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Facility Resource Materials

The Facility Resource Material provides updated materials set forth by the Network 13 Medical Review Board (MRB) and helpful information regarding the care of ESRD patients. The information is printer friendly so please feel free to copy materials as needed.

The current Network standards and recommendations are provided for reference, as well as the updated Clearinghouse Library. Use the Table of Contents to direct focus to the information needed.

All applicable Quality Improvement (QI) correspondence will continue to be forwarded to the dialysis and transplant facilities. The Network QI responsibilities will continue to include:

  • Submittal of any required QI items to the Network;
  • Maintenance and knowledgeable about what QI materials are mailed to nurse managers;
  • The responsibility for dissemination of this information to the appropriate people in your facility.

With 250+ facilities in the Network, it is known that everyone approaches Network QI responsibilities in a variety of ways. It is our hope that the information on this site can be utilized by the facilities in improvement of ESRD patient care outcomes.

Revisions and modifications occur annually. We distribute replacement copies for inclusion in the manual each spring. Requests for information can be done at any time by contacting the Network. Updated as of 8/6/2007

Table of Contents

All Sections
 
     
 

 

1. NETWORK 13 Information

A.      Network 13 Glossary of Terms

B.    Listing of Board of Directors (BOD), Medical Review Board (MRB) and Network Committees (Available Upon Request)

C.     ESRD Network 13 Office Staff (Available Upon Request)

2. NETWORK 13 Directives

 

A.      NETWORK STANDARDS (Overview)

1.      Placement of Patients in Self-/Home- Care Setting

2.      Transplantation

3.      Vocational Rehabilitation

4.      Adequacy of Hemodialysis

5.      Adequacy of Hemodialysis:  Performance of Delivery of Care Audits

6.      Anemia Management in Chronic Renal Failure

7.      Vascular Access

a.      Catheters

b.      Arteriovenous Fistula (AVF’s)

c.       Monitoring for Access Dysfunction

8.      Nutrition in Chronic Renal Failure

9.      Transplant Surgeon Involvement or Designee Compliance with Transplant Requirements Specific to Patient Long-Term Programs (LTP) / Transplant Designee Draft Letter

10.  Mineral Metabolism in Chronic Renal Failure

11.  Peritoneal Dialysis (PD) Adequacy “Frequency and Timing of Measurement of Kt/Vurea, Total Ccr, PNA and Total Creatinine Appearance”

B.      NETWORK RECOMMENDATIONS (Overview)

1.      Nephrologist as Dialysis Facility Medical Director

2.      Continuing Education Credits in Renal Health Care

3.      Management of Hyperkalemia

4.      Disaster Preparedness / Louisiana Hurricane Preparedness

5.      Involuntary Discharge of Patients

6.      Advance Directives

7.      CMS Criteria to Determine Eligibility For the ESRD Program

C.     LONG TERM PROGRAM (LTP)

1.      Recommended Network LTP

D.     UNIFORM ESRD TRANSIENT FORMS

1.      Hemodialysis

2.      Peritoneal Dialysis

E.      ESRD MEDICAL RECORDS – A NATIONAL MODEL

F.      NETWORK 13 GRIEVANCE POLICY

G.     NETWORK 13 HIV POLICIES

1.      Human Immunodeficiency Virus (HIV – AIDS)

2.      Understanding the Rights of HIV+ / AIDS Patients

H.      ALTERNATE SANCTION RECOMMENDATION: NETWORK 13 PROCEDURE

I.         Concealed Weapons: Sample Policy

J.       CLIA – Clinical Laboratory Improvement Amendments / Regulations http://www.cms.hhs.gov/clia/

K.      KNOW YOUR OPTIONS – Medical Device and Laboratory Product Problem Reporting Program

L.      WEB SITES OF INTEREST, As of April 2007

 

