THE NORTH WEST REGIONAL RENAL AUDIT OUTCOMES PROGRAMME

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THE NORTH WEST REGIONAL RENAL AUDIT  OUTCOMES PROGRAMME Powered By Docstoc
					NORTH WEST REGION
RENAL AUDIT PROGRAMME

ANNUAL REPORT 2001-2002
October 2002
Contents



1     Introduction                                            1

2     Principal aim                                           1

3     Centres participating in the regional audit programme   1

4     Programme management                                    1

5     Programme framework                                     2

6     Audit planning                                          2

7     Regional recommendations and guidelines                 2

8     Programme development                                   3

9     Results from the programme of ongoing audit             4

10    Results from the programme of individual audit          13

11    Plans for 2002 - 2003                                   16

12    Further Information                                     16

      References                                              16

      Appendix one                                            i

      Appendix two                                            ii

      Appendix three                                          iii

      Appendix four                                           iv

      Appendix five                                           v

      Appendix six                                            vi
1 Introduction


The North West Region Renal Audit Programme, established in 1992, is a standards based
programme of continuous quality improvement. Over recent years it has been developed to
improve the delivery of clinical services to renal patients situated in the North West Region and
so assist in the process of Clinical Governance.

This report briefly describes the regional renal audit programme and its development, and
provides an account of the audit activity that has taken place within the programme between
1st April 2001 and 31st March 2002.




2 Principle aim


The principal aim of the North West Region Renal Audit Programme is to improve the quality
and effectiveness of the renal services in the North West Region through a continuous
collaborative process of multidisciplinary evidence based clinical audit of the care provided in
the hospital and community. The principal aim is achieved through the objectives listed in
appendix one.




3 Centres participating in the regional audit programme


Within the North West Region (which incorporates Greater Manchester, Lancashire and
Merseyside), all renal units and their satellites participate in the Regional Renal Audit
Programme (see appendix two).




4 Programme management


The audit programme is directed and managed by the chairmen of the multidisciplinary North
West Region Renal Audit Steering Group:

   Dr R Ahmad          Consultant Renal Physician - Royal Liverpool University Hospital
                        Liverpool Chair of the NW Region Renal Audit Steering Group

   Dr R Coward         Consultant Physician and Nephrologist - Royal Preston Hospital
                        Lancashire Chair of the NW Region Renal Audit Steering Group

   Dr M Venning        Consultant Renal Physician – Manchester Royal Infirmary
                        Manchester Chair of the NW Region Renal Audit Steering Group

Members of the steering group, who represent the views of clinicians from the renal units in the
region, advise and assist the chairmen with the programme management (see appendix three).
5      Programme framework


The audit programme has been running for 10 years and in this time, it has shown that
individual units sometimes fall below the national average for some standards. However,
successive audits (for example CAPD peritonitis and haemoglobin levels and Epo usage) have
brought about and demonstrated improvements in standards. Consequently, the audit
programme has been developed in two separate programmes:

   Programme of ongoing audit: A prospective programme of ongoing audit that has been
    devised around six separate topics (see section 9 below). Using the data collected for the
    ongoing audit programme and the data published by the UK Renal Registry1, clinical care
    can be benchmarked regionally and nationally.

   Individual audit programme: A separate programme of audit that is carried out to improve
    clinical care in areas not covered by the programme of ongoing audit. This programme is
    devised by looking at the feasibility of new audits and including those with a strong
    evidence base for achievable change (see section 10 below).

A regional renal audit database has also been established as a basis for the ongoing
programme of audit and to monitor survival and other outcomes. All patients established on
dialysis in the region have been enrolled on the database and this is updated regularly.




6   Audit planning


To maximise the effectiveness of the clinical audit process, audit planning follows a well-
established protocol. For all audits, the audit facilitator works with a consultant lead, a
specialist registrar and clinicians with an interest in the audit. Together they develop and
implement an audit plan (see appendix four). An evidence base must exist for all audits and
most audits are performed against the recommended standards set out by the Standards
Subcommittee of the Renal Association2,3 or against established guidelines i.e. the National
Service Frameworks for diabetes4 and older people5; Dialysis Outcomes Quality Initiative6; The
Kidney Alliance7.




7   Regional recommendations and guidelines


When the data has been collated, the audit facilitator analyses the data and then discusses the
results with the audit team to determine the conclusions and to propose recommendations
and/or guidelines. Audits and the proposed recommendations/guidelines are then presented to
a wide audience at an audit presentation evening to which renal clinicians, managers and,
public health and patient representatives are invited. Following presentation, audits are
discussed to share good practice and to finalise the recommendations/guidelines.

