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Nephrology Co-Management

Reserved space on Med B

  • Renal transplant (still viable) complications: infection, rejection, etc.
  • Vasculitis workup/management
  • Nephritis workup/management
  • Intrinsic AKI
  • Peritonitis related to PD

Patients appropriate for Co-Management on closed unit (Med J)

  • AKI, unknown/NOS
  • Significant electrolyte disorders in setting of AKI
  • CKD 4 or higher with infection
  • Medication toxicity in setting of renal failure
  • New start dialysis

Patients appropriate for Med H (outside of closed unit) if not on Med B and are not being considered for Con- management on the closed unit.

  • Failed transplant patients (now on dialysis) admitted to hospital for non-nephrology reasons.
  • Vascular access issues not appropriate for discharge from ED (as below).
  • Missed dialysis/volume overload with hypoxia.
  • Pre-renal AKI
  • Mild electrolyte disorders
  • Calculus/obstruction causing hydronephrosis

Admit Process:

  • Identification of patients appropriate for co-management:
  • MAO considers team assignment based on criteria outlined above (ED or MICU downgrades).
  • Paged to Med B directly
  • Paged to hospitalist admitter with suggestion for Med H versus Co-management
  • Direct admits. Input from Med B attending regarding need for closed unit admission or not and appropriateness for Med B versus co-management.
  • Hospitalist completes admission orders and H&P. Admitted in EPIC under Hospitalist Co-Management (MEDJ). Assign Magnolia as treatment team (leave Co-Management as primary). Place consult order for Nephrology.
  • Nephrology Consult fellow to leave consult note- same day or next day for overnight admissions. Place orders as appropriate.

Co-Management Expectations

  • Both teams round in AM. Once consult team is finished rounding, the consult team ‘runs the list’ by phone with co-management provider with clear emphasis on new recommendations, orders, and action items.

  • Both services will review orders daily.

  • Primary team will debrief with consult team following rapid response/change in patient status.

  • Consult team places orders for specialty-specific recommendations.
  • Please designate section of recommendations within consult note to clearly itemize new recommendations and which orders are being placed by the consult team.
  • Indicate if a lab or radiology study may require more urgent follow-up and action overnight so that we can communicate this with our covering providers.
  • Consult providers or fellows should NOT order electrolyte replacement for patients.
  • Nursing is expected to direct all cross-cover issues and questions to hospitalist provider.
  • When patients approach discharge, the consult team outlines discharge medication recommendations within consult note. Hospitalist ultimately responsible for discharge med reconciliation and scripts.

Disposition:

  • Unless consult team feels it necessary, would generally not transfer from Magnolia to MedB or vise versa.
  • Magnolia will not continue to follow patients needing upgrade to MICU.
  • For discharge, hospitalist does med reconciliation, hospital course, discharge summary. Nephrology fellow to facilitate follow-up with nephrology and communicate with outpatient dialysis unit. Patients who can be discharged from ED with Nephrology consult and Outpatient follow up:
  • CKD Stage 5 patients – with no uremic symptoms and volume overload
  • ESRD patients - missing dialysis for => 1 week. Labs within acceptable range and no hypoxia – could be discharged to be dialyzed at outpatient dialysis unit, if the patient’s outpatient dialysis unit has agreed to dialyze the patient. The consult fellow/attending must document their communication with the outpatient dialysis clinic in the medical record prior to patient discharge from the ED.
  • Hyperkalemia with no EKG changes and no volume overload
  • ESRD patients:
  • K > 6.0 mEq/L – dialysis or potassium binders – discretion of consult attending
  • ESRD patients with K: 5.0 -6.0 mEq/L – treat with potassium binder and outpatient dialysis.
  • Non –ESRD patients – treat with potassium binders, repeat and discharge home
  • Patient with clotted access – An attempt should be made to call CVA and get them an appointment same day or next for declotting or perm cath placement (exception if patient comes on Friday or over the weekend). If appointment cannot be made in a safe period of time, patient should be admitted (see attached referral process).
  • Benign essential microscopic hematuria
  • Transplant patient with dehydration – can be discharged after IVF if creatinine is at baseline. Communication with on-call nephrology team should occur prior to patient discharge.
  • Transplant patients with UTI and normal vitals – can be discharged with PO antibiotics (exceptions are patient with recurrent UTI or resistant to PO antibiotics in the past). Communication with on-call nephrology team should occur prior to patient discharge.
  • Volume overload with normal saturation – either txp or CKD 3-4, can be treated with diuretics and discharged once documented good urine output
  • ESRD or Transplant patients with DVT – admission based on discretion of consult attending
  • CKD 5 or ESRD or transplant patients with Gout

Urologic/Surgical considerations. Not intended for MedB or closed unit.

  • Vesicointestinal fistula
  • Vesical fistula
  • Diverticulum of bladder
  • Urethral fistula
  • Urethral diverticulum
  • Cystostomy hemorrhage/infection/malfunction/complications
  • Nephrostomy catheter or its complications such as displacement/infection
  • Presence of urinary tract stoma or its complications
  • Presence of urinary stent or its complications such as displacement/infection
  • Contusion or laceration of the right or left kidney
  • </= 2 weeks post-transplant (admit to SRF).

VAC Access Pathway

  • For patients requiring semi-urgent dialysis access repair
  • Consider for the following types of cases:
  • Declot/Thrombectomy
  • Angiogram/Fistulogram
  • Angioplasty, Stenting
  • Tunneled catheter insertion, exchange, removal.
  • Temporary dialysis catheter placement.
  • Appropriate for patients requiring any of the above procedures without other acute indications for admission.
  • Can still consider referral for patients short of breath but not hypoxic and for hyperkalemia <5.6 mmol/L.
  • Transportation resources are available to help patients in need.
  • VAC staff is able to coordinate follow-up dialysis scheduling with patient’s outpatient dialysis unit. The online referral form can be found at www.carolinavac.com/referring-physicians/.
  • For referrals during daytime hours:
  • Fill out electronic referral form.
  • Call the Vascular Access Clinic at 919-908-6080 to confirm receipt and discuss scheduling.
  • For referrals after hours:
  • Fill out the electronic referral form.
  • VAC staff will contact the patient in the morning to discuss expedited scheduling.
  • Patients should also be given the phone number to the Vascular Access Clinic (919-908-6080) upon discharge from the ED.
  • Patients should remain NPO the following morning in case procedure is possible.
  • After hours, specific questions regarding procedures can be directed to the on-call nephrology fellow.