Management of Renal Dialysis Patients at the Emergency Department Document No.
Guideline and
Procedure
Management of Renal Dialysis Patients at the Emergency Department
Sites where Guideline and Procedure
applies
Target audience:
All Emergency departments within HNELHD
All clinicians working in the Emergency Department and
the Nephrology Department in HNELHD, including
Doctors, Registered and Enrolled nurses and Managers.
Description
This Guideline and Procedure applies to:
1. Adults
2. Children up to 16 years
3. Neonates – less than 29 days
Keywords
Yes
No
No
Renal, Dialysis, Emergency Department, RenalCard, Fistula,
Graft
Replaces Existing Guideline and Procedure Yes
Registration Number(s) and/or name and of JHH Nephrology SWP G.3
Superseded Documents
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_Medic
al_responsibility_transfer_care.pdf
Prerequisites (if required)
No
Guideline and Procedure Note This document reflects what is currently regarded as safe and appropriate
practice. The guideline section does not replace the need for the
application of clinical judgment in respect to each individual patient but the
procedure/s require mandatory compliance. If staff believe that the
procedure/s should not apply in a particular clinical situation they must
seek advice from their unit manager/delegate and document the variance
in the patient’s health record.
If this document needs to be utilised in an area outside of Emergency
Department please liaise with the Emergency and Nephrology Service to
ensure the appropriateness of the information contained within the
Guideline and Procedure.
Position responsible for the
HNELHD Renal Clinical Stream Leadership Group & Emergency
Guideline and Procedure and Clinical Stream Leadership Group
authorised by
Version Number
Month and Year
Management of Renal Dialysis Patients at the Emergency Department Document No.
Contact Person
Contact Details
Date authorised
This Guideline and
Procedure contains advice
on therapeutics
Date of Issue
Review due date
TRIM Number
Version Number
Ginger Chu (Nephrology CNC); Diana Williamson (Emergency CNC)
(02) 49048815;
No
Month and Year
Management of Renal Dialysis Patients at the Emergency Department Document No.
Note: Over time links in this document may cease working. Where this occurs please source the document in
the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
RISK STATEMENT
OUTCOMES
1
Appropriate management of renal dialysis patients presenting to the Emergency Department
2
Minimising delay for patients receiving dialysis treatment
3
Management of dialysis related problems by Nephrology staff
ABBREVIATIONS & GLOSSARY
Abbreviation/Word
Definition
ED
Emergency Department
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
PREAMBLE
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:
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, a medically unstable chronic haemodialysis patient 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 usually do not require clinical assessment (apart from usual dialysis
practice needs) prior to each dialysis session. Satellite dialysis units would not usually perform
dialysis for patients who are concurrently hospital inpatients as appropriate medical management
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Management of Renal Dialysis Patients at the Emergency Department Document No.
is mostly to transfer such patients’ to a location with “In Centre” facilities.
Satellite units do not have consultant Nephrologists within close proximity, do not provide an “oncall” 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 haemodialysis. Most home haemodialysis patients with either technical or medical
issues will require transfer to a suitable “In Centre” facility for dialysis.
GUIDELINE
This Guideline does not replace the need for the application of clinical judgment in respect to each
individual patient.
The purpose of this guideline is to assist emergency staff to recognise the appropriate
management required for renal dialysis patients. Common reasons for dialysis patients presenting
to the emergency department include but are not restricted to fluid overload, sepsis, peritonitis,
hyperkalemia or access issues such as clotted fistula or graft. Adequate assessment can facilitate
early diagnosis and treatment. This guideline has been developed to describe the minimum
assessment process required of a renal dialysis patient, to assist ED clinicians in early diagnosis of
patients’ presenting problems and referrals to the appropriate team for further treatment.
The following points are the important guidelines to follow when receiving a renal dialysis patient
presenting to an Emergency Department:

Appropriate triage on arrival by taking full set of vital signs and documenting 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_2011_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,
a 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, please follow local clinical guideline: Management of patients with Peritoneal
Dialysis in the John Hunter Emergency Department (GNAH: 0239).

All acutely unwell renal patients should be considered for urgent transfer to the
nearest hospital with 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:
1. Tamworth Rural Referral Hospital switch board staff – 02 67677700 and ask for the
Nephrologist “On call” to be paged.
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Management of Renal Dialysis Patients at the Emergency Department Document No.
2. If the Nephrologist “On Call” is unavailable or not responding contact Dr Stephen May –
0407 293253.
3. 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.
APPENDICES
Appendix 1- A sample of “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_re
sponsibility_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.
Appendix 1
I AM A RENAL DIALYSIS PATIENT OF
THE
WANSEY DIALYSIS
UNIT
FOR INFORMATION ON MY DIALYSIS
PLAN OF CARE PLEASE CALL 02
49048800 BETWEEN
7AM – 9.30PM MONDAY TO SATURDAY
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
PLACE PATIENT ID STICKER HERE
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/
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