3. Continuous Quality Improvement (CQI)

A.      CQI

1.   Measures of Morbidity and Mortality

B.      Accelerating Quality Improvement

C.     QI TOOLS

1.   Sample Quality Improvement Plans

a.      Quality Improvement Project

b.      QI Sample (Word™ & Excel™)

c.       Facility Quality Indicators  

2.   ADEQUACY OF DIALYSIS

A.      Hemodialysis

1.   Prescription and Delivery Audit Tool and Instructions

2.      Adequacy of Hemodialysis Tools

3.      Dry Weight Algorithm

4.      Dry Weight Monitoring Tool

5.      Pre- and Post-Dialysis Blood Sampling Validation Forms

6.      Frequent Hemodialysis Adequacy of Hemodialysis

7.      Illustrative Conversions: G-Codes/URR to stdKt/V

B.      Peritoneal Dialysis

1.      PD Adequacy Flow Sheet

2.      Infection Control for Peritoneal Dialysis (PD) Patients: CDC Fact Sheet

3.      ANEMIA MANAGEMENT

A.      Anemia Management Worksheet (with medication adjustment)

B.      Anemia Management Barrier Worksheet

4.      DIALYSIS-SPECIFIC INFECTION CONTROL ISSUES

A.      Hemodialysis Infection Control Log

B.      Peritoneal Infection Control Log

C.     Peritonitis – Exit Site Infections

D.     Hand Hygiene Fact Sheet

E.      Hand Hygiene Poster

5.      NUTRITION MANAGEMENT

A.      Malnutrition in ESRD Patients

B.      Management of Hypoalbuminemia In Adult Dialysis Patients Algorithm

C.     Patient Facility Percent Albumin

D.     Subjective Global Assessment Rating Form

6.      ACCESS TOOLS

A.      AVF (see Fistula First Toolkit) http://www.network13.org/ff_tools.asp

B.      AVF Functionality Tool

C.     Catheter Reduction Worksheet

7.      SELF-/HOME-CARE TRAINING MATERIALS

A.      Hemodialysis Home Training Checklist

8.      DIABETES FOOT SCREENING

A.      Diabetic Foot Examination Risk Categories

B.      Basic Foot Assessment Check List

C.     Prevention of Serious Complications from Diabetes (NIH)

D.     Preventing Foot Ulcers and Amputation

9.      AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

A.      SAMPLE Procedure:  AED

B.      SAMPLE Policy (supplied from Medtronic)

10.  HEMOLYSIS

 

 
4. Quality Improvement Activities: Year 2007
5. DATA ABSTRACTION ACTIVITIES

A.      FACILITY REPORTING

1.      Monthly Activity Reports

a.      Network Patient Activity Report (NPAR) and Instructions

b.      Patient Event Definitions and Business Rules for Facilities

c.      Transplant Activity Report and Instructions

d.      Helpful Hints for Completing NPAR

B.      PATIENT FORMS

1.      CMS 2728 (Medical Evidence Report)

a.      Form with Instructions http://www.cms.hhs.gov/cmsforms/downloads/CMS2728.pdf

b.      Primary Causes of ESRD

1.      By Category

2.      By Narrative

3.      By ICD-9 Code

2.      CMS 2746 (Death Notification)

a.      Form with Instructions http://www.cms.hhs.gov/cmsforms/downloads/CMS2746.pdf

b.      Death Cause Codes – Numeric List

C.     FORMS VALIDATION

1.      CMS – 2728 Form Mandatory Fields, Changes and Most Common Errors

a.      2728 Shaded training tool (Page 1)

b.      2728 Shaded training tool (Page 2)

c.      2728 Forms Completion Training Tool

2.      Most Common Errors found on CMS 2746 form

a.      2746 Forms Completion Training Tool

D.     FORMS COMPLIANCE

1.      Corrective Action Plan Sample Template

E.      ANNUAL FACILITY SURVEY (CMS 2744)

1.      Page 1 – Dialysis Facility Survey
http://www.cms.hhs.gov/cmsforms/downloads/cms2744a.pdf
and Instructions

2.      Page 2 – Transplant Facility Survey
http://www.cms.hhs.gov/cmsforms/downloads/cms2744b.pdf
and Instructions

F.      WHERE TO OBTAIN FORMS AND MATERIAL

G.     ELECTRONIC SUBMISSION OF PATIENT DATA

1.      Quality Net Registration

 

 

6. Infection Control

A.      Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients

B.      Preventative Measures for Health-Care Settings

1.      Universal Precautions

2.      Hand Hygiene Fact Sheet http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

C.     Hepatitis Control Measures for Dialysis Centers

1.      New Global Guidelines for Kidney Disease and Hepatitis C

2.      Hepatitis Glossary http://www.cdc.gov/ncidod/diseases/hepatitis/resource/glossary.htm

3.      Hepatitis A, B, and C: Learn the Differences http://www.immunize.org/catg.d/p4075abc.pdf

4.      Guidelines for Viral Hepatitis Surveillance and Case Management
http://www.cdc.gov/ncidod/diseases/hepatitis/resource/pdfs/revised_guidelines_formatted5.pdf

