Patient & Family Guide 2015

Day Surgery Peritoneal Dialysis Catheter Insertion at the QEII

Bring this guide with you to all your appointments. This guide belongs to:

www.nshealth.ca

Contents What is day surgery?.................................................................................1 Your appointments...................................................................................2 Phone numbers.........................................................................................3 Point Pleasant Lodge (PPL)......................................................................4 Renal Access Clinic....................................................................................5 The week before surgery..........................................................................6 Pre-Admission Clinic.................................................................................7 Getting ready for surgery..........................................................................8 The day of surgery...................................................................................10 The Operating Room (OR).......................................................................11 After your surgery....................................................................................12 Things to remember for going home.....................................................12 Protecting your peritoneal dialysis (PD) catheter.................................15 Peritoneal dialysis and keeping your bowels regular after surgery 16 The Home Dialysis Unit...........................................................................17 Map of the QEII........................................................................................19

Day Surgery Peritoneal Dialysis Catheter Insertion at the QEII We have written this guide to help you and your family through your peritoneal dialysis (PD) catheter insertion steps. It will tell you about the care you will get and how you can help yourself before and after your surgery. Please ask your family to read the booklet as well. We hope it will be helpful as you get ready for your surgery. Please read this guide. You may want to use the space at the back of the booklet to make notes or to write down your questions. Bring this guide with you to all your appointments and to the hospital on the day of your surgery. There are a number of people who will be involved in your care. You and your family are the most important members of the team. Other team members are: your surgeon, resident surgeons, nurses in the Renal (kidney) Program, Renal Access Clinic, Pre-Admission Clinic, Same Day Surgery, Peritoneal (Home) Dialysis Unit, anesthetist (doctor who gives you medicine to put you to sleep before surgery), staff from the Continuing Care branch of Home Care, and clerical staff. Because there are so many people involved in your care, things may not always be clear to you. If you have any questions about your care, you may call the peritoneal dialysis nurse coordinator at .

What is day surgery? A day surgery patient will: • Come to the hospital on the day of their surgery, • Have surgery in the operating room (OR), and • Return home after surgery. If you live outside the Halifax area, arrangements will be made for you and your escort to stay at Point Pleasant Lodge (PPL) overnight.

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Your appointments Pre-Admission Clinic Your appointment at the Pre-Admission Clinic is on: Date: Time: at the site of the QEII Health Sciences Centre.

Peritoneal dialysis catheter exit site marking Your peritoneal dialysis catheter exit site marking appointment is on: Date: Time: at the site of the QEII Health Sciences Centre.

Continuing Care Coordinator Before your surgery, you will get a phone call from an RN (Continuing Care Coordinator) to talk about the care of your peritoneal dialysis catheter dressing when you go home.

Surgery Your surgery to have a peritoneal dialysis catheter inserted is on: Date: Time: at the site of the QEII Health Sciences Centre. Your surgeon’s name is:

Point Pleasant Lodge (if needed): Dates:

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Phone numbers • Renal Access Clinic/Transplant Clinic: 902-473-4359. • PD Nurse Coordinator in the Renal Clinic: . • Home (Peritoneal) Dialysis Unit: 902-473-6527 (local) or 1-800-268-8646 between 7:30 a.m.–3:30 p.m., Monday–Friday. • Between the hours of 3:30 p.m.–7:30 a.m. there is a Home Dialysis Nurse on call. If you are in the Halifax area, call 902-473-2220 and ask for the Home Dialysis Nurse. If you live outside the Halifax area call 1-800-268-8646. • Continuing Care Coordinator in your area: (The Continuing Care Coordinator in your area will call you.) • VON (Victorian Order of Nurses) in your area (The Continuing Care Coordinator in your area will give you this number.)

Point Pleasant Lodge (PPL): 902-421-1599 • Your surgeon’s office number is: • Pre-Admission Clinic: ›› Victoria General (VG) site: 902-473-5496 ›› Halifax Infirmary (HI) site: 902-473-3120

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Cancelling pre-admission visits If you can’t keep your appointment for pre-operative testing, please call 902-473-8410 (VG site) or 902-473-4929 (HI, Robie Street) between 7 a.m.–3 p.m.

