All Physicians’ Forms

Please ensure that your patients are aware that you will send their personal health information to another organization (Northwest Kidney Centers). This will allow us to prepare records and offer information, counseling and education services.

CKD
Nephrologists may refer CKD patients for Choices class (modality education); Eating Well, Living Well (nutrition education for CKD patients) or Next Step class covering either home hemodialysis, peritoneal dialysis or transplant by contacting the CKD Program at 206-292-2771, ext. 1082.

New Patient Referral
Northwest Kidney Centers Active and Courtesy medical staff may refer Stage 5 CKD patients to Northwest Kidney Centers by submitting the following to the Admitting and Patient Services Supervisor to the fax number identified on the Dialysis Patient Referral Form:

• Dialysis Patient Referral form
• History & Physical, Discharge Summary or Renal Progress Notes within 30 days
• HbsAg, total anti-HBc and anti-HBs drawn within 30 days
• Chest X-ray within 30 days
• Signed Initial Physician’s Orders

Completing the Referral Form
Complete responses on the referral form are essential to fulfill the CMS’s reporting mandate. On the referral form, there should be documentation of:

• Chronicity or progressive renal failure: This can be done with an old creatinine, historical information, ultrasonography results, presence of radiographically manifested osteodystrophy, renal biopsy results or other evidence that the patient has chronic, progressive renal disease.
• Rationale for beginning renal replacement therapy: Evidence that renal replacement therapy was required to maintain life (such as symptomatic uremia, intractable ECFV excess, wasting/malnutrition, metabolic acidosis, hyperkalemia unmanageable by conservative measures, etc.) should be provided.
• Evidence that the patient does not have acute renal failure: If this information is not apparent from the data provided, you will be asked to clarify this issue.
• Record all patient co-morbidities on the 2728 form. Note TB exposure. Northwest Kidney Centers must document tuberculosis exposure when a patient is admitted to the dialysis facility. We do require a recent chest x-ray within 30 days of admission.
• Code Status-Please discuss this topic with your patients when they begin their dialysis treatments and mark it appropriately on the referral form. Note that orders for no resuscitation need to be renewed yearly.
• Indicate whether or not you have addressed the issue of transplantation with the patient before they started dialysis and if not, please indicate the reason in the checkboxes provided.
• Your signature on the referral form serves as your endorsement of initiation of Northwest Kidney Centers’ standing orders for your ESRD patient.(Standing Orders do not apply to AKI patients.)

History and Physical
To assure appropriate care and patient safety, the Conditions for Coverage require a pre-initiation nursing review of a new patient’s clinical history (V715). The nurse must determine whether any critical clinical issues exist which might make initiation of dialysis problematic. We need at least one of the following completed within 30 days of start of dialysis:

• A Medical history and physical examination; or
• A discharge summary from a recent admission which includes a current medication and problem list; or
• Detailed nephrology progress notes with a current medication and problem list.

Hepatitis B
Hepatitis B surface antigen results are required for admission to Northwest Kidney Centers and can be no more than 30 days old. Please note these results on your referral form, and provide the hard copy as well. Hepatitis B core Ab is now required and will be collected at the time of a patient’s arrival if not provided as part of the referral (V124).

Transfer In
Transfer-in patients are accepted upon referral by a member of the Northwest Kidney Centers Active or Courtesy Medical staff using the Northwest Kidney Centers Referral Form. Records are also required from the sending facility.

Acute Non-ESRD Patients Requiring Dialysis
The same referral form and process is used for acute non-ESRD patients requiring dialysis.

Please send the following:

• Dialysis Patient Referral form (selecting “Acute” rather than “ESRD”)
• Complete medical summary for the CMO to review
• HbsAg, total anti-HBc and anti-HBs drawn within 30 days
• Chest x-ray within 30 days
• Initial Acute Dialysis orders — No standing orders will be accepted for acute (non ESRD) patients.

All standing orders, including chronic standing and initial orders are available on:

1. Knet under “Clinical”,
2. NKC website www.nwkidney.org under “For Physicians and Staff” – “For Nephrologists” – “Physicians’ Forms.”

Orders requiring CMO Signoff – Please contact the CMO directly:

• Nonstandard bath
• DFO (desferoxamine, Desferal)
• Unusual antibiotic or drug regimen
• Any off-menu dialyzer

Dialysis Orders Post Hospital Discharge

Verify dialysis orders with Northwest Kidney Centers facility the patient is going to post discharge (including dialysis prescription, bath, dry weight, etc.)

