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KCER Provider Needs Assessment - February 2017
Coordinated by the Kidney Community Emergency Response (KCER) Program
1.
Please enter the state or territory where your clinic provides treatment:
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2.
Please select your discipline:
Nurse
Patient Care Technician
Facility Administrator
Social Worker
Dietitian
Physician
Biomed Technician
3.
Do you provide emergency preparedness resources in languages other than English?
Yes
No
If 'yes', please identify the other languages:
4.
How do you educate patients in your clinic about emergency preparedness?
Video
Written (i.e., flyer, booklet, handout)
Face-to-Face (i.e., talking with staff, doctor, or other patients)
Internet (i.e., website or email from facility)
Other (please specify):
5.
In the last year, how often have you educated your patients on emergency preparedness?
One time
Two times
Three times
More than three times
6.
In the last year, how often has your clinic conducted or participated in a disaster drill or exercise?
One time
Two times
Three times
More than three times
Our facility did not conduct or participate in a disaster drill
7.
My patients have a good understanding of where to go, what to do, and whom to contact in an emergency.
Strongly agree
Agree
Disagree
Strongly disagree
Strongly agree
Agree
Disagree
Strongly disagree
8.
My patients have a good understanding of the 3-day emergency renal diet.
Strongly agree
Agree
Disagree
Strongly disagree
Strongly agree
Agree
Disagree
Strongly disagree
9.
Do you educate your patients about medications that can help reduce their potassium level, such as Kayexalate?
Yes
No
10.
Does your clinic provide a "grab and go" packet for each patient?
Yes
No
11.
If yes, what does it contain? Check all that apply:
Treatment summary information
Medication list
Most recent plan of care
Current facility contact information
Copy of the 3-day emergency renal diet
Toll-free emergency number for your dialysis facility or corporate
Other (please specify):
12.
Please provide any additional comments you would like to share, including any specific challenges or best practices related to emergency preparedness.