Other numbers

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Point Pleasant Lodge (PPL) Point Pleasant Lodge is a not-for-profit hotel that has rooms for people who need health care in the Halifax/Dartmouth area and their families. PPL is within walking distance of the QEII Health Sciences Centre and is located at: 1121 South Park Street, Halifax, Nova Scotia, B3H 2W6 Phone: 902-421-1599 Fax: 902-429-9722 Website: https://pointpleasantlodge.com

Guest rooms • There is no cost to you for the room on the night before and the day of surgery. You will have to pay for any extra days at the following rates: ›› Single room - $40 plus tax ›› Double room - $60 plus tax • You must call Point Pleasant Lodge before 10 a.m. on the day of your arrival to guarantee your room. • You will be asked for your credit card number to reserve your room (for you and your guest). • The check-out time from Point Pleasant Lodge is noon. • There is a free shuttle service that runs Monday–Friday from 6 a.m.–6 p.m. from PPL to all hospital sites at the QEII Health Sciences Centre. The shuttle phone number is 902-830-0992.

Dining room (located on level 1) • Hours of operation: ›› Monday–Friday: 7 a.m.–1 p.m. and 4 p.m.–6 p.m. ›› Saturday: 8 a.m.–10 a.m., 11:30 a.m.–12:30 p.m., 4:30 p.m.–5:30 p.m. ›› Sunday: 8 a.m.–10 a.m., 11:30 a.m.–12:30 p.m., 4 p.m.–6:00 p.m. • You need to call ahead to let them know if you are on a special diet.

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Essential escort • An essential escort is a responsible (mature) adult who will stay with you after you have had an anesthetic (drug that causes you to not feel pain). • Your essential escort will have their room at PPL paid for by the hospital on the day of surgery. • If you have to stay at PPL the night before your surgery (if you live far away), your essential escort will have to pay $35. ›› Parking is on a first-come, first-served basis and is $10 plus tax per day. ›› High speed wireless Internet access is available for $10 plus tax per 24-hour period.

Renal Access Clinic Once you and your kidney doctor or nurse practitioner decide it is time for you to start dialysis, they will set up a time for you to see a surgeon about having a PD (Peritoneal Dialysis) catheter inserted. You will get a card in the mail with a date and time to see a surgeon for a health check in the Renal Access Clinic. On the day of your clinic visit, you will need to register at the Renal Access Clinic/ Transplant Clinic.

Renal Access Clinic/Transplant Clinic location 4th floor Dickson Centre, Room 4074, VGH site QEII Health Sciences Centre 5820 University Avenue, Halifax, Nova Scotia B3H 1V8 Phone: 902-473-4359 You will see a surgeon and an RN (Registered Nurse) at this visit. The surgeon will see you to make sure you are ready for surgery. The RN in the Renal Access Clinic will teach you about your PD catheter insertion surgery and go over all the facts in this guide with you. You will get a bag of peritoneal dialysis catheter dressing supplies to take home with you. This is so your VON will have the supplies to do your peritoneal dialysis dressing after your surgery.

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The week before surgery Getting your bowels ready for surgery One week before your surgery, you should start getting your bowels ready for surgery. It is important to have good bowel movements so that the bowel is well cleaned out before your surgery. Your nurse will give you prescriptions for the bowel medicines you will need to take one week before your surgery. During the week before surgery you should take: • Senokot one tablet twice a day If your bowels are not moving well by day 4, you should take Lactulose 30 mLs twice a day. You may take the Lactulose up to 4 times a day at the most. You should still keep taking the Senokot. • If your bowels are not working well (1-2 soft bowel movements a day) by day 5, call the PD Nurse Coordinator in the Renal Clinic at 902-473-5244. You will also be given a prescription for a topical cream (antibiotic). This cream will be used by the VON when they change your PD dressings after surgery. Stop taking these medicines one week before your surgery:

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Pre-Admission Clinic The Pre-Admission Clinic provides out-patient services before your surgery. At the clinic, staff will meet with you to help you get ready for your surgery.