Verification of Orders for Medical Staff with cyberREN:

• Orders must be verified by the physician within 30 days. Verification means that you have seen the order. If you do not agree with the order, you still need to verify that you have seen it. You should then call, fax or send a new order. In cyberREN, there are three ways to communicate an order. You can write the order as the physician (which automatically verifies the order,) have your office staff call or fax the order to the Unit, or call the Unit directly with the order. Once the order is in cyberREN, Northwest Kidney Centers staff will carry out the order as directed. Orders could be completed before they are verified.
• The attending nephrologist is responsible for verifying orders in cyberREN placed by covering nephrologists, whether active or courtesy staff.

Delinquency in Verifying Orders

To be in compliance with Medicare regulations, nephrologists with unverified orders >30 days will be notified that the orders must be verified by the end of the working day, or privileges for verbal order submission will be suspended until they are in compliance. A letter will be placed in the medical staff file that privileges for verbal orders have been suspended until the physician has verified their orders and is in compliance with Northwest Kidney Centers policy.

Nephrologists with unverified orders >60 days, after having been given a warning notice and written letter of suspension of verbal orders, will be notified that  Medical Staff privileges have been suspended until they are in compliance, and a letter will be placed in the credentialing file.

Faxed Orders

Northwest Kidney Centers has developed a fax form to communicate more effectively with you and your office staff. This form is used by all Northwest Kidney Centers facilities.

Dialysis > 3 Times Per Week

It is critical that patients receiving > thrice weekly treatments are reviewed monthly for accurate and specific documentation of ongoing need. (i.e., volume, metabolic problems. pericarditis, calciphylaxis.)

If the patient requires an extra treatment during the month for patient or procedure-related matters (i.e., frequent treatment interruptions due to bathroom breaks, poor catheter function, machine malfunction, etc.) the reason should be noted and an ICD-10 code provided. Neuropathy is not an acceptable rationale for more than three treatments per week.

Issues related to inadequate delivery of dialysis dose should be indicated as “inadequate” dialysis.

DNR Policy

Northwest Kidney Centers supports the belief that the patient is the primary decision-maker for personal health care. Every patient of Northwest Kidney Centers will receive life-saving intervention unless otherwise specified by the attending physician. A “DNR” status given by a physician indicates that a patient and/or family or legally authorized person acting in the patient’s best interest and physician have agreed that no resuscitative measures will be taken in the event of a respiratory or cardiac arrest. A DNR order should have an advance directive attached or obtained from patient or designee. Verbal DNR orders will not be accepted.

Death With Dignity Act

Northwest Kidney Centers will not provide life-ending medication based on the November 2008 “Death With Dignity Act.”  In keeping with our mission and values, Northwest Kidney Centers physicians, employees, independent contractors and volunteers, including our hospital services staff and pharmacy staff, will not assist a patient by providing life-ending medication on our premises or while acting on behalf of Northwest Kidney Centers.

Dialyzers

Dialyzer options include Revaclear/Revaclear Max.

Prior to changing a patient to a Revaclear Max,, please try to maximize other components of the patient’s dialysis prescription, including time, blood flow rate (as is possible given access), and dialysis flow rate.

In the instance that a physician feels strongly a patient requires a different dialyzer, this should be discussed on an individual basis with the CMO.

Clinical Report from Ascend

Per Ascend policy, critical labs are called to the unit between 6 a.m. and 10:45 p.m. After hours or in case of closure, Ascend calls critical labs to the physician or their covering provider.

Physicians are required to provide a diagnosis with an ICD-10 code when ordering an antibiotic or other medication to be administered intravenously on dialysis (except routine medications such as an ESA, iron or vitamin D analog).

Generic Orders for Medications

Use of generic orders for medications avoids potential errors in entry of dose, interval and description. Please use the generic dropdown in CyberREN, and write out your order. The order will be entered in CyberREN field by the nurse.

Albumin IV

IV albumin may be given for volume support to patients whose serum albumin concentrations are <2.6 g/dL. If the patient’s albumin is ≥ 2.6 g/dL, please enter a comprehensive note in CyberREN explaining the potential need for this specific therapy. A maximum of 3 doses will be allowed.