Use of regional recommendations and guidelines are then promoted through the publication of
a report; circulation of the recommendations and guidelines to all those affected by the audit;
and through presentation of the audit, regional recommendations and guidelines.
Presentations are given to renal clinicians at local hospital meetings, and whenever appropriate
they are given to professional groups based in the North West Region.
8     Programme development


8.1      Patients

To involve patients in the audit process they are invited to audit presentation evenings and are
asked to participate in patient focused audits. To represent the patients’ views in the running
of the audit programme, patients and patient representatives in patient support groups, will be
invited to put forward their ideas for audit. When the individual audit programme is put
together, consideration will be given to these suggestions.

Processes to keep patients informed are also being developed. A patient information leaflet
has been produced and is being distributed to all dialysis and pre-dialysis patients in the North
West Region. Patient consent forms are also being distributed to all dialysis patients, who are
involved in the ongoing audit programme. Arrangements for giving presentations to patient
groups are also under discussion and a patient newsletter has been drafted. The newsletter
contains results and recommendations from completed audits, details of ongoing audits and
information for patients and carers who want to get involved in the audit programme.


8.2      Zonal audit facilitators

To enforce the process of clinical governance, processes by which audit results and the
associated recommendations/guidelines are systematically reported to the renal unit
management teams, and are subsequently implemented, are being established. To help in the
development of these processes, the central renal audit facilitator post has been split into three
part-time zonal renal audit facilitator posts. Nurses who work locally fill these posts.

The remit of the zonal facilitators is to provide the renal unit management teams with a
standards based assessment of the quality and effectiveness of the renal services provided by
their unit. To do this, they will develop local systems for feedback through liaison with local
and satellite unit managers.

The zonal facilitators will also assist the process of change at individual units. Working locally,
they will be aware of local processes and can decide with the renal unit management teams,
how to best implement the recommendations/guidelines. They will also be aware of local
problems and can discuss changes needed to improve individual unit performance.

By addressing their training needs, the zonal facilitators will also support health professionals in
the delivery of quality care. Educational programmes, to inform staff about clinical audit and
its relationship with clinical governance, are being developed by the zonal facilitators. They
also promote the importance of following recommended change to support the process of
clinical governance and to improve the service delivered to patients.


8.3      Audit review evenings

To develop and sustain a culture in which unit performance is discussed openly audit review
evenings have been extended. At these events audit methodologies and results are presented.
Units are named in all the presentations and individual performance is discussed to exchange
ideas that could explain and improve poor performance. Following open discussion,
recommendations are agreed and when appropriate guidelines are developed.

The evenings help units to compare their performance, identify those areas in which change is
necessary, and achieve the required change. They also give renal professionals based in the
North West Region, the opportunity of collaborating in the development of regional
recommendations and guidelines.
9     Results from programme of ongoing audit


9.1       Audits

     Six audits are included in the programme of ongoing audit

         Adequacy
         Bone chemistry
         Cardiovascular risk
         CAPD peritonitis
         Haemoglobin and Epo usage
         Survival


9.2       Datasets

     The audits described below relate to the first round of data collection in the programme of
      ongoing audit. HD adequacy data was not included in the first dataset because at the time
      of data collection, a HD adequacy audit had been recently completed. HD adequacy data
      has been included in the second dataset relating to the second round of data collection (see
      section 11.1).

     For all audits, except PD adequacy and CAPD peritonitis, data was obtained from one group
      of patients and collated into one dataset.


9.3       Patients

     For all audits, except HD Adequacy (see section 9.2 above), PD adequacy and CAPD
      peritonitis

      All patients enrolled on a dialysis programme in the North West Region on 1 st May 2000
      were involved in the audits.

     PD adequacy and CAPD peritonitis audits

      All CAPD patients on a dialysis programme between 1st April 2000 and 31st March 2001
      were involved in the audits.


9.4       Methods

   Data came from computer systems, patient records and patients.
   Data was collated and analysed by the regional audit co-ordinator.


9.5       Results

     Details of all the audits listed in 9.1 above are given in the sections 9.6 to 9.11.
     A preliminary analysis of the first dataset has been performed and results from the

         Bone chemistry
         Cardiovascular risk
         CAPD peritonitis
         Haemoglobin and Epo usage

      audits are presented in sections 9.7,9.8,9.9 and 9.10 below.
     Abbreviations used in this report are given in appendix five.
     Results from the preliminary analysis are illustrated in the two ongoing audit programme
      presentations, which can be found in appendix six.
9.6       Audit of Adequacy


9.6.1     Aims & objectives

   To measure achievement of the Renal Association standard for dialysis adequacy and
    albumin
   To examine the characteristics of patients not achieving the Renal Association standard for
    dialysis adequacy
   To examine the efficacy of interventions given to patients not achieving the Renal
    Association standard for dialysis adequacy