Clinic locations The clinics are on the: • 10th floor of the Victoria General site • 5th floor of the Halifax Infirmary (HI, Robie Street entrance)

Clinic hours and contact details Monday–Friday (except for holidays) from 7 a.m.–4 p.m. • VGH Site: 902-473-5496 • Halifax Infirmary site: 902-473-3120

Purpose of the Pre-Admission Clinic The Pre-Admission Clinic will call you to book an appointment for a nursing review about 1-2 weeks before your surgery. You will also be seen by an anesthetist, a doctor who looks after people during surgery. You may need to have tests done, such as blood work, an EKG, or a chest X-ray. Your visit will last between 2-4 hours. You should bring: • All of your medicines, in the original bottles. This is very important. • Your health card. • Your private health insurance card if you have one. • Items to help pass the time, such as a book or a magazine. • A family member or friend, if you wish. This person could be someone who will be at home with you after your surgery, or someone who will help with your care.

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Getting ready for surgery If you are having a general anesthetic, local anesthetic, or regional anesthetic, please read the following. A regional anesthetic means an area of your body is frozen. A drug that will make you drowsy is given before the freezing. With a general anesthetic, you will be given a drug to put you to sleep for your surgery. • Do not eat any solid food after midnight the night before your surgery. • If your surgery is before 11 a.m., do not drink any liquids after midnight. • If your surgery is after 11 a.m., you may drink up to 8 ounces of clear liquids before 7 a.m. Examples of clear liquids are water, apple juice, clear tea, or coffee without milk. Do not drink milk or orange juice. You must not drink anything after 7 a.m. • We will ask you to check in to the hospital 3 hours before your surgery. • You may take your medicines as usual with sips of water. If you have diabetes, you will need to find out if you should take your medicine for diabetes. Please make sure that you talk about this with the nurse in the PreAdmission Clinic or your surgeon.

Health and hygiene • Call your surgeon before coming to the hospital if you have a fever, cold, or signs of the flu. • Get a good night’s sleep before surgery. • Take a full bath or shower and shampoo your hair the night before or the morning of surgery. • Nova Scotia Health Authority is scent-free for all patients, visitors, and staff. Do not use scented products. • Keep your PD exit site marking covered.

Medicines Follow the advice you were given at your Pre-Admission Clinic visit or by your surgeon about taking your medicines. • Tell your surgeon at least one week before your surgery if you are taking Aspirin® (ASA) or blood thinners. You may need to stop taking these medicines before your surgery. • If you take medicines, please bring them with you in their original bottles or containers. Tell the nurse that you have your medicines with you. 8

• Let your surgeon know if you are taking “over the counter” medicines and/or herbal products.

Smoking • Please do not smoke after your evening meal the night before surgery. • Smoking can cause more fluid to build up in your lungs, and you could have problems with your breathing.

Food and drink • Eat at least 3 good meals the day before surgery and have a bedtime snack (before midnight). • Healthy eating helps you heal faster. • Do not drink alcohol for 48 hours (2 days) before your surgery.

Dentures • You may wear your dentures to the hospital. • Just before you go the Operating Room (OR), you will take out your dentures and put them in a denture cup until after surgery. • If you have permanent bridges, caps, or crowns that can’t be taken out, or loose teeth, please tell your nurse.

Glasses/contact lenses • Bring a case to keep your glasses in when they are not being used. • We will take your glasses just before you go to the OR. You will get them back in the post-recovery area. • If you have contact lenses, it is best if you wear your glasses on the day of your surgery. If this is not possible, please bring your lens case and cleaning solutions. Always tell your nurse you are wearing contact lenses. They must be taken out before you go to the OR.

Hearing aids • If you wear a hearing aid, bring it and a storage case with you. • Depending upon how much hearing loss you have, we may let you wear it to the OR. It will be returned to you in the recovery area after your surgery.

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Valuables Leave all valuables (jewelry, money, credit cards, cheque books) at home. The hospital is not responsible for lost items. All jewelry, including toe rings, must be removed at home. Any item used to pierce a body part, such as the nose, belly button, tongue, or ear, must be taken out.

The day of surgery On the day of your surgery, please come to the Same Day Surgery Unit: ____ 10th floor, VG site (see map at end of this guide) ____ 5th floor, HI site (see map at end of this guide)

Check in to the hospital 3 hours before your surgery. Please bring your: • Hospital card • Provincial health card • Medicines in their original bottles or containers Bring any walking aids (crutches, canes, braces) that you have been told you will need. You may take your medicine as usual with sips of water. If you are not sure of what to take, check with your surgeon. • A nurse will talk with you about the details of your surgery. • You will be asked to put on a johnny shirt, dressing gown, and slippers. • Your clothes and other belongings will go in a locker. • You will have a wait before going to the OR. The nurse will be on hand to talk about any questions or concerns you have. He or she will review with you any part of this guide you need help with or are worried about. • Just before leaving for the OR, you will be asked to remove your dentures and eyeglasses. All jewelry, rings, studs, and chains should be left at home.

