Entrustable Professional Activities

EPA 14: Dialysis

NP-EPA-14

Dialysis

  • AIM

    Prescribe and manage dialysis for patients with kidney failure

  • PCH

    Prescribe and manage dialysis for paediatric and neonatal patients with kidney failure

This activity requires the ability to:

  • select and interpret appropriate investigations
  • identify indications for kidney replacement therapy, and assess patients for suitability
  • arrange dialysis, and examine, monitor, and maintain access function
  • order and adjust dialysis prescriptions
  • discuss patients’17 goals of care to inform shared decision making about the prescription of individualised, patient-centred dialysis
  • prevent and manage kidney replacement therapy complications to improve morbidity, mortality, and quality of life
  • collaborate with other health professionals to develop a holistic care model to include physical, mental, social, and spiritual wellbeing.

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • establish goals of care, which may include slowing disease progression, improving function, and palliation
  • describe different dialysis modalities
  • select and interpret infectious investigations specific to dialysis patients
  • recognise individual patients’ factors that will contribute to the success of dialysis compared with comprehensive conservative care, such as comorbidities and frailty
  • ascertain volume status and determine dry weight/target weight for dialysis, and prescribe the rate of ultrafiltration either on the haemodialysis (HD) machine or the concentration of the peritoneal dialysis (PD) bag
  • apply knowledge of mechanisms of fluid delivery, machine mechanics and membrane physiology as they relate to dialysis modalities, including dangers of high ultrafiltration (UF) rates in HD patients and concentration of bags
  • monitor and manage vascular access
  • use strategies to optimise solute clearance
  • recognise the importance of residual kidney function and how to preserve it, linking to better modality and patient survival
  • document dialysis prescriptions as per local standards and health records
  • manage and develop long-term plans for access, transplantation, or independent dialysis
  • prescribe, adjust, and maintain high-quality, patient-centred dialysis
  • recognise and manage acute dialysis emergencies
  • develop advanced care plans, anticipating future needs in consultation with patients, families and/or carers

  • PCH

    • recognise the barriers to dialysis in very low weight infants
    • identify the technical issues and potential complications of dialysis in children and infants

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • describe methods of creating vascular access for HD and PD
  • manage common medical comorbidities in patients on PD or HD, such as unique diabetes characteristics
  • examine and assess the dialysis access, monitoring and troubleshooting access function or dysfunction
  • manage common symptoms of PD including:
    • constipation
    • exit site issues and technique issues
  • manage common symptoms of HD, including:
    • pre-dialysis overload
    • uremic symptoms of itch
    • post-dialysis symptoms of fatigue and dizziness
  • develop and implement plans to manage traditional and non-traditional cardiovascular system (CVS) risks specific to dialysis patients
  • determine if the patient requires transition to another access or modality due to underdialysis or technique failure

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • encourage and educate patients to be involved in their care, enabling supportive problem-solving environments
  • encourage patients’ access to self-monitoring devices and assistive technologies
  • communicate with multidisciplinary team members and patients, families and/or carers, including working closely with the:
    • dietitian, due to restrictions
    • dialysis coordinators, to improve quality of life with changes in timing, location of dialysis, and transport
    • clinical psychologists, to help cope with dialysis
  • use cognitive aids, such as pre-printed orders or care paths
  • discuss travel and holiday plans with patients on dialysis, including organising holiday dialysis using Big Kidney Red Bus (AU only)
  • discuss the therapeutic and lifestyle implications of home versus hospital-based dialysis with patients, families and/or carers

  • PCH

    • work with parents/carers of children on dialysis and recognise the impact of dialysis on the family
    • outline unique issues regarding dialysis initiation and maintenance in children and infants
    • communicate with educators to maintain educational outcomes, particularly for children on HD

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • provide lifestyle advice that is beyond healthy lifestyle, including fluid and diet restriction in HD patients, as well as high fibre diets in PD patients
  • work in partnership with patients and motivate them to comply with agreed care plans, including:
    • fluid restrictions
    • low phosphate diets
    • low salt and cholesterol due to high CVS risk
    • early presentations to kidney units when dialysis complications occur