Cefazolin

Due to concern about the potential risks to bacterial ecology from repetitive use of empiric vancomycin therapy Cefazolin is available as an alternative choice in empiric therapy of presumed gram-positive infections.

Deferoxamine (DFO)

The CMO will review orders for DFO in discussion with the primary physician, so that therapies can be individualized. This policy stems from the infrequency of these orders, the potential for other clinical strategies which accomplish similar results, and the small, but finite risks (Yersinia, optic neuritis, etc.) of repetitive administration, particularly large doses.

Levocarnitine

Previously it was felt that there were two indications for L-carnitine supplementation: 1) ESA resistance and 2) intradialytic hypotension.  However, data has not supported the latter indication.  Several consensus conferences as well as the NKF-K/DOQI  groups concluded that routine carnitine supplementation in dialysis patients is NOT justified by available data though it may be considered for intradialytic hypotension, muscle cramping, cardiomyopathy or anemia unresponsive to ESA. Evidence is not strong enough to endorse the use of L-carnitine for any of the indications for which it has been recommended.  If it is administered, the course should be limited to 3 months and documentation of benefit should be obtained.

New orders for Levocarnitine: Fax the Levocarnitine Administration Order Form to Pharmacy at 206-343-4884.

Renewal orders for Levocarnitine at 3 months:  Fax the Levocarnitine Administration Order Form to Pharmacy at 206-343-4884.

When seeing patients in the dialysis facility, be aware of areas which are considered microbiologically clean or dirty, the need for hand hygiene when entering and exiting the clinical areas of the facility and for appropriate lab coat or gown coverage when interacting with the patient if potential blood or body fluid exposure is possible.

C. Diff

Some select NKC units have private rooms that can accommodate C difficile patients as necessary.

Hepatitis B Positive Patients
Dialysis for HbsAg-positive patients will be provided in-center or at the patient’s home. Two centers have Hepatitis B isolation available. The Conditions for Coverage require us to obtain hepatitis B core antibody (anti-HBc) as one of the routine hepatitis serologies before a patient starts care in a dialysis facility. Patients with the combination of positive hepatitis core antibody (+anti-HBc), negative surface antigen (-HbsAg) and negative surface antibody (-anti-HBs) do not require isolation because surface Antigen is not detectable. V124

VRE/MRSA
Patients infected or colonized with multi-resistant microorganisms such as MRSA or VRE may require precautions during dialysis. Immediately upon notification that a patient has cultured positive for MRSA or VRE, the Infection Control Department will be notified. A decision will be made by the Infection Control Department in conjunction with the nephrologist or other appropriate physicians if contact isolation is necessary. Decisions regarding infection precautions will be made based on containability of potential sources of organisms, the hygiene of the patient, and whether the patient can comply with a simple wound-care regimen.

QA/PI (Quality Assessment/Performance Improvement)

A critical component of patient care oversight is facility-wide quality assessment and performance improvement (QA/PI). QA/PI is separate from the individual medical staff member’s responsibility under the Conditions for Coverage, which centers on completing individual patient assessments and plans of care, meeting treatment goals and more extensive attention to unstable patients. QA/PI, in contrast, is a process supervised by the facility’s medical director and interdisciplinary team to evaluate and improve overall facility performance and quality of care. Data on current professionally-accepted clinical practice standards must be used to track health outcomes, and the program must allow for identification, prevention and reduction of medical errors, mortality, and morbidities. Refer to the Measures Assessment Tool (MAT) which lists expected outcomes based on these standards and CMS Clinical Performance Measures (CPMs). (V626)

Although the medical director and the interdisciplinary team execute the QA/PI program, you are involved through the daily care of your patient. From this standpoint, you participate in efforts to improve the quality of medical care to your patients. These efforts must be reflected both in documentation of the QA/PI program and in the medical records of individual patients. Examples include the development of the patient’s plan of care and addressing poor patient outcomes with a change in the plan of care. (V763)

Evidence of understanding and agreement of your responsibilities relating to QA/PI will be documented in your credential files (V760)

Face-to-Face Encounters and Office Visits

A significant component of the Conditions for Coverage is documentation of face-to-face visits with your patients. The patient’s physician, practice partner, ARNP or PA must see the patient each month at the office or dialysis facility. They then must document that encounter (or specify the reason the visit did not occur) for both in-center and home dialysis patients. Any of these practitioners (MD, ARNP or PA) must also see and document having seen the patient during dialysis at the facility once quarterly. V560 Visits, whether in office or unit, are to be documented in an area of cyberREN designed for this purpose.