Your surgery may be cancelled if you are late. Delays in the OR may cause a change in your surgery. There is a chance that your surgery could be cancelled if there is an emergency. If this happens, your PD Coordinator will call you with a new surgery date. 10

The Operating Room (OR) • An OR staff member will take you to the OR. • A nurse will greet you and ask you some questions. This is to meet the standards of patient safety. • The staff will be dressed in masks, caps, and special green clothing to make sure the operating area is kept clean. • The OR is kept cool. We will give you a warm blanket. • The staff will help you move to an OR bed. A belt, like a car seat belt, will go around you to make sure you stay safe. • You will have an intravenous (IV) started before you go to sleep. • Three white disks will go on your chest and shoulder. This lets the anesthetist check your heart rate while you are asleep. • Depending on the procedure, a larger pad may be placed on your leg, back, or shoulder. This is a grounding pad, and is one more thing to keep you safe. • A clothespin-like tool, called an Oximeter Probe, may be put on your finger. It will help the anesthetist measure your oxygen levels during surgery. • Your surgeon and anesthetist will talk with you just before the anesthesia is given and you go to sleep.

Waiting room We have a waiting area for a relative or friend to stay in while you are in surgery or the recovery room.

Surgical Liaison Nurse (SLN) The SLN visits the waiting area several times during the day. This nurse will keep your family and friends up to date about your condition and progress. The SLN works 8 a.m.–4 p.m. every weekday except Wednesday, which is 9 a.m.–5 p.m.

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After your surgery Your surgery will take about 1 hour. You will be taken to a special recovery area until your anesthetic wears off. The nurses in the recovery area will often check your: ›› Blood pressure and pulse ›› Breathing ›› Intravenous (IV) ›› Dressings They will also ask you about your pain and give you medicine as needed. You may be sleepy, your mouth may be dry, and there may be a small plastic airway in your mouth to help you with your breathing. You may get oxygen for a short time. The patches put on your chest to check your heart may still be there. The clothespin-like tool may still be on your finger to measure your oxygen levels. There may be a small amount of drainage (liquid) on your dressings. Do not worry as this often happens. Your nurse will watch this and call the surgeon if needed. When you are more awake and pain-free, we will take you to one more recovery area where you will get ready to go home.

Last recovery area We will go over guidelines about your care at home and answer your questions. Your nurse will talk with you about your surgeon’s guidelines for after surgery. Some of these guidelines will include what type of activity you will be able to do when you go back home (housework, lifting, driving), dates and times for followup visits, and medicines, if needed. You will change into your clothing.

Things to remember for going home After a general anesthetic, regional anesthetic, or intravenous (IV) sedation:

For 24 hours DO NOT: ›› ›› ›› ››

Work with heavy machinery Sign legal papers Drive a car Drink alcohol 12

More information about going home: • If you are put to sleep during surgery (have a general anesthetic) or get a drug through your IV that will make you sleepy, you must plan for someone to drive you home (or to Point Pleasant Lodge (PPL)). After surgery, you will not be able to drive. • If you are taking a taxi, a family member or friend must go with you. When you are ready to leave the hospital, staff will call this person. You will not be able to walk home or take a bus. • You must have a responsible adult stay with you at home for 24 hours after your surgery. • If you have small children, plan for someone to help you for a few days if needed. • Bring loose-fitting clothing, such as a sweat suit and sneakers, to wear home. Anything that fits tightly may cause pain on your incision. • If you live outside the Halifax area, plans will be made for you and your escort to stay at PPL overnight. Your escort is a responsible family member or friend who will help you. • Bring the bag of peritoneal dialysis catheter dressing supplies to PPL with you. This is so the VON will have supplies to do your peritoneal dialysis catheter dressing the day after your surgery, if needed. • You also need to stop taking these medicines for one week after your surgery:

In case of emergency Go to the Emergency Department at the Halifax Infirmary if your dressing is unusually bloody or wet, if you have fever, chills, or very bad stomach pain. Keep in mind, it is normal to have some drainage on your dressing because you have an incision (cut). 13