9.6.2     Evidence base

   Churchill D, Taylor D, Keshaviah P et al. Adequacy of dialysis and nutrition in continuous
    peritoneal dialysis: association with clinical outcomes. J AM Soc Nephrol 1996;7:198-207
   Lowrie EG, Laird NM, Parker TF, Sargent JA. Effect of haemodialysis prescription on patient
    morbidity: report from the National Co-operative Dialysis Study. N Engl J Med
    1981;305:1176-81
   Maiorca R, Brunori G, Zubani R et al. Predictive value of dialysis and nutritional indices for
    morbidity and mortality in CAPD and HD patients: a longitudinal study. Nephrol Dial
    Transplant 1995;10:2295-305
   Owen WF, Lew NL, Liu Y et al. The urea reduction ratio and serum albumin concentration as
    predictors of mortality in patients undergoing haemodialysis. N Engl J Med 1993;329:1001-
    6


9.6.3     Standards

   HD patients

    Renal Association Recommended minimum standard2

    Every patient for thrice weekly haemodialysis should show

    EITHER       Stable URR > 65%
    OR           Stable Kt/V > 1.2 (dialysis and residual renal function)


     PD patients

      Renal Association Recommendation2

      A total weekly creatinine clearance (dialysis and residual renal function) of 50 l/week/1.73
      m2 and/or a weekly dialysis Kt/V urea off greater than 1.7, checked 6-8 weeks after the
      beginning of dialysis, should be regarded as minima. These studies should be repeated at
      least annually, or if a suspicion arises that residual function has declined more rapidly than
      usual.


9.6.4     Data

   Data includes age, sex, duration of dialysis, albumin, pre and post urea, Kt/V, creatinine
    clearance.


9.6.5     Health disciplines

   Nurses
   Physicians


9.6.6      Results

     HD patients

HD adequacy data was not included in the first dataset (see section 9.2). HD adequacy data
has been included in the second dataset, relating to the second round of data collection, which
will soon be available for analysis (see section 11.1).


     PD patients

The first PD adequacy dataset is incomplete, as data was not available from all units at the
time of the first audit. The data collected will therefore be incorporated as a baseline into the
second PD adequacy audit. The second dataset will be available soon and it will be analysed
when it has been combined with the first dataset.


9.6.7      Conclusions

     Conclusions will be drawn for the HD and PD adequacy audits when the analyses are
      complete.


9.6.8      Recommendations

     Recommendations will be made when the analyses are complete.




9.7        Audit of Bone Chemistry


9.7.1      Aims and objectives

     To   assess   calcium and phosphate control.
     To   assess   the use of phosphate binders.
     To   assess   local guidelines for the management of bone disease.
     To   assess   the drug records.
     To   assess   management of bone disease in relation to ethnicity.
     To   assess   management of bone disease in relation to the role of the dietician.


9.7.2      Evidence base

     Gerakis A et al. Biochemical markers for non invasive diagnosis of hyperparathyroid bone
      disease and adynamic bone disease in patients on haemodialysis. Neprol Dial Trans 1996
      11 2430-2438.
     Malluche H et al. Risk of adynamic bone disease in dialysed patients. Kid Int 1992 42
      (suppl 38) 62-67.
     Sharrad D et al. The spectrum of bone disease in end stage renal failure – An evolving
      disorder. Kid Int 1993 43 436-442.


9.7.3      Standards

     Haemodialysis patients
Renal Association Recommended Standard2

The following are target ranges for pre-dialysis biochemical variables:

Phosphate           1.2 – 1.7 mmol/l
Calcium             Total calcium within the normal range quoted by the local pathology laboratory,
                    corrected for serum albumin concentration or normal ionised calcium where
                    available.
Albumin             A target serum albumin within the normal range quoted by the local pathology
                    laboratory in all patients should be the target after 6 months on regular
                    haemodialysis.
PTH                 iPTH should be maintained at between 2 and 3 times the local normal range
                    (130 – 210 pg/ml).

     Peritoneal dialysis patients

Renal Association Recommended Standard2

The following are target ranges for pre-dialysis biochemical variables:

Phosphate           1.1 – 1.6 mmol/l
Calcium             Total calcium within the normal range quoted by the local pathology laboratory,
                    corrected for serum albumin concentration or normal ionised calcium where
                    available.
Albumin             The serum albumin of at least 70% of patients should be within the local
                    normal range.
PTH                 iPTH should be maintained at between 2 and 3 times the upper limit of the local
                    normal range.