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use innovative models of home HD and PD care using telehealth and digitally integrated support services and remote monitoring
  • review the anaemia, mineral and bone disorder (MBD), and CVS medications, and ensure patients understand their importance
  • support home HD and PD patients’ self-management by balancing between minimising risk with new safety monitoring and helping patients become more independent
  • participate in quality improvement processes examining issues impacting on patients’ abilities to undertake normal activities of daily living

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • participate in continuous quality improvement processes and clinical audits, particularly the regular review of blood results:
  • HD and PD access surveillance
    • solute clearance
    • electrolyte management
    • fluid assessment
    • anaemia management
  • identify activities that may improve patients’ quality of life, including help with transport, timing of dialysis, and other home support services

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • educate patients to recognise and monitor their symptoms and present early to their dialysis service

  • PCH

    • educate families regarding the management of dialysis in children
    • provide appropriate information to schools regarding children on dialysis

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use local CARI or KDIGO guidelines for chronic diseases management

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • prepare reviews of literature on dialysis advances to present at journal club meetings
  • search for and critically appraise evidence related to dialysis

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • search literature using Problem/Intervention/Comparison/ Outcome (PICO) format
  • recognise appropriate use of review articles

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • encourage patients from diverse backgrounds to join local networks to receive the support needed for long-term self-management, in particular the specific needs of Indigenous dialysis patients
  • recognise the statistics indicating a higher incidence of kidney failure resulting in dialysis in Indigenous populations

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • provide culturally safe chronic disease management

  • PCH

    • provide children and young people with information that is appropriate for their age and cognitive level

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • share information about patients’ dialysis plans, consistent with privacy law and professional guidelines about confidentiality
  • use consent processes before commencing dialysis
  • assess patients’ decision-making capacities about commencing and continuing dialysis, and appropriately identify and use alternative decision makers when needed
  • outline financial support options for dialysis, including travel and carer supports
  • support patients who choose to withdraw from or refuse dialysis

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • share information between relevant service providers
  • recognise the contribution of access surgeons, dietitians, dialysis nurses, and psychologists involved in patients’ care

  • PCH

    • discuss care plans with children and young people at an age- and cognition-appropriate level

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • implement stepped care pathways in the management of dialysis, including responding to underdialysis and clinical complications
  • recognise patients’ needs and the supports required on long-term health care journeys

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise personal limitations and seek help in an appropriate way when required, including from the dialysis team
  • synthesise patients’ information to determine dialysis solute clearance and solutions to non-achievement

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • lead monthly bloods meetings and dialysis quality assurance meetings with the multidisciplinary team
  • use a multidisciplinary approach across services to manage patients with the unique issues of dialysis patients
  • develop collaborative relationships with patients, families and/or carers, and the dialysis team, including dialysis nurses, educators, dietitians, and social workers
  • coordinate whole-person care through involvement in all stages of patients’ care journeys

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • organise the day-to-day management of HD and PD units
  • demonstrate an understanding of the range of personal and other team members’ skills, expertise, and roles
  • recognise the cost implications of different catheters, fluids, and systems in both HD and PD
  • participate in multidisciplinary team care for patients with chronic diseases and disabilities, including organisational and community care on a continuing basis, appropriate to patients’ context

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use health screening for early intervention and chronic diseases management
  • assess alternative models of health care delivery to patients with chronic diseases and disabilities
  • participate in government initiatives for dialysis, including promoting home dialysis to reduce hospital admissions and to improve patients’ quality of life
  • refer patients to available disability and chronic disease initiatives and services
  • contribute to the development of clinical pathways for dialysis management based on KHA-CARI and KDIGO guidelines
  • understand the implications of green dialysis, and work towards minimising environmental impact

  • PCH

    • outline the effect of hospital versus home dialysis on children’s education

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate awareness of government initiatives and services available for dialysis patients, including transport and medication funding, and how to access these
  • document dialysis prescriptions as per local standards, and help provide ANZDATA entries

  • PCH

    • work in partnership with educators of school-age children to maximise educational attainment