Deep breathing and coughing exercises You will be asked to do deep breathing and coughing exercises when you are home: 1. Take a deep breath in through your nose. 2. Hold your breath for 2 to 3 seconds, by counting 1, 2, 3, in your head. 3. Blow the air out through your mouth. 4. Repeat this type of breathing in and out 6 or 7 times. 5. On your last breath in, hold it for a second and firmly cough. If you cough up any phlegm (mucous), repeat the exercise. These exercises help keep your lungs clear and make your breathing easier. The best time to do these exercises is about 20 minutes after you take your pain medicine. When doing these exercises, hold a pillow over any belly incisions. This will help support your incision and ease any pain.

Foot and leg exercises Exercising your feet and legs helps the blood to move around your body better. 1. Point your toes downward towards the floor, then relax your foot. Then point your toes upward to the ceiling, then relax. 2. Make circles with both ankles going to the right. Repeat the same going to the left. Relax. 3. Bend your knees up and down. Don’t do these exercises if your surgeon tells you not to. Please try to not stay in bed for long periods of time without moving your legs and feet. Try to do these exercises at least 5 times every hour.

Activity You may feel sore but do not let it stop you from doing things for yourself. Each day, you will feel like doing more. To help yourself move from a lying position in bed to a sitting position: • Roll on your side and swing your feet over the side of the bed. • Push yourself to a sitting position with your hand by pushing on the bed. Early walking also helps the blood to move around your body better. Walk as much as you can, but check with your surgeon first.

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Protecting your peritoneal dialysis (PD) catheter A PD catheter is a small tube that can bend. It is put into your belly (by a surgeon) in the operating room. It will be used for your dialysis.

Peritoneum

Care of your incision/exit Peritoneal site cavity

• Your first dressing will be left on for 7 days. This will give the PD exit site time to Catheter heal. • If your PD dressing becomes really wet or is falling off, the Home Dialysis Nurse will plan to have your PD dressing changed as soon as possible by the VON. • Once you leave the hospital, the VON or Home Care Nurse will visit your home every 7 days to change your dressing. • The VON will take out your staples, if you have them, about 10-14 days after your surgery. • Your dressing will be changed every 7 days for about 6-8 weeks. After this time, you will be taught the shower technique. • Sometime during the week after your surgery, more dressing supplies will be ordered for you by the staff in the Home Dialysis Unit.

DO: • • • • •

Keep your dressing dry. Wash your hands before you touch your dressing. Check your dressing every day to make sure it is dry and not falling off. Bend at the knees when you pick anything up. Hold your tummy when you cough. 15

• Call VON or Home Care if: ›› Your dressing falls off. ›› Your dressing feels wet or is sore underneath. ›› You have a fever, chills, or pain in your belly. • Take your laxative and stool softeners regularly (so you won’t have problems with bowel movements).

DO NOT: • • • • • • • •

Get your dressing wet. Soak in a bath tub. Shower or swim until your nurse or doctor says it’s OK. Wear tight clothing (belts, tight elastic waists, jeans). Lift anything over 20 lbs (heavy laundry, groceries). Chop wood, shovel snow, vacuum floors, or scrub tubs. Over extend your reach (such as reaching up into a high cupboard). Become constipated or strain when you have a bowel movement.

Peritoneal dialysis and keeping your bowels regular after surgery It is very important that you do not become constipated after having your catheter put in. Your bowel movements must be soft and regular if your catheter is to work well for peritoneal dialysis. Here is the routine you need to follow:

Daily: To keep your bowel movements soft, take Senokot (1-2 pills in the morning and 1-2 pills in the evening).

Day 2 - without a bowel movement: Take Lactulose (1-2 ounces in the morning and 1-2 ounces in the evening), along with Senokot (1-2 pills in the morning and 1-2 pills in the evening).

Day 3 - without a bowel movement: Take Lactulose (1-2 ounces every hour) until you have a bowel movement. Keep taking the Senokot as above. 16

If you are still constipated after 4 days, call your family doctor for instructions.

The Home Dialysis Unit The Home Peritoneal Dialysis Unit is on the 6th floor of the Dickson Building, VG site. It is an outpatient department that is open Monday-Friday from 7:30 a.m.– 3:30 p.m. The staff in the Home Dialysis Unit teach patients (and their families) to do their own peritoneal dialysis treatments.