Please “cc” your dictated office visits, discharge summaries and medical correspondence to Northwest Kidney Centers Medical Records, 700 Broadway, Seattle, WA 98122 or via fax: 206-901-8725 rather than directly to the unit, and they will be scanned into cyberREN under Treatment “Consultations”. Case managers are notified when a document has been scanned, and they can print it from cyberREN.

The Crystal Report “MD Patient Seen or Not Seen” now includes your office note. Once your office note is scanned by Northwest Kidney Centers Medical Records, you will not have to check “Patient seen in clinic” in the encounter screen. Continue to check “Pt Seen” if you see the patient in the dialysis unit. Please record the reason a patient was “Not Seen” in a month if that is the case.

Comprehensive Assessment and Plan of Care

The Conditions for Coverage delegate the mechanics of care planning entirely to the patient’s MD as the captain of an interdisciplinary care planning team. This team is composed of the patient’s MD, the MSW, renal dietitian, clinical director, case manager, and patient, who are together responsible for determining the direction of care planning and generating relevant documents which chart its forward course. This responsibility includes generating initial assessments at 30 and 120 days for new patients (called the Comprehensive Assessment), assessing stability (obligating yearly comprehensive assessment) or instability (obligating monthly comprehensive assessment and plan of care) on the basis of criteria established by CMS. V501-V520 and V540-V559

The Comprehensive Assessment/Plan of Care is completed on the computer. This is on the K‑Net  under “POC Application.”

Unstable Care Plans

Patients determined to be unstable require monthly assessments on the basis of criteria established by CMS; and charting the timelines for improvement in specific benchmarks of care (e.g., adequacy, anemia, volume, etc) depending on the patient’s key issues. V520

Each member of the interdisciplinary team will need to complete their section of the Unstable Care Plan in the Discipline Centric portion of the electronic medical record by the 15th of the month. (See attached policy: Patient Care Plans-Unstable). You will subsequently participate in a discussion regarding patient’s plan of care and sign the final document. For those physicians who do not have access to the EMR, the case manager/nurse educator will initiate the care plan form and ensure completion of the form by the disciplines. The care plan form will be faxed to the physician for completion and to be faxed back to the unit for review.

Chronic Renal Disease Medical Evidence Report (CMS 2728 Forms)

These green forms enroll all patients in the ESRD program, provide for Medicare entitlement if the patient is under 65, and generate important epidemiologic information for the USRDS and Networks. The Northwest Kidney Centers RHIT (Registered Health Information Technician) completes these forms using the information provided on the referral form. It is crucial that you complete all information on the referral form to enable Northwest Kidney Centers to submit these essential documents promptly, maintain their accuracy, minimize telephone calls asking you for further information, and most importantly, ensure that your patients get the benefits they need.

Death Report-CMS 2746 Forms

A 2746 form must be completed within 30 days of a patient death. A 2746 form will be faxed to the nephrologist for completion. You will need to enter the primary cause of death and indicate if there were any secondary causes contributing to the patient’s death. If the patient discontinued dialysis prior to death, you will need to indicate who requested discontinuation, the reason, and whether the patient was receiving hospice care. Once you fax back to the Northwest Kidney Centers ART, they will complete the actual form and forward it to the Northwest Renal Network with a copy to the quality improvement and regulations manager.

Northwest Kidney Centers conducts a sentinel event root cause analysis of every patient who dies unexpectedly in the unit. Please remember to send a copy of the death summary to Northwest Kidney Centers.

Catheter Surveillance and Reduction Program
In order to reduce the number of catheters, NKC has created a tool showing the number of days a catheter has been in place. Part of the care conference with the Medical Director of each facility will address access removal using this tool. Close attention will be given to patients with catheters of extended vintage (particularly >90 days). For patients with catheters in >90 days, the NKC Case Manager will communicate with you regarding the plan for catheter removal as well as the overall access plan. You may indicate:

1. in fact “access never,” or
2. that the information you have is not current, or
3. that the patient has received a reasonable access.

