External+Renal+Service


 * __ CRGH Renal Unit: EXTERNAL RENAL SERVICES __**

The External Renal Services (ERS) in the Renal Unit at Concord Repatriation General Hospital aims to coordinate the care of patients who are:
 * Aim **
 * complex outpatients under the care of the Renal Unit (eg: recent discharges who are transitioning back to care by LMO or Specialist Rooms) who need frequent review
 * inpatient consultations from other Units within CRGH


 * Eligibility for referral to the External Renal Service **
 * Patients under the care of the Consultant Nephrologists of Concord Repatriation General Hospital
 * A consultant nephrologist has been identified who will supervise care of the patient delivered by the ERS. The identified consultant nephrologist is expected to be the patient’s primary nephrologist except in circumstances such as leave of the patient’s primary nephrologist. When the primary nephrologist is not available the consultant who is on-call for consultations will be responsible.
 * Presence of specific and concrete goal(s) of review for each appointment with ERS. Examples of goals of review may include:
 * Adjustment of ideal body weight
 * Titration of immunosuppressives
 * Decision on the need for ongoing dialysis in patients with resolving acute renal failure


 * Responsibility for the ERS **
 * The Nephrology Advanced Trainee is responsible for supervising the running of the ERS and the duties of the Dialysis Resident relating to the ERS. When there are two such trainees at CRGH, one will be designated as the person responsible.
 * The RMO in Dialysis Resident is responsible as the first point of contact when patients arrive for review, maintaining the current Powerchart list of patients being reviewed by the ERS, maintaining the ERS Master List of patients reviewed by the ERS and arranging for notes of patients discharged from the ERS to be sent to Medical Records.
 * If there is no assigned Dialysis Resident or the Dialysis Resident is absent, the Nephrology Advanced Trainee will perform the duties of the Dialysis Resident.


 * Referral process **
 * Ward patients who are going to be discharged are referred by the inpatient team (or one of the Consultant Nephrologists) to the Nephrology Advanced Trainee.
 * The attached referral form is completed by the inpatient team.
 * After approval by the Nephrology Advanced Trainee, the referral and a copy of the discharge referral are placed in the ERS folder kept in 4N
 * Outpatients can be referred by a Consultant Nephrologist by notifying the Nephrology Advanced Trainee. Sufficient information should be provided in this referral to allow completion of the attached referral.
 * Once accepted to the ERS program:
 * a definite date must be arranged for the first review.
 * The RMO in Dialysis adds the name of the patient to the ERS current patient list kept in Powerchart.
 * The Dialysis Resident adds the name of the patient to the ERS Master List of patients ever seen by the ERS (an Excel sheet kept on a computer in 4N), entering the name and MRN of the patient, the name of the Consultant Nephrologist supervising care, the patient’s date of birth, the date of referral, the date of each visit and (ultimately) the date of discharge from the service.


 * Process of ERS review **
 * The patient arrives in 4N.
 * The nursing staff contact the RMO in Dialysis.
 * The patient is reviewed by the RMO in Dialysis with respect to the pre-identified specific goal of ERS review.
 * If not previously determined, the RMO in Dialysis determines whether the Nephrology Advanced Trainee should also review the patient.
 * The RMO in Dialysis or the Advanced Trainee contacts the Consultant Nephrologist and a decision on next steps is made, including the need for further review or suitability of discharge from ERS.
 * The RMO in Dialysis discusses the outcome of the review with the patient, updates the patient’s medical notes and updates the ERS Master list.


 * Weekly review of service **
 * All patients under the care of the ERS are to be discussed at the Renal Unit Multidisciplinary Meeting (Monday 2pm)
 * The Dialysis Resident and the Nephrology Advanced Trainee review the records of all patients currently under the care of the ERS to ensure the following is up to date:
 * Any patients who have missed appointments have been contacted
 * The ERS Master List is up to date
 * All current patients are on the ERS Powerchart list.
 * Patients discharged from the service are deleted from the Powerchart list
 * Records for patients discharged from the service have been sent to Medical Records.