9.7.4     Data

     Calcium, corrected calcium, phosphate, albumin, alk phos, PTH and bicarbonate were
      collected from the three most recent blood tests.
     Drug treatment including vitamin D, phosphate binders and steroids, and the systems used
      to record this information was recorded.
     The number of females and their menopausal state was defined using age and HRT
      treatment.
     The number of patients who have received a transplant was recorded.
     Ethnic group, first language and ability to read English were recorded.
     Dietician : patient ratio was recorded for each unit.


9.7.5     Health disciplines

     Dietitians
     Physicians
     Pharmacists


9.7.6     Results

Preliminary analysis shows that

     The overall achievement of the Renal Association standard for phosphate is poor.
     Since the last audit, phosphate control in PD patients has improved at LTH and SRH.
     Since the last audit, phosphate control in HD patients has improved at MRI and SRH.
     Control of phosphate for non-Caucasian HD patients and non-caucasian PD patients is not
      significantly different to that for Caucasian equivalents.
     As in the previous audit, the overall achievement of the Renal Association standard for
      calcium is good.
     Control of calcium for non-Caucasian HD patients and non-Caucasian PD patients is
      significantly poorer than in Caucasian equivalents.
     Since the last audit, the proportion of patients with hyperparathyroidism has decreased at
      LTH, MRI and SRH.
     Control of PTH for non-Caucasian PD patients is significantly poorer than in Caucasian PD
      patients.


9.7.7     Conclusions

     Conclusions will be drawn after further analysis.


9.7.8     Recommendations

     Recommendations will be made when the analysis is complete.




9.8       Audit of Cardiovascular Risk


9.8.1     Aims & objectives

   To assess cardiovascular risk in the dialysis population in the North West Region
   To assess cardiovascular risk intervention in the dialysis population in the North West Region
   To compare blood pressure control at unit and regional level, with national performance
    measured by the UK Renal Registry.
   To provide a basis for prospective evaluation of the relationship between cardiovascular risk
    factors, interventions and patient outcome.


9.8.2     Evidence base

   RN Foley, PS Parfrey and MJ Sarnak. Epidemiology of cardiovascular disease in chronic renal
    disease J Am Soc Nephrol 9 S16-S23 1998
   P Jungers et al. Incidence and risk factors of atherosclerotic cardiovascular accidents in pre-
    dialysis chronic renal failure patients: A prospective study. Nephrol Dial Transplant 12
    2597-2602 1997
   KB Meyer and AS Levey. Controlling the epidemic of cardiovascular disease in chronic renal
    disease: Report from the National Kidney Foundation task force on cardiovascular disease. J
    Am Soc Nephrol 9 S31-S42 1998


9.8.3     Standards

   Regional Association Recommended Standard2

Target pre-dialysis blood pressures should be:

Age <60: BP<140/90 mmHg (Korotkoff V if auscultation is used)
Age >60: BP<160/90 mmHg (Korotkoff V if auscultation is used)



9.8.4     Data

   Data collected from patient records included: blood pressure, Hb, Albumin, PTH, URR, total
    cholesterol, LDL and HDL cholesterol.
   Data collected from patients included: age, sex, socio-economic status, obesity, smoking
    history, no alcohol consumption, physical inactivity, history of hypertension, diabetes,
    menopause, current medication, family history of early onset CVD, history of MI, history of
    stroke, history of CABG, history of angioplasty, history of vascular surgery.


9.8.5     Health disciplines

   Physicians
   Hospital nurses


9.8.6     Results

Preliminary analysis shows that

     52% of the patients in the North West Region achieved the Renal Association standard for
      blood pressure.
     Blood pressure control in the five hub units was fairly uniform with LTH achieving the best
      blood pressure control by a small margin.
     Control of diastolic pressure was better than that of systolic pressure.
     Blood pressure control was effectively the same in PD patients and HD patients.
     LTH achieved the best control in HD patients and SMH achieved the best control in PD
      patients.
     The percentage of HD and PD patients meeting the Renal Association standard is greater in
      the Caucasian population than in the non-Caucasian population.
     Since the last audit, the percentage of patients achieving the Renal Association standard
      has increased in patients under 60 years of age and in patients over 60 years of age.


9.8.7     Conclusions

     Conclusions will be drawn after further analysis.


9.8.8     Recommendations

     Recommendations will be made when the analysis is complete.




9.9       Audit of Peritonitis


9.9.1     Aims & objectives

   To measure achievement of the Renal Association standard for peritonitis
   To benchmark peritonitis rates within the North West Region


9.9.2     Evidence base

   Golper TA and Tranaeus A Vancomycin revisited Perit Dial Int 1996 16 116 – 117
   Keane WF et al Peritoneal dialysis related peritonitis: treatment recommendations Perit Dial
    Int 1996 16 557 - 573
   Port FK et al Risk of peritonitis and technique failure by CAPD connection technique: a
    national study Kidney Int 1992 42 967 - 974


9.9.3     Standards

     Renal Association Recommended minimum standard using the disconnect system2
       Peritonitis rates should be < 1 episode/18 patient-months
       The negative peritoneal fluid culture rate in patients with clinical peritonitis should be
        less than 10%
       The initial cure rate of peritonitis should be more than 80% (without the necessity to
        remove the catheter).