Challenging Patient Program
The Challenging Patient Program provides staff with clear and concise guidelines on how to deal with a challenging patient who is abusive, threatening, and/or exhibiting violence toward staff, patients or others. NKC has a zero tolerance policy for possession of weapons, violence or threats against persons on our properties.

Chaplaincy Program
To help patients and their families through end-of-life issues and other difficult times, NKC has established the Chaplaincy Program which is funded entirely through donations. An experienced, certified chaplain on staff is available to patients receiving services in the NKC Special Care Units to provide compassionate listening and non-judgmental guidance in times of physical, emotional and spiritual distress.

CKD – Chronic Kidney Disease Program

Patient education is an integral part of high quality patient care. The CKD program aims to support patients through the continuum of care—from the early stages of CKD, to advanced kidney failure, through dialysis and transplant, as well as post-transplant. Patient-centered, evidence-based, health literate and culturally appropriate education is provided for patients to make informed decisions and is proven to improve patient outcomes.

CKD classes and counseling offered include:

1. “Eating Well, Living Well” provides RD education about a heart-healthy, kidney friendly diet. CKD patients hear about foods that are good for the heart, hidden sources of salt and low-salt alternatives. Discussion includes protein portions, how potassium and phosphorus are linked to kidney disease, and the importance of exercise.  Patients leave with tips for dining out, shopping, and cooking tasty, kidney-friendly meals at home. Offered to anyone living with chronic kidney disease and not yet on dialysis.
2. “Choices” modality education, taught by an MSW, gives people with chronic kidney disease an opportunity to learn about treatment options, including dialysis, transplant, and supportive care. The aim of education is to begin planning and preparing to help patients achieve their healthcare goals, maximize outcomes and quality of life. Patients get questions answered, fears and barriers addressed, and gather more information before making a decision about how to treat their chronic kidney disease. Offered to anyone living with chronic kidney disease and not yet on dialysis.
3. “Next Step” classes for Home Hemo, PD and Transplant are for people with kidney disease who have attended our Choices class as well as current dialysis patients. Through Next Step Home Hemo and PD, patients gain more in-depth information about dialyzing at home, see the equipment and supplies, and tour the training units. In Next Step Transplant, patients learn about the evaluation, how to prepare, living and deceased donors, and the wait list.

To schedule classes, call 206-292-2771, ext 1082. 

Diabetic Lower Extremity Amputation Program (LEAP)

The LEAP program provides diabetic patients with routine lower extremity monitoring and surveillance in an effort to reduce the number of amputations among our diabetic population. Northwest Kidney Centers collaborates with Priority Footwear and Pedorthic Services to provide footwear for eligible patients.

Hospital Services
Provides high quality comprehensive, cost-effective renal replacement therapy and related extracorporeal therapies to hospitalized patients at contract hospitals/medical centers. Treatments available include hemodialysis, hemoperfusion, pump ultrafiltration, TPE (Therapeutic Plasma Exchange), and CRRT (Continuous Renal Replacement Therapy). Please contact the program at 1-855-292-3045.

Language Translation
Language translation services are available to rounding physicians. In-Demand Interpretive Services offers more than 100 languages and is most approprite for conversations of 30 minutes or less. Each Northwest Kidney Centers dialysis facility is equipped with the In-Demand service via teleconference or phone. Staff can assist you if needed. If a longer session is anticipated, Northwest Kidney Centers will arrange for a professional translator to come onsite.

New Patient Education
Northwest Kidney Centers staff teach new patients about their illness and treatment during a 6-8 week program. They are given information about all NKC services and education about kidney failure. A plan for long-term treatment is made at this time.

Nutrition and Fitness Services
Offers detailed information on the best diet choices for a patient’s individual needs. Provides referrals and resources to help patients maintain the strengths they have and regain lost physical abilities. For CKD patients, they can receive services through our CKD department (see CKD services).

Renal Supportive Care Program
NKC has launched a Renal Supportive Care Program designed to work with patients to manage symptoms and assist with quality of life choices . You may refer a patient by contacting the Renal Supportive Care Coordinator at 206-720-8675.

Patient Finance
Financial Coordinators help patients find and keep the funding needed to pay for chronic kidney disease care. They are knowledgeable about Medicare, Medicaid, insurance issues, the best sources for low-cost medication and how to apply for funding.