5.      Hepatitis B Frequently Asked Questions http://www.cdc.gov/ncidod/diseases/hepatitis/b/faqb.htm

6.      Hepatitis B Fact Sheet http://www.cdc.gov/ncidod/diseases/hepatitis/b/bfact.pdf

7.      Hepatitis C: “What Vaccinations are Needed?” http://www.immunize.org/catg.d/p4042.pdf

8.      Hepatitis C Fact Sheet http://www.cdc.gov/ncidod/diseases/hepatitis/c/cfact.pdf

9.      Hepatitis C Test http://www.labtestsonline.org/understanding/analytes/hepatitis_c/test.html

10.  Hepatitis C Info in Spanish http://www.hcvadvocate.org/espanol.asp#sencillos

D.     Human Immunodeficiency Virus (HIV-AIDS)

1.      Recommendations for Prevention of HIV Transmission in Health-Care Settings
http://wonder.cdc.gov/wonder/prevguid/p0000318/P0000318.asp

2.      Sterilization or Disinfection of Patient Equipment HIV Related
http://www.cdc.gov/ncidod/dhqp/bp_sterilization_patient_care.html

3.      Advancing HIV Prevention: Fact Sheet
http://www.cdc.gov/HIV/topics/prev_prog/AHP/resources/factsheets/Progress_2005.pdf

E.      Prevention of Intravascular Catheter-Related Infections

1.      Guidelines for the Prevention of Intravascular Catheter-Related Infections
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

2.      Examples of Clinical Definitions for Catheter-Related Infections
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a2.htm

F.      Antimicrobial Resistance in the Healthcare Settings / Drug-Resistant Pathogens

1.      Prevent Antimicrobial Resistance in Healthcare Setting Fact Sheet
http://www.cdc.gov/drugresistance/healthcare/dialysis/12steps_dialysis.pdf

2.      Multi-Resistant Organisms in Non-Hospital Healthcare-Settings FAQ:
MRSA-VRE-ESBLS-PRSP  http://www.cdc.gov/ncidod/dhqp/ar_multidrugFAQ.html

3.      Amino glycoside Resistance in Enterobacteriaceae and Pseudomonas aeruginosa
http://www.cdc.gov/ncidod/dhqp/ar_lab_amino.html

4.      Vancomycin-resistant Enterococci (VRE) and the Clinical Laboratory
http://www.cdc.gov/ncidod/dhqp/ar_lab_vre.html

5.      Recommendations for Preventing the Spread of Vancomycin Resistance - Us Department of Health & Human Services - September 1995 http://www.cdc.gov/mmwr/PDF/RR/RR4412.pdf

6.      Methicillin-resistant Staphylococcus aureus – MRSA
http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

G.     Tuberculosis

1.      Tuberculosis Q and A - Large File - http://www.cdc.gov/tb/faqs/pdfs/qa.pdf

2.      Tuberculosis Glossary http://www.cdc.gov/tb/faqs/qa_glossary.htm

3.      TB Facts for Health Care Workers 2006
http://www.cdc.gov/tb/pubs/TBfacts_HealthWorkers/default.htm

4.      Questions and Answers About TB for Patients http://www.cdc.gov/tb/faqs/default.htm

5.      Update:  OSHA Enforcement Policy for Occupational Exposure to Tuberculosis
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21919

6.      Tuberculosis Surveillance Information/Management http://www.cdc.gov/tb/tims/default.htm

H.      Immunization Information
General Links
http://www.immunize.org/
http://www.cdc.gov/vaccines/default.htm

1.      Adult Immunization Recommendations (Schedule USA 2007/2008 version)
http://www.cdc.gov/nip/recs/adult-schedule.htm - print
http://www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf (PDF Version)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a7.htm?s_cid=mm5641a7_e (text Version)

2.      2008 Childhood & Adolescent Immunization Schedules
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable

3.      Adult Vaccination Screening Forms (English and Spanish)

4.      Online Vaccine Quiz http://www2.cdc.gov/nip/adultImmSched/

5.      Summary of Recommendations Immunizations http://www.cdc.gov/vaccines/

6.      Updated Infection Control Measures for Prevention and Control of Influenza in Long-Term care Facilities http://www.cdc.gov/flu/professionals/infectioncontrol/pdf/longtermcare.pdf