9.9.4   Data

   Data includes patient months per episode, negative peritoneal fluid culture rate and initial
    cure rate of peritonitis.


9.9.5   Health disciplines

   PD nurses
   Physicians


9.9.6   Results

   The region achieved the standard of 1 episode of peritonitis / 18 patient-months.
   All units except SMUH achieved this standard.
   Disconnect peritonitis rates decreased from 99/00 for Region, MRI, SMH, and SRH.
   APD/IPD peritonitis rates are lower than the disconnect rates for Region, MRI, LTH, RLH,
    and SRH.
   The Region failed to reach the standard of negative peritoneal fluid culture (i.e. no bacterial
    growth NBG) rate < 10%.
   No unit achieved the standard for NBG rates.
   The NBG rate increased from 99/00 in all units except RLH.
   The region achieved the standard of initial cure rate > 80%.
   All units except MRI/RLH achieved this standard.
   The use of disconnect/APD/IPD has increased.
   The trend in gram +ve/gram –ve/yeasts/NBG is up and the trend in CNS/staph aureus is
    down.


9.9.7   Conclusions

   Peritonitis rates are decreasing.
   APD/IPD systems have lower peritonitis rates than disconnect systems.
   NBG rates are increasing.
   Initial cure rates are increasing.


9.9.8   Recommendations

   To further reduce peritonitis rates the use of APD/IPD systems should be increased.
   The increase in NBG rates should be investigated with microbiology departments.




9.10    Audit of Haemoglobin and Epo use


9.10.1 Aims & objectives

   To determine the extent of Epo therapy in the region
   To measure achievement of the Renal Association standard
   To benchmark haemoglobin levels regionally and nationally using data from the UK Renal
    Registry
   To measure efficacy of treatment
   To monitor improvement in control of anaemia


9.10.2 Evidence base

   Moreno et al Influence of haemotocrit on quality of life of haemodialysis patients Nephrol
    Dial Transplant 1994 9 10-34
   Eschbach et al Normalising the haemotocrit in haemodialysis patients with Epo improves
    quality of life and is safe 1993 J Am Soc Nephrol 4 425


9.10.3 Standards

   Regional Association Recommendation2

    A target haemoglobin concentration of not less than 10g/dl should be achieved in the great
    majority (>85%) of patients after 3 months on HD or PD. Transfusions should be avoided
    wherever possible in patients likely to be transplanted to avoid sensitisation.


9.10.4 Data

   Data includes haemoglobin, Epo therapy, iron status and mode of dialysis.


9.10.5 Health disciplines

   Anaemia co-ordinators
   Nurses
   Physicians


9.10.6 Results

Preliminary analysis shows that

   None of the renal hub units achieved the Renal Association standard for haemoglobin.
   The percentage of patients achieving the standard for haemoglobin was fairly uniform in
    the five hub units with RLUH achieving the best result and MRI achieving the worst.
   Five satellite units (WAH, WDH, DRH, FGH and LEH) achieved the Renal Association
    standard for haemoglobin.
   The difference in achievement of the standard in HD and PD patients was minimal.
   The percentage of patients achieving the Renal Association standard has increased in all
    renal hub units except the MRI.
   The percentage of patients with a ferritin > 200 was fairly uniform in the five hub units with
    RLH achieving the best result and MRI the worst.
   Epo use is greatest at SRH and lowest at MRI.
   Epo use is greater in HD patients than PD patients.
   Epo use has increased in all units except the MRI.
   The difference between the haemoglobin data in Caucasian and non-Caucasian patients is
    not significant.


9.10.7 Conclusions

   Conclusions will be drawn after further analysis.


9.10.8 Recommendations

   Recommendations will be made when the analysis is complete.
9.11    Audit of survival


9.11.1 Aims & objectives

   To measure achievement of the Renal Association Recommendation (provisional targets).
   To benchmark survival within the North West Region
   To examine the characteristics of patients who do not achieve the Renal Association
    Recommendation.


9.11.2 Evidence base

   Brunner FP et al Survival on renal replacement therapy: data from the EDTA registry.
    Nephrol Dial Transplant 1998 2 109-122 16 116 – 117.
   Khan IH et al Survival on renal replacement therapy in Europe: is there a ‘centre effect’
    Nephrol Dial Transplant 1996 11 300-307.
   Valderrabano F et al Use of APACHE II classification to evaluate outcome and response to
    therapy in acute renal failure patients in a surgical intensive care unit. Ren Fail 1995 17
    731-742.


