New NP going into nephrology

  1. Hello, so I just got offered a position at an educational institution seeing patients for outpatient dialysis. I graduated in June 2017 and this will be my first job. The nephrologist said he would train me for 3-6months and go from there depending on my comfort level. I'm still filling out paperwork and doing background check, so I won't start for another month or two. I plan to just review all things renal in the meantime. Can anyone tell me what their day is like as a nephrology NP? Do you have any suggestions/advice/tips regarding this specialty as well as starting out as a new NP? Thank you so much.
  2. Visit penNpaper profile page

    About penNpaper, MSN, NP

    Joined: Aug '15; Posts: 5; Likes: 2


  3. by   traumaRUs
    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:

    M-W-F 0500-0900
    MWF 1000-1500
    MWF 1600-2300
    TTS 0500-0900
    TTS 1000-1500

    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.
    Last edit by traumaRUs on Nov 5, '17
  4. by   penNpaper
    Thank you for the thorough and descriptive reply, I appreciate that! The information is very helpful. And thanks for the heads up on on CMS and AKIs. I have a few more questions and will ask them here in case anyone else is curious also.

    Since you have been working as a nephrology APRN for 11.5 years, what are the things you enjoy about working in this area? Is there anything you don't like so much?

    Regarding #3 with the 4 patient visits, how do you space out the visits. I am guessing you see them once per week? You mentioned that one visit is usually done by the MD and the other three can be by the NP/PA-- does that mean the NP/PA essentially sees a patients for 3 weeks and is off the 4th week when the MD makes their visit?

    In your practice do you manage any acute/primary care issues of patients or do you refer them to their pcp?
  5. by   traumaRUs
    Good questions.

    I'm actually changing jobs: going from this neph practice to a big hospital system to work in their heart failure service. The reason? I want to go back to the hospital. I love this practice but would like to see more acute issues. I like establishing a relationship with most of the pts and there are some pts I'm sincerely going to miss seeing. However, the chronicity does get to you too - those pts who are not on the transplant list will die on dialysis and they know it. This relationship is much more of a partnership then most NP/pt relationships.

    You can ideally see pts once/week. However, to be honest many of my patients don't come to HD often so I have to do multiple visits and I try to get as many visits as I can as the goal is that 90% of my pts will have 4 visits/month. The doctors vary their days so no, (unfortunately) you don't get the fourth week off - lol.

    Yes, I manage as much primary care as possible: pneumonias, other resp distress, DM, HTN, wounds and as much as I can do.