SHOULD ONLY BE USED FOR DIALYSIS.
ALSO IF I HAVE A AVF / AVG PLEASE DO NOT PERFORM
VENIPUNCTURE OR BLOOD PRESSURES ON THAT LIMB
RENAL CLINICAL GUIDELINES
HTTP://PPG.HNE.HEALTH.NSW.GOV.AU/
ALTERNATIVE CONTACTS OUTSIDE OF THESE
HOURS IS THE JOHN HUNTER CENTRE DIALYSIS
UNIT ON 492 14338 OR THE ON CALL
NEPHROLOGIST THROUGH THE JOHN HUNTER
HOSPITAL SWITCH BOARD 492 13000
Version Number
Month and Year
Page 6