Where will I stay for my peritoneal dialysis teaching? Residents of Nova Scotia If you live more than 40 kilometers from Halifax, we will book one room for you and your essential escort at Point Pleasant Lodge. Each of you will get $10.00 per day towards the cost of meals. The staff in the Home Dialysis Unit will give you a bagged lunch on your teaching days. Your essential escort will be with you when you are learning to do your peritoneal dialysis. The Home Dialysis Unit can only pay for one extra person. There is a shuttle (van) that will take you from Point Pleasant Lodge to the VG site, one round trip each day. Residents of Prince Edward Island (PEI) The PEI Liaison will book one room for you and your essential escort at Point Pleasant Lodge. Each of you will get $28.25 per day towards the cost of meals in the dining room at PPL. Order your boxed lunch from the dining room at the lodge on the day before a planned teaching day. You must pick up your boxed lunch at breakfast and take it with you to the Home Dialysis Unit. Your essential escort will be with you as you are learning to do your peritoneal dialysis. The Home Dialysis Unit can only pay for one extra person. There is a shuttle (van) that will take you from Point Pleasant Lodge to the VG site, one round trip each day. • The Unit Clerk in the Home Dialysis Unit will book you and your essential escort into Point Pleasant Lodge for the night before your first peritoneal dialysis teaching session. • To make sure your room is held for you, please call Point Pleasant Lodge at 902-421-1599 before 10 a.m. on the day you plan to arrive. • On the first day of your peritoneal dialysis teaching sessions, please come to the Home Dialysis Unit between 8 a.m.–8:30 a.m.

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About the peritoneal dialysis teaching Teaching takes about 5 working days. You will work with one nurse as you learn to do your own peritoneal dialysis exchanges. The Home Dialysis nurse will start by showing you and explaining the steps for peritoneal dialysis. You will then practice until your nurse feels you are able to do dialysis safely on your own. You will not be on your own until your nurse feels you are ready. You will be given a peritoneal dialysis guide to keep. It has written directions for all the steps you need to know. This guide will help you when doing your own dialysis at home.

Supplies The Home Dialysis Program will give you all the supplies for peritoneal dialysis. You do not have to pay for these supplies. Supplies for peritoneal dialysis will be sent to your home every month. A person from the company will call you one week before the supplies are sent to find out what you need. These supplies are given to everyone who does peritoneal dialysis. You will be asked to get your own heating pad and scissors. Bring them with you to Point Pleasant Lodge when you come for peritoneal dialysis teaching.

Follow up When your peritoneal dialysis teaching is over, you become part of the Home Dialysis Program. One of the kidney doctors will follow up on your care. You will go back to the Home Dialysis Unit in about one month for a check-up. Your one month check-up will be about 4-5 hours. The nurse will go over all your PD procedures with you to make sure you are doing them right. The nurse will also teach you how to do the “shower technique” for your PD catheter. You will also see the doctor. If your kidney doctor feels you are doing well, your check-ups will be every 3 months.

Call the Home Dialysis Unit if you have any questions or concerns • The Home Dialysis Unit is open Monday–Friday from 7:30 a.m.–3:30 p.m. • Call 902-473-6527 or 1-800-268-8646 if you live outside the Halifax area. • A Home Dialysis Nurse is on call from 3:30 p.m.–7:30 a.m. • If you are in the Halifax area, call 902-473-2220 and ask for the Home Dialysis Nurse. If you live outside the Halifax area, call 1-800-268-8646.

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Looking for more health information? Contact your local public library for books, videos, magazines, and other resources. For more information go to http://library.novascotia.ca Nova Scotia Health Authority promotes a smoke-free, vape-free, and scent-free environment. Please do not use perfumed products. Thank you! Nova Scotia Health Authority www.nshealth.ca Prepared by: Renal Program & Same Day Surgery Unit © Illustration by: LifeART Super Anatomy 4 Images, Copyright © 1994, TechPool Studios Corp. USA Designed by: Nova Scotia Health Authority, Central Zone Patient Education Team Printed by: Dalhousie University Print Centre The information in this brochure is for informational and educational purposes only. The information is not intended to be and does not constitute healthcare or medical advice. If you have any questions, please ask your healthcare provider. WQ85-1226 Updated December 2015 The information in this pamphlet is to be updated every 3 years or as needed.