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

30.10.03         Providing Hemodialysis without Heparinization 

30.20             Dialysate Delivery System

30.20.01         Use of Fresenius 2008K Delivery System *No longer in use*

30.20.03         Responding to Fresenius 2008K Blood Leak Alarms *No longer in use*

30.20.04         Fresenius 5008 ISO Ultrafiltration (Sequential Therapy)

30.20.05         Fresenius 2008K Air Detector Alarm Troubleshooting Guide *No longer in use*

30.20.07         Use of Fresenius 5008 Delivery System *Revised*

30.20.08         Fresenius 5008 Air Detected Below the Venous Bubble Catcher  *Revised*

30.20.09         Fresenius 5008 Blood Leak Alarms; responding to (30.20.03b) *Revised*

30.20.10         Changing the Extracorporeal circuit during hemodialysis treatment for the Fresenius 5008 delivery system

30.20.18         Fresenius 5008 Recirculation of Extracorporeal Circuit with Normal Saline and with Blood  *Revised*

30.20.19         Single Needle (Click-Clack) Hemodialysis for Fresenius 5008 Dialysis Delivery system 

30.30.             Vascular Access

30.30.01         Venipuncture of Arteriovenous Fistual/Graft  *Revised*

30.30.02         Accessing and Locking Dialysis Central Venous Catheter (Anticoagulant/Thrombolytic/Antibiotic Locking) *Under Review*

30.30.03         Establishing and Maintaining Buttonhole Venipuncture Sites

30.30.04         Use of Closed Needleless Access Device with Hemodialysis Central Venous Catheters (CVC)

30.30.06         Hemodialysis Central Line Dressing Change 

30.30.07         Fresenius 2008K Recirculation of Extracorporeal Blood Circuit *No longer in use*

30.30.08         AVF/AVG Vascular Access Assessment 

30.30.09         Obtaining Blood Specimens Pre and Post Hemodialysis *Revised*

30.30.11         Removal of Non-Tunnelled Hemodialysis Central Venous Catheters *Revised*

30.30.12         Alteplase for Clearing Hemodialysis Catheter Thrombosis using the Push (30 minute) Method

30.30.13         Alteplase IV Infusion for Clearing Hemodialysis Catheter Thrombosis 

30.30.14         Antibiotic Lock Preparation Procedures for Hemodialysis Central Venous Catheters 

30.30.15         Collection of Blood Culture Specimen From a Hemodialysis Access *Revised*

30.30.15a       30.30.15 Appendix A: Summary Poster Gold Standard Blood Cultures *New*

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

30.50.01         Use of Lauer Aquaboss EcoRO Dia II HT Reverse Osmosis System (RO) Health Sciences Centre – Central Dialysis Unit & Sherbrook Dialysis Unit, St. Boniface Dialysis Unit, Seven Oaks Dialysis Unit, Pine Falls Dialysis Unit, Dauphin Dialysis Unit

30.50.02        Fresenius AquaC UNO H Reverse Osmosis System; use of

30.50.04        Use of Lauer Aquaboss Eco RO Dia 70 Reverse Osmosis System 

30.50.05       Fresenius AquaUNO Reverse Osmosis System; use of 

30.50.06        Use of Reverse Osmosis System via the Multi-Media Interface Nurse Remote Panel (Boundary Trails, Island Lake, Selkirk, Swan Valley Health Centre, Ashern Lakeshore Hospital and Flin Flon)

30.70              Standards of Care

30.70.01        Obtaining Blood Samples for International Normalized Ratio (INR) from Central Venous Catheters *Revised*

30.70.02        Intradialytic Blood Product Administration 

30.70.08        Discharge Criteria for Hemodialysis Patients from the Dialysis Unit following Treatment

30.70.12         Administration of Intradialytic Parenteral Nutrition to the Hemodialysis Patient *Under Review*

30.70.13         Calcium chloride additive for Hemodialysis Patients 

30.70.13a      Attachment A:  Calcium Chloride for Haemodialysis CACL-0827

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)

60.10.05        Hemodialysis Renal Medication Flow Sheet Standard 

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

60.10.05B    Hemodialysis Renal Medication Flow Sheet Standard (eKHR) *Revised*

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


# 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


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


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

60.50.01       Bellco (Formula 2000)—Delivery System; Use of 

60.50.02       Guidelines for the Prevention of Hypophosphatemia in Patients Receiving Nocturnal/Long Daily Hemodialysis by utilizing phosphate additives

60.50.04       Changing the Dialyzer During Treatment with the Formula Delivery System

60.50.05      Ordering Dialysis Supplies for Home Hemodialysis Patients

60.50.05a    Ordering Dialysis Supplies for Home Hemodialysis Patients

60.50.06      Single Needle Double Pump on the Formula 2000

60.50.10       Use of the Horizon Mini E Centrifuge