9.11.3 Standards

   Renal Association Recommendation2 (provisional targets)

    The following provisional targets may be set for mean survival:

    For all patients with ‘standard’ primary disease aged 18-55 years

    1 year > 90%
    5 years > 80%
    10 years > 70%

    For all patients except those with diabetes mellitus aged 18-55 years

    1 year > 90%
    5 years > 75%
    10 years > 65%


9.11.4 Data

   Data includes date started dialysis, risk factors and co-morbidity.



9.11.5 Health disciplines

   Nurses
   Physicians


9.11.6 Results

This data is currently being analysed.
9.11.7 Conclusions

    Conclusions will be drawn when the analysis is complete.


9.11.8 Recommendations

    Recommendations will be made when the analysis is complete.




10     Results from programme of individual audit


10.1 Audits

Two audits were started in the period 1st April 2001 to 31st March 2002

    An audit of patient information
    Pre-dialysis: management of anaemia




10.2 Pre-dialysis: Audit of Haemoglobin and Epo use


10.2.1 Aims & objectives

    To determine the extent of Epo therapy in the pre-dialysis population
    To compare criteria for prescribing Epo in pre-dialysis patients
    To compare Hb levels in Epo prescribed pre-dialysis patients and non-Epo prescribed pre-
     dialysis patients (taking account of the induction and maintenance stages of Epo therapy).
    To observe and compare the relationship between ferritin and Hb
    To observe and compare trends in blood transfusions in Epo prescribed pre-dialysis patients
     and non-Epo prescribed pre-dialysis patients


10.2.2 Evidence base

    Revicki et al (1995) Health related quality of life associated with recombinant human
     erythropoietin therapy for pre-dialysis chronic renal disease. American Journal of Kidney
     Disease, (25), 548-554.
    Richardson D, Barlett C, Will, E. (2001) Optimising Erythropoietin Therapy in Haemodialysis
     Patients (38) 109-117
    Consensus Development Conference Panel (1994): Morbidity and mortality of renal dialysis:
     An NIH consensus conference statement. Annuals of Internal Medicine, 121, 62-70.
    Silverberg et al (2001), The effect of IV iron alone or in combination with low dose
     Erythropoietin in the rapid correction of anaemia of chronic renal failure in the pre-dialysis
     period. Clinical Nephrology,3. 212-219.


10.2.3 Standards

Draft Renal Association Standard 20023

    Target haemoglobin: Patients with chronic renal failure should achieve a haemoglobin of
     >10g/dl within 6 months of being seen by a nephrologist, unless there is a specific reason.
    Adequate iron status: Patients should be iron replete to achieve and maintain target
     haemoglobin whether receiving Epo or not. A definition of adequate iron status is a serum
     ferritin >100g/l and 10% hypochromic red cells (transferrin saturation >20%).
10.2.4 Patients

   All follow up patients attending Pre-dialysis (Low clearance) and Nephrology clinics in
    August 2001 at MRI, SRH, RLH and LTH and who had a creatinine above 400mol/l.


10.2.5 Methods

   Data was obtained from computer systems and patient records.
   Data was collated and analysed by the regional audit facilitator (Manchester zone).


10.2.6 Health disciplines

   Specialist renal nursing (Epo co-ordinators and pre-dialysis co-ordinators)
   Renal dietetics
   Haematology
   Biochemistry
   Blood Transfusion


10.2.7 Results

      With the exception of the MRI where fewer pre-dialysis patients are on Epo, prescribing of
       Epo is uniform. At the time of the audit, the MRI was in a period of change and 81% of
       the pre-dialysis population had just started therapy.
      RLH, SRH and LTH are close to meeting the draft Renal Association standards in this audit.
       MRI performs less well.
      With the exception of LTH, ferritin tests are not systematically performed in pre-dialysis
       patients not receiving Epo.


10.2.8 Conclusions

   There are many pre-dialysis patients who are not receiving Epo who could benefit from
    intervention.


10.2.9 Recommendations

   The recommendations are currently under discussion.




10.3     Patient Information


10.3.1 Aims and Objectives

        To determine whether the information given to patients meets their needs in relation
         to: timeliness, relevance, usefulness and whether it was in their native language.
        To assess whether the information is adequate for the preparation of dialysis
        To assess whether written information is consistent with verbal information
        To observe differences between Haemodialysis patients and CAPD patients




10.3.2 Evidence base
       Spiers H. Communication. Clarity begins at home. Health Service Journal 1998 108
        (5594) 28-30
       Charnock D et al. DISCERN: an instrument for judging the quality of written information
        on treatment choices. Journal of Epidemiological Community Health 1999 52) 22) 105 –
        111.