Pharmacy
The NKC Pharmacy which is located in Haviland Pavilion, specializes in the drugs required by dialysis and kidney transplant patients. With a focus on personal service, pharmacists fill prescriptions and provide information to patients. Drugs can be picked up at the pharmacy or delivered to the patient’s NKC unit. The NKC Pharmacy offers one free delivery a month of all prescriptions.

Social Services
Offers counseling, resource information, support groups and help with problem solving and handles all patient requests for shift changes.

Special Services
Special Servicers is an outpatient dialysis program in some of our clinics that includes highly skilled nursing care, personal care assistance, management of multiple medications, greater staff to patient ratio than available in a community dialysis unit, majority licensed nursing staff, proactive care coordination across multiple settings (including nursing homes and hospitals), care planning and end of life family consultation, chaplaincy service, palliative care consultation, hospice coordination and a bed during treatment.

The medical director, clinical director or their designee of each special services unit will make the decision before admission whether or not to accept a new or transferred patient. The chief medical officer and vice president of clinicalservices will be consulted as needed. The medical director or special services leadership may ask to convene the Northwest Kidney Centers Ethics Committee to consult.

Eligibility for Special Care

1. ESRD patients transferred from within Northwest Kidney Centers
2. New ESRD patients
3. Patients from other outpatient dialysis providers

Patients most suitable for Special Care usually need several or more of these services:

1. Two-person transfer assistance from stretcher or wheelchair
2. Higher level of surveillance, detecting subtle, rapid and frequent changes in status than normally a dialysis technician in an outpatient unit can safely provide
3. Frequent comprehensive physical assessments
4. Regular monitoring of hypotension and chest pain
5. Frequent interventions during dialysis for hypotensive episodes
6. Multiple communications with attending nephrologists
7. Management of multiple medications during a visit
8. Personal needs care that requires skilled nursing assistant-level skill
9. Staff knowledge about how to work with patients with medical devices i.e. ostomy tubes, tracheotomy tubes, etc
10. A bed for medical necessity
11. Hep B isolation services are available assuming patient meets other eligibility criteria
12. VRE and MRSA isolation
13. Private rooms with adjacent bathroom for patients positive for C-difficile with uncontained diarrhea

Exclusion criteria for Special Care:

1. Ventilator dependent
2. Dependent on others for tracheostomy suctioning
3. Need continuous cardiac monitoring during dialysis due to inotropic agents
4. Are in a persistent vegetative state before starting treatment
5. Regularly require one-on-one or one-to-two staff to patient ratio

As with other NKC units, patients will not be admitted if they:

1. Have active tuberculosis
2. Meet other medical or behavioral exclusion criteria for outpatient dialysis
3. NKC lacks capacity to care for the patient

Transplantation Education, Support and Status Tracking
Northwest Kidney Centers provides a comprehensive, ongoing program of patient treatment and education in support of transplantation and organ donation. This includes: providing pharmacy services for transplant patients under the care of the Northwest Kidney Centers medical staff; promoting transplantation through “Choices” and “Next Step Transplant” educational classes for patients; coordinating with hospital transplant programs, tracking the patient’s status in cyberREN; assisting potential transplant recipients with insurance planning by financial counselors; providing transplant patients access to NKC emergency grants and rehabilitation scholarships; highlighting organ donation and transplant at public awareness events; and publishing a regular newsletter called “Transplant Connection” to familiarize patients with these services. V561-V562.

Transportation
The Admitting and Patient Services Office assists patients in setting up transportation for their dialysis. The Transportation phone number is 206-292-2704 or toll-free 866-989-4932.

Visitor Dialysis
The Visitor Dialysis Coordinator handles all dialysis requests from non-NKC patients who require dialysis while visiting our area. This includes patients temporarily in the area for medical reasons, and non-NKC patients incarcerated in the King County Jail. Thirty days advance notice is required in order to schedule visitor treatments. Exceptions can be granted in the case of a death in the family or urgent medical need.

Communications
All attempts should be made to respond to facility pages, faxes or other requests for communication expeditiously, either through the MD or his/her designee.

Please cc your dictations to Northwest Kidney Centers Medical Records.

Dialysis Academy
All new clinical and technical services employees participate in an extensive education program that is designed to meet their needs and make them capable employees when they report to work in their units on a regular basis.