MRP Policy and Procedure Manual

Click on the links below for specific sections of the Manitoba Renal Program Policy & Procedure Manual.

Table of Contents

10.00 Administration \ Committee

10.10.01 Terms of Reference

30.00 MRP POLICIES & PROCEDURES

30.10 Dialyzers

 

30.20 Dialysate Delivery System

 

30.30 Vascular Access

 

30.40 Accessory Equipment

30.40.01 Use Neo-Stat/Neo-Stat Plus Dialysate Conductivity Meter *NO LONGER IN USE*

30.40.04A Use of BARD Dialysis Catheter Repair Kit *Revised*

30.40.04B Use of Covidien™ Acute and Chronic Catheter Repair Kit: Palindrome™ Chronic Care and All Mahurkar™ Acute and Chronic Care Catheters *Revised*

30.40.05 Use of the HEMOdialert™ Device with Hemodialysis

30.40.25 Use of DWA Continuous Concentrate Mixing System *No Longer in Use*

 

30.50 Water Treatment

 

30.70 Standards of Care

 

30.80 Peritoneal Dialysis

30.80.01 Attachment of Twin Bag Transfer Set to Peritoneal Catheter *Revised*

30.80.01a Attachment of Twin Bag Transfer Set to Peritoneal Catheter *New*

30.80.02 Changing Titanium Adaptor in a Peritoneal Catheter

30.80.03 Instillation of Medication into Peritoneal Dialysis Solution

30.80.03a Appendix A: Instillation of Medication into Peritoneal Dialysis Solution (IP Drugs Manual)

30.80.03b Appendix B: IP KCI

30.80.04 Application of Locking Cap to Peritoneal Catheter

30.80.05 Peritoneal Catheter Flush

30.80.05 A Appendix A: Decision Tree for Managing Contamination

30.80.06 Peritoneal Exit Site Care *Revised*

30.80.06a Appendix A: Physician Management of Exit Site Infection

30.80.06b Appendix B: Catheter Dressing *Revised*

30.80.06c Appendix C: Peritoneal Dialysis Exit Site *Revised*

30.80.07 Intraperitoneal tPA for Obstructed Peritoneal Dialysis Catheters

30.80.08 Peritoneal Dialysis Bag Exchange Utilizing Twin Bag System *Revised*

30.80.08a Appendix A: Decision Tree for Managing Contamination *Revised*

30.80.08b Appendix B: W00353 CAPD Flow Sheet *Revised*

30.80.09 Home Choice Cycler Set-Up: Initiation of Cycling and End of Treatment (utilizing a luer lock cycler set) *Revised*

30.80.09a Appendix A: Decision Tree for Managing Contamination *Revised*

30.80.09b Appendix B: W00354 Automated Peritoneal Dialysis Record *Revised*

30.80.11 Peritoneal Catheter Irrigation

30.80.12 Silver Nitrate Application

30.80.17 Ascites Drainage Utilizing a Peritoneal Catheter

30.80.17a Decision Tree for Managing Contamination

30.80.18 Collection of Peritoneal Dialysis Effluent from a Peritoneal Dialysis Drain/sample Bag for Peritonitis Investigation

30.80.18a Appendix A: Site Specific Requisitions for Peritonitis Investigation

30.80.18b Appendix B: Decision Tree for obtaining peritoneal effluent sample

30.80.18c Appendix C: POSTER: Sending Peritoneal Dialysis Effluent Sample for Culture and Cell Count *New*

30.80.19 Peritoneal Equilibrium Test (PET)

30.80.19a Appendix A: PET Collection Sheet

30.80.19b Appendix B: Decision Tree for Managing Contamination

30.80.20 Measuring Peritoneal Dialysis Adequacy: KT/V Collection

30.80.20a Appendix A: Incremental PD Protocol

 

60.00 MRP STANDARDS PROTOCOL

60.10 Standards

60.10.01 Hemodialysis Treatment Record Standard *Revised*

60.10.01a Appendix A: Hemodialysis Treatment Record for Fresenius 5008 (Form #1592) *Revised*

60.10.01b Appendix B: Appendix B: HSC Hemodialysis Treatment Record *New*

60.10.01c Appendix C: Form W-00497 HSC Hemodialysis Treatment Record *New*

60.10.02 Hemodialysis Flow Sheet Standard

60.10.02a Appendix: Hemodialysis Flow Sheet (Form #W-1593)

60.10.03 Renal Health / Hemodialysis Nursing Kardex Standard *Revised*

60.10.03a Appendix A: Renal Patient Kardex (Form #W-00195A) *Revised*

60.10.03b Appendix B: Hemodialysis Patient Kardex (Form #W-00195B) *Revised*

60.10.04 Hemodialysis Signature Sheet Standard

60.10.04a Appendix: Hemodialysis Signature Sheet (Form #NS 00714)

60.10.05a Hemodialysis Renal Medication Flow Sheet Standard  *New*

60.10.05b Hemodialysis Renal Medication Flow Sheet Standard (eKHR) *New*

60.10.05 Appendix: Hemodialysis Renal Medication Flow Sheet (Form #85561) *Under Review

60.10.06 Hemodialysis Vascular Access Record Standard

60.10.07 Standard for completion of Cardiorenal Ascites Peritoneal Dialysis Catheter Drainage Assessment Report ( Form # W-00471 )