10.3.3 Standards

       No standards or guidelines were available at the time of this audit.


10.3.4 Patients

       10 HD and 10 CAPD patients from MRI, LTH, RLH and SRH, who had started dialysis
        between the 1st October 2001 and 31st December 2001 were included in the audit.
       10 patients from each satellite unit, who on 1st October 2001 had most recently started
        dialysis.


10.3.5 Methods

       Patients were asked to fill in a questionnaire about the information they had received.
       Data was collated and analysed by the Regional Renal Audit Facilitator


10.3.6 Health disciplines

     Dietetics
     Nursing
     Pharmacy


10.3.7 Results

       CAPD patients received the most information.
       Deficient topics (i.e. those where <80% of the patients received information) were
        blood pressure and medication for CAPD patients.
       Unit HD patients had deficiencies in all topics.
       Satellite unit patients had deficiencies in all topics with the exception of diet.
       Although some information is available in languages other than English through tapes
        and video, there is still no or little written information.
       Fewer patients from the satellite units wanted more information.


10.3.8 Conclusions

   There are significant deficiencies in the written information given to haemodialysis patients.
   The needs of patients who are unable to read English should be assessed to determine
    whether they require more written information.


10.3.9 Recommendations

  All units should review the information given to haemodialysis patients.
  Units should consider asking individual patients about their needs for written information
   and introducing training programmes, similar to those arranged for CAPD patients, for new
   maintenance haemodialysis patients.
  Re-audit haemodialysis patients in 2 years.
11      Plans for 2002 - 2003
11.1    Programme of ongoing audit

All patients enrolled in a dialysis programme in the North West Region on 1 st May 2002 are
involved in the second round of data collection. This data is being collated at this time, and
analysis should commence soon.


11.2    Programme of individual audit

Audits under consideration for this programme include

    Withdrawal and withholding of treatment
    Patient facilities within renal outpatients’ departments
    Pre-dialysis: BP and cardiovascular risk / management of bone chemistry
    Evaluation of unmet need: renal impairment in patients not under renal review
    Depression in patients with renal disease


11.3    Pre-dialysis audits

A proposal to incorporate pre-dialysis patients into the audit process has been initiated with the
first pre-dialysis audit of anaemia presented in July 2002. This work is to be extended with a
view to incorporating this important area into the programme of ongoing audit.




12      Further Information


For further details on the North West Region Renal Audit Programme, please contact Dr N M K
Reid, the Regional Audit Co-ordinator, email: nicola.reid@smuht.nwest.nhs.uk, Mrs B Bellingham,
Regional Renal Audit Facilitator, email: bernadette.bellingham@smuht.nwest.nhs.uk or Miss L Palmer,
Regional Renal Audit Facilitator, email: lorraine.palmer@smuht.nwest.nhs.uk at the Clinical Audit
Department in Wythenshawe Hospital (telephone: 0161 291 5821).


References




1       Ansell D, Feest T. UK Renal Registry Report 2001. Bristol: UK Renal Registry 2001.
2       Renal Association Standards subcommittee. Treatment of adult patients with renal
        failure: Recommended standards and audit measures (Second edition) London: Royal
        College of Physicians, 1997.
3       Renal Association Standards subcommittee. Treatment of adult patients with renal
        failure: Recommended standards and audit measures (Third edition) London: Royal
        College of Physicians 2001. Draft chapters available at www.nephronline.org/standards3/
4       NHS Executive. Diabetes National Service Framework. London: Department of Health
        2002.
5       NHS Executive. Older People National Service Framework. London: Department of
        Health 2001.
6       Kidney Diseases Outcomes Quality Initiative. Kidney Diseases Outcomes Quality
        Initiative: Clinical Practice Guidelines. New York: The National Kidney Federation 2000.
7       The Kidney Alliance. End Stage Renal Failure – A Framework for planning and service
        delivery. London: Royal College of Physicians, 2001.
Appendix one




Objectives of the North West Region Renal Audit Programme




To achieve the principal aim the objectives of the programme are:

   To implement standards of care using clinical effectiveness indicators based on the Renal
    Association Standards Document.
   To effect change by benchmarking data collected in a programme of ongoing audit, against
    data from other regional renal units and data from renal units contributing to the UK Renal
    Registry.
   To evaluate outcome (including cardiovascular outcome) by monitoring risk factors and
    patient management on a regional renal audit database and relating these to data from the
    programme of ongoing audit.
   To improve cost effectiveness in the audit process by designing audits around automated
    data capture.
   To improve clinical care in areas not covered by the programme of ongoing audit by looking
    at the feasibility of new audits and including those with strong evidence for resultant
    improvement in a separate programme of individual audit.
   To develop the Regional Renal Audit Programme in collaboration with the Study of
    Implementation of Renal Standards.
Appendix two




