UHNM CKD 11102017 Proportion of CKD 4 amp 5 patients not on RRT with RA anaemia guideline ESA if available Spot audit December 2016 In December 2016 222 patients with CKD 4amp5not on RRT had a Hb checked Of those patients 168 76 met RA anaemia guideline 54 patients in t ID: 1041421
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1. West Midlands Renal Peer ReviewUHNM -CKD 11/10/2017
2. 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 100.2Anaemia management in CKD
3. 3Modality on Commencement of RRT,known to renal for more than 3 months unless otherwise specifiedFirst Modality HD PD TX TotalTotal Number 90 (71%) 33(27%) 3 (2%) 126
4. Total4Access at commencement of dialysis, known to renal services for more than3 monthsOn HD with AVFOn HD with AVGOn HD with lineOn PDTotalTotal Number 54 (60%) 0 36 (40%) 33123
5. Total 355Audit data for patients starting on a line known for more than 90 days Increased rate of progressionDNA’sAccess issues(Failed/Clotted)OrganisationalIssues(delayed referrals)ModalitychangeOther Causes * 21 2 2 3 3 4* Other causes include planned Live donor Tx, nephrectomy, patient preference.
6. 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%)6Percentage of patients in CKD Stage 5 who have opted for Supportive Care
7. Manage a caseload of 65 patients who have chosen not to dialysePerform assessment on referral - eGFR 15Home visit initiated when eGFR 8-10Monthly telephone clinicProvide holistic care and facilitate end of life care by visiting patients in their homes and care establishmentsFacilitate end of life care with GP, District Nurses, MacMillan Nurses and Hospices Symptom managementPost bereavement visits7Description of Renal Supportive Care Process
8. Proportion of patients who are late presenters 41/164Breakdown of patientsAKI turned ESKD : 8True late presenters ,not known to have renal disease until 3 months before start :5Unplanned start,CKD known to renal sudden decline from e GFR more 20 ml/min to RRT in less than 3 months :14Unplanned starters CKD unknown to renal sudden decline from e GFR more 20 ml/min to RRT in less than 3 months :148Unplanned starters /Late presenters
9. 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 Nurses9Patient education/information in CKD stages 4 & 5 including those with unplanned start
10. Education programme which is tailored to the needs of the individualProvide education, information and demonstrations relating to Haemodialysis, Home Haemodialysis, CAPD, APD, and aAPD to patients and carersInvite 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 way10Patient Education
11. Arrange a ‘one to one’ demonstrations pertaining to Haemodialysis , Home Haemodialysis, CAPD, APD and aAPDDiscuss patients in a fortnightly MDT CKD meetingWeekly review meeting with clinical leadMaintain and update CKD audit data11Patient education
12. Proportion of patients undergone full course Hepatitis B vaccination prior to commencement of dialysis : 96/164 (59%)Description of the processHepatitis 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 ProtocolWe do not pursue Hep B vaccination if patients have already indicated a clear preference for supportive care rather than RRTHepatitis 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 annually12Hepatitis B vaccination in CKD patients
13. Drawbacks of the current Hep B immunisation processVaccine dates are not recorded anywhere on the electronic system, hence missing follow upNo robust system for Hep B audits to send timely reminders for boosters and annual blood tests13Hepatitis B immunisation
14. Conservative care audits and visitMultidisciplinary clinic- Nurse led clinic as future goalSame day counselling for “Renal Rapid Response Clinic” patients if necessary.Examples of practice to share14
15. Hepatitis B immunisation and follow up blood testsRevamping patient education programme based on patients feed back and process mapping.We strive to make further improvements to our incident and prevalent access rates. Examples of areas for improvement 15
16. Nurse led clinic- Set up,ProformasHepatitis B audits and follow upsVascular access monitoring – VAN Clinics as a future goalExamples of areas you would welcome advice 16