60.10.07 Appendix W-00471 Cardiorenal-Ascites Peritoneal Dialysis Catheter Drainage Assessment Record

60.10.08 Standard for completion of Continuous Ambulatory Peritoneal Dialysis Assessment Report (Form # W00472)

60.10.08 Appendix W-00472 Continuous Ambulatory Peritoneal Dialysis Assessment Report

60.10.10 Documentation Standard – Manitoba Renal Program & Long Term Care Communication Record

Form #W-00273

#WR-16

# CL0065-5

Stepwise Approach to Uremic Pruritus *New*

Appendix: Hydroxyzine (Atarax®) and Risk of QT Interval Prolongation and Torsades de Pointes *New*

 

60.30 Protocols

60.30.03 Human Leukocyte Antigen Antibody Testing Routine and Post Transfusion Protocol *Revised*

60.30.04 Adult Patient Screening and Vaccination Protocol for Hepatitis B and Hepatitis C

60.30.04a Appendix A: Algorithm for Hepatitis B Vaccination and Monitoring in Susceptible Patients

60.30.04b Appendix B: Schedule for Routine Blood Testing for Hepatitis B & Hepatitis C Virus Infections

60.30.04c Appendix C: How to switch a patient from one product to the other

60.30.06 Initial and Monthly Lab Tests Protocol for Chronic Hemodialysis Patients

60.30.06a Appendix A: Dialysis Panel Health Sciences Centre (HSC) and Local Renal Health Centre (LRHC) 2015

60.30.06b Appendix B: Dialysis Panel Seven Oaks General Hospital (SOGH) *Revised*

60.30.06c Appendix C; Dialysis Panel St. Boniface Hospital (SBH)

60.30.06d Appendix D: Dialysis Panel Brandon Hospital

60.30.06e Appendix E: HIV Testing Letter

60.30.07 Management of Hemodialysis Patients with Infectious Diseases Protocol including HBsAg Positive Patients *UNDER REVIEW*

60.30.08 Management of HBsAg Positive Hemodialysis Patients

60.30.09 Screening of Dialysis Patients for Hepatitis B, MRSA and VRE when Travelling *UNDER REVIEW*

60.30.12 Continuous Ambulatory Peritoneal Dialysis Protocol

60.30.12a Appendix A: Fluid Management Guidelines

60.30.12b Appendix B: CAPD Flow Sheet (Form #W-00353)

60.30.13 Continuous Cycling Peritoneal Dialysis Protocol

60.30.13a Appendix A: Fluid Management Guidelines

60.30.13b Appendix B: Automated Peritoneal Dialysis Record (Form #W-00354) *

60.30.14 Peritonitis Protocol

60.30.15 Care of Patient on Home Peritoneal Dialysis Protocol

60.30.16 Care of the Patient on Home Hemodialysis Protocol

60.30.19 Protocol for Transfer of Patients between Dialysis Units and/or Sites within the Manitoba Renal Program

60.30.19a Appendix A: Transfer Checklist for dialysis patients transferring between Winnipeg units or sites

60.30.19ai Appendix Ai: Form #W-00226 Manitoba Renal Program Transfer of PatientsBetween Dialysis Units and or Sites within the Manitoba Renal Program Checklist

60.30.19b Appendix B: Patient Transfer Letter

60.30.19c Appendix C: Hemodialysis Patient Permanent Transfer Algorithm

60.30.20 Protocol for Providing Acute/Emergent Dialysis Treatment Outside the Operating Hours of the Hemodialysis Units at St. Boniface Hospital – Renumbered to 60.40.13

60.30.21 Protocol for Providing Acute/Emergent Dialysis Treatment Outside the Operating Hours of the Hemodialysis Units at Heath Sciences Centre – Renumbered to 60.40.12

60.30.21a Addendum – Renumbered to 60.40.12a

 

60.40 Guidelines

60.40.02 Guidelines for Heparinization during Hemodialysis

60.40.03 Guidelines for the Prevention of Hypophosphatemia in Patients Receiving Nocturnal/Long Daily Hemodialysis – Renumbered to 60.50.02

60.40.04 Ordering & Returning Dialysis Supplies for Local Centre Dialysis Units

60.40.04a Appendix LC: Exchange Cart and Forms/Labels

60.40.05 Contacting a Patient who does not Attend a Hemodialysis Treatment *Under Review*

60.40.06 Guidelines for Managing Hospitalized Hemodialysis Patients Form W-00346

60.40.07 Guidelines for Patient Identification of Outpatients receiving services or procedures from the MB Renal Program Team

60.40.09 Guidelines for Medication Reconciliation

60.40.09a Appendix A: Guidelines for Medication Reconciliation – Medication Change Form

60.40.09b Appendix B: Guidelines for Medication Reconciliation – Medication Card

WORD DOC

60.40.09b Appendix B: Guidelines for Medication Reconciliation – Medication Card

PDF

60.40.09c Appendix C: Medication Change Form Letter

60.40.10 Guidelines for Assessing, Monitoring and Documenting Patient Care Pre, Post and During the Hemodialysis Treatment

60.40.10a Appendix A: Guidelines for the Treatment of Intradialytic Hypotension

60.40.10b Appendix B: Guidelines for the Treatment of Post Hemodialysis Hypotension

60.40.11 Guidelines for Assessing, Documenting and Verbally Reporting Patient Care at the Time of Transfer from One Health Care Provider to Another

60.40.11a Appendix A: Manitoba Renal Program Health Information Transfer Tool

60.40.12 Providing Acute/Emergent Hemodialysis Treatments outside the Operating Hours of the Hemodialysis Units at the Health Sciences Centre

60.40.12a Addendum to Protocol for Providing Acute/Emergent Dialysis Treatment Outside the Operating Hours of the Hemodialysis Units at Heath Sciences Centre

60.40.13 Providing Acute/Emergent Hemodialysis Treatments outside the Operating Hours of the Hemodialysis Units at SBH *Revised*

 

60.50 Home Hemodialysis