Renal units participating in the North West Region Renal Audit Programme




   Accrington & Victoria Hospital - Communicare NHS Trust
   Arrowe Park Hospital - Wirral Hospital NHS Trust
   Birch Hill Hospital - Rochdale Healthcare NHS Trust
   Clatterbridge Hospital - Wirral Hospital NHS Trust
   Chester Dialysis Unit - Wirral Hospital NHS Trust
   Devonshire Road Hospital - Blackpool, Wyre & Fylde Community Health Services NHS Trust
   Furness General Hospital – Morecambe Bay NHS Trust
   Hope Hospital - Salford Royal Hospitals NHS Trust
   Leighton Hospital - Mid Cheshire Hospitals NHS Trust
   Macclesfield District General Hospital - East Cheshire NHS Trust
   Manchester Royal Infirmary - Central Manchester and Manchester Children’s University
    Hospitals NHS Trust
   Broad Green Dialysis Centre - Royal Liverpool & Broadgreen University Hospitals NHS Trust
   North Manchester General Hospital - North Manchester Healthcare NHS Trust
   Prestwich Hospital - Mental Health Services of Salford NHS Trust
   Royal Liverpool University Hospital - Royal Liverpool & Broadgreen University Hospitals NHS
    Trust
   Royal Preston Hospital – Lancashire Teaching Hospitals NHS Trust
   Warrington Hospital - Warrington Hospital NHS Trust
   Waterloo Day Hospital - Aintree Hospitals NHS Trust
   Westmorland General Hospital - Morecambe Bay NHS Trust
   Whiston Hospital - St Helens and Knowsley Hospitals NHS Trust
   Withington Hospital - South Manchester University Hospitals NHS Trust
   Wythenshawe Hospital - South Manchester University Hospitals NHS Trust
Appendix three




Membership of the North West Region Renal Audit Steering Group




Members of Steering        Title                                   Organisation
Group

Dr R Ahmad                 Consultant Renal Physician              Royal Liverpool University
                           (Mersey Chair)                          Hospital

Mrs B Bellingham           Regional Audit Facilitator              Manchester Royal Infirmary


Dr R Coward                Consultant Physician and Nephrologist   Royal Preston Hospital
                           (Lancashire Chair)

Sr L Crosby                Senior Haemodialysis Sister             Hope Hospital


Sr N Kerigan               Senior Haemodialysis Sister             Royal Preston Hospital
                           Regional Audit Facilitator

S/N V Mitchell             Haemodialysis Staff Nurse               Royal Liverpool University
                           Regional Audit Facilitator              Hospital

S/N L Palmer               CAPD Staff Nurse                        Manchester Royal Infirmary
                           Regional Audit Facilitator

Dr N Reid                  Regional Audit Co-ordinator             Manchester Royal Infirmary


Dr D Smithard              Consultant Physician                    Birch Hill Hospital


Sr N Tannahill             Epo Co-ordinator                        Royal Liverpool University
                                                                   Hospital

Sr L Uttley                Senior CAPD Sister                      Manchester Royal Infirmary


Dr M Venning               Consultant Renal Physician              Manchester Royal Infirmary
                           (Manchester Chair)

Sr R Worsman               Senior Haemodialysis Sister             Westmorland General Hospital
Appendix four




Audit planning




To improve the effectiveness of the clinical audit process a project plan is developed for every
audit topic. For all audits the plan identifies


The reasons for topic selection:

   the purpose of the audit
   the patient health improvement
   the evidence base
   whether the audit addresses national or regional renal service priorities


The methodology:

   the   standards available
   the   methods
   the   sample
   the   time scale of project
   the   disciplines involved


The implementation of change:

   how recommendations might be implemented
   the persons responsible for monitoring change (this process is developed as the audit is
    undertaken)
Appendix five




Abbreviations used in this report




   AVH         Accrington & Victoria Hospital
   APH         Arrowe Park Hospital
   BHH         Birch Hill Hospital
   CBH         Clatterbridge Hospital
   CDU         Chester Dialysis Unit
   DRH         Devonshire Road Hospital
   FGH         Furness General Hospital
   SRH         Hope Hospital
   LEH         Leighton Hospital
   MDH         Macclesfield District General Hospital
   MRI         Manchester Royal Infirmary
   BGC         Broad Green Dialysis Centre
   NMH         North Manchester General Hospital
   PRH         Prestwich