“Renal Peer Review at UHNM - CKD Data and Care Processes”

West Midlands Renal Peer Review UHNM -CKD 11/10/2017 www.england.nhs.uk

Anaemia management in CKD Proportion of CKD 4 & 5 patients (not on RRT) with RA anaemia guideline(+/- ESA if available) .Spot audit December 2016 In December 2016, 222 patients with CKD 4&5,not on RRT, had a Hb checked. Of those patients 168 (76%) met RA anaemia guideline. 54 patients in the audit (24%) had Hb of less than 100. www.england.nhs.uk 2

Modality on Commencement of RRT,known to renal for more than 3 months unless otherwise specified First Modality Total Number HD PD TX Total 90 (71%) 33(27%) 3 (2%) 126 www.england.nhs.uk 3

Access at commencement of dialysis, known to renal services for more than 3 months Total On HD with AVF On HD with AVG 0 On HD with line On PD Total Total Number 54 (60%) 36 (40%) 33 123 www.england.nhs.uk 4

Audit data for patients starting on a line known for more than 90 days Total 35 Increased rate of progression Access issues (Failed/ Clotted) 2 Organisational Issues (delayed referrals) 3 Modality change Other Causes * DNA s 21 2 3 4 * Other causes include planned Live donor Tx, nephrectomy, patient preference. www.england.nhs.uk 5

Percentage of patients in CKD Stage 5 who have opted for Supportive Care Proportion of CKD 4 & 5(not on RRT) documented for Conservative Care :27/435 (6.2%) Proportion of CKD 5(not on RRT) documented for Conservative Care :16/165 (9.7%) Number of patients classified as conservative care with e GFR less than 10 : 5/27 (19%) Number of patients classified as conservative care with e GFR less than 15 : 11/27 (41%) www.england.nhs.uk 6

Description of Renal Supportive Care Process Manage a caseload of 65 patients who have chosen not to dialyse Perform assessment on referral - eGFR 15 Home visit initiated when eGFR 8-10 Monthly telephone clinic Provide holistic care and facilitate end of life care by visiting patients in their homes and care establishments Facilitate end of life care with GP, District Nurses, MacMillan Nurses and Hospices Symptom management Post bereavement visits www.england.nhs.uk 7

Unplanned starters /Late presenters Proportion of patients who are late presenters 41/164 Breakdown of patients AKI turned ESKD : 8 True late presenters ,not known to have renal disease until 3 months before start :5 Unplanned start,CKD known to renal sudden decline from e GFR more 20 ml/min to RRT in less than 3 months :14 Unplanned starters CKD unknown to renal sudden decline from e GFR more 20 ml/min to RRT in less than 3 months :14 www.england.nhs.uk 8

Patient education/information in CKD stages 4 & 5 including those with unplanned start Process referrals received from renal consultants middle grades . In addition to CKD patients we counsel small numbers of patients with heart failure and ascites for starting PD for fluid management. At the moment we do home visit to deliver treatment options information. Symptom assessment and management which includes liaising with Clinicians, General Practitioners, and Practice Nurses www.england.nhs.uk 9

Patient Education Education programme which is tailored to the needs of the individual Provide education, information and demonstrations relating to Haemodialysis, Home Haemodialysis, CAPD, APD, and aAPD to patients and carers Invite patients to an Pre-dialysis education seminar which is held monthly and is organised for patients, family members and carers to see a demonstration (and discussion) on peritoneal dialysis and haemodialysis Unplanned Start programme set up to give treatment options to patients who have started treatment in an unplanned way www.england.nhs.uk 10

Patient education Arrange a one to one demonstrations pertaining to Haemodialysis , Home Haemodialysis, CAPD, APD and aAPD Discuss patients in a fortnightly MDT CKD meeting Weekly review meeting with clinical lead Maintain and update CKD audit data www.england.nhs.uk 11

Hepatitis B vaccination in CKD patients Proportion of patients undergone full course Hepatitis B vaccination prior to commencement of dialysis : 96/164 (59%) Description of the process Hepatitis B infection screen is checked in clinic when patients reach CKD stage 4 or 5 and if its negative ,GP s are advised to vaccinate the patients as per UHNM Hepatitis B Protocol We do not pursue Hep B vaccination if patients have already indicated a clear preference for supportive care rather than RRT Hepatitis B immunity is checked 2-3 months after the last dose of vaccination and based on those results a second course or a booster is advised Thereafter Hepatitis B immunity is checked annually www.england.nhs.uk 12

Hepatitis B immunisation Drawbacks of the current Hep B immunisation process Vaccine dates are not recorded anywhere on the electronic system, hence missing follow up No robust system for Hep B audits to send timely reminders for boosters and annual blood tests www.england.nhs.uk 13

Examples of practice to share 1. 2. 3. Conservative care audits and visit Multidisciplinary clinic- Nurse led clinic as future goal Same day counselling for Renal Rapid Response Clinic patients if necessary. www.england.nhs.uk 14

Examples of areas for improvement 1) 2) Hepatitis B immunisation and follow up blood tests Revamping patient education programme based on patients feed back and process mapping. We strive to make further improvements to our incident and prevalent access rates. 3) www.england.nhs.uk 15

Examples of areas you would welcome advice 1. 2. 3. Nurse led clinic- Set up,Proformas Hepatitis B audits and follow ups Vascular access monitoring VAN Clinics as a future goal www.england.nhs.uk 16