Well....I've been a nephrology APRN for 11.5 years now. I'll be glad to help. I also do dialysis rounding (although up until recently we were also in the hospital). I work for a large 20+ MD, 8 mid-level practice. We have our own vascular access center. There are 7 of us that do nothing but dialysis rounding. This covers 17 dialysis units which range in size from 6 chairs to 32 chairs. We each care for approx 130 patients in several units. At times I have cared for up to 250 patients but this is not sustainable if you have to travel.
This was my first APRN position also - my nursing background was ED and ICU. I had 4 months orientation with an NP and also spent quite a bit of time with several MDs. It is very autonomous as (due to billing), only one provider can bill for a visit per day. Our dialysis units are open from 0500-2300 Monday thru Saturday. You have between 3-4 hours to see a shift of pts. The shifts are staggered so that "on-time" gives the staff the required (by CMS) time between patients. Patients generally dialyze 3-6 hours - depending on their size. The shifts are generally:
So you have time to see the pts.
1. These are chronic pts who are SICK! Even the very young ones (17-30) are SICK! They get fluid overloaded especially if they are anuric. Its not a fun life. They do not always follow our instructions but in their defense they have been ill for a very long time usually. If they aren't on the transplant list, dialysis will be their life. However, CMS does encourage and pays more actually if they do home dialysis: either home hemodialysis or home peritoneal dialysis.
2. Your pts will have many comorbidities including DM and HTN (the two big reasons Americans have ESRD).
3. Fortunately in the US, Medicare covers ESRD pts. If the pt has never worked or not worked long enough to pay into Medicare, Medicaid pays. Important to realize that these pts are on a lot of meds - so keep copays low if possible. CMS cont to add meds to the "bundle
". CMS pays the nephrologist for caring for the dialysis pt. It is recommended that the nephrologist provide 4 visits/month - one is usually done by the MD and the other three can be done by the NP/PA. The way the payment works is that you get X-amt (the amt changes yearly) for the first visit, then you get a smaller x-amt for the second visit, you get NOTHING for the third visit but you get another small x-amt for the 4th visit. So - you can see why its important to get 4 visits. Your visits will usually be focused on one of these topics:
anemia - hgb goal of 10-11 - weekly hgb are drawn. Ferritin, tsats, are also drawn frequently.
bone/mineral metabolism - ensuring pt has phos binders and takes them appropriately - you will hear lots of constipation/diarrhea complaints regarding binders - and there are multiple binders that can be tried
fluid balance - usual fluid restriction is approx 32 oz. If they urinate >8 oz/day, then the additional fluid can be added in. This is very difficult for pts to manage. Fluid gain goal is 1kg/24 hour day.
BP - mostly fluid mediated: if you get the excess fluid off BP normalizes. Not unusual for pts to be on up to 5 BP meds. Sometimes very difficult to control. Compliance with complicated med regimen sometimes problematic.
I personally do med reconciliation with pts as these pts see many different providers. All our pts know that if they go to any other provider, call us prior to filling meds as most need to be renally dosed.
4. At the dialysis units (at least at Fresenius and Davita - the two big commercial dialysis companies) you will have a unit or facility manager (may or may not be a nurse), charge nurse, social worker and dietician - they are all very knowledgeable and helpful.
5. Bone and mineral metabolism
are big deals to our pts: high phosphorous levels leach calcium out of the bones, making it very easy for these pts to fracture bones.
6. CMS now pays the outpt dialysis units to care for AKI (acute kidney injury) pts also (this just started Jan 2017). So you will also have AKI pts who are treated differently then ESRD pts: these pts should not be "dried out" as the goal is that they will (hopefully) regain function. So, fluid restriction is not as strict, you will do weekly CBC/RFP (renal function panel) and assess and document differently on these pts. They will be dialyzing with a PC (permcath).
7. All renal failure pts are considered immunocompromised so infection is always a huge risk especially if they have a PC. We draw BC (blood cultures) and give Vancomycin (for gram + bacteria) and also something to cover gram - flora, usually Gent/Tobra - these are readily available at the dialysis units. These pts become septic VERY VERY quickly - you can almost watch it.
Well - hopefully this will help with some general info - if I can help further, please don't hesitate to PM me or answer here.