7.       Antiviral Agents for Influenza: Background Information for Clinicians
http://www.cdc.gov/flu/professionals/treatment/

8.      CDC launches a new influenza website for health professionals and the public: http://www.cdc.gov/flu/ Posted 9/26/2007

9.       Spanish-language version/ English Version of VIS for inactivated influenza vaccine available on IAC website. For information about the use of VISs, and for VISs in more than 30 languages, visit IAC's VIS web section at http://www.immunize.org/vis Posted 9/26/2007

10. Interim VIS for hepatitis B vaccine
To obtain a ready-to-print (PDF) version in Spanish, go to:
http://www.immunize.org/vis/sphepb01.pdf

To obtain it in English, go to:
http://www.immunize.org/vis/hepb01.pdf

11.       Additional CDC highlights resources for influenza season Posted 9/26/2007

* The National Influenza Vaccine Summit---has a website with additional influenza resources:
http://www.preventinfluenza.org

* the American Medical Association (AMA) hosts the Influenza Vaccine Availability Tracking System (IVATS) on its website. IVATS, a tool to assist healthcare professionals in finding vaccine to purchase, can be found at http://www.ama-assn.org/ama/pub/category/16919.html

I.         Communicable Disease and Injury Reporting as known by state (Available via Internet)

ARKANSAS:             Arkansas Disease Information

http://www.healthyarkansas.com/data/pdf/reportable_disease2004.pdf

LOUISIANA:              Louisiana Disease Information

http://www.dhh.louisiana.gov/offices/miscdocs/docs-249/annual/LaIDAnnual__Diseaselist2006.pdf

OKLAHOMA:            Oklahoma Disease Information

(http://www.health.state.ok.us/program/cdd/Blue%20Card%20Poster.pdf)

J.       Other Infectious Diseases

1.      Avian (Bird) Influenza and Avian Influenza A (H5N1) Virus Information:
http://www.avianflu.gov

Ø       http://www.cdc.gov/flu/avian/gen-info/pdf/avianflufacts.pdf

Ø       http://www.cdc.gov/flu/avian/professional/pdf/possible-exposure-avianflu.pdf

Ø       http://www.cdc.gov/flu/avian/professional/pdf/infectcontrol.pdf

Ø       http://www.cdc.gov/flu/avian/outbreaks/current.htm

Ø       http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm

Ø       http://www.cdc.gov/flu/avian/gen-info/facts.htm

Ø       http://www.cdc.gov/flu/avian/gen-info/qa.htm

2.      Anthrax: What you Need to Know http://www.bt.cdc.gov/agent/anthrax/pdf/needtoknow.pdf

3.      Severe Acute Respiratory Syndrome (SARS):  Preparedness and Response in Healthcare Facilities http://www.cdc.gov/ncidod/sars/guidance/C/pdf/c.pdf

4.      Responding to Detection of Aerosolized Bacillus anthracis by Autonomous Detection Systems in the Workplace http://www.cdc.gov/mmwr/pdf/rr/rr53e430-2.pdf

 

7. Patient Services

A.      Patient Education

1.      Patient Education Web Links

2.      Dialysis Facility Compare - http://www.medicare.gov/Dialysis/Home.asp

B.      Patient Centeredness

1.      Patient Centered Web Links

2.      Patient Centeredness: In the Dialysis Unit (Power Point)

C.     Difficult Situations Behavioral Management

1.      Difficult Situations Behavioral Management Web Links

2.      Behavioral Agreement(SAMPLE)

3.      Violence Policy (SAMPLE)

D.     Quality of Life

1.      QOL Web Links

2.      Measurement of Physical Functioning In Older Adult Populations (May Require Log-in)
http://www.nia.nih.gov/NR/rdonlyres/AF0997F6-0C16-4A76-96C0-D3780F00E6D4/2300/phys_perform_meet_agend_particip_12_12_03.pdf

E.      End Of Life

1.      End of Life Web Links

2.      FAQ About End of Life Care for Renal Patients

3.      End of Life Issues and Care http://www.apa.org/pi/eol/issues.html

4.      Guidelines for Terminating Treatment (University of Michigan)
http://www.med.umich.edu/psm/guidelines.html

F.      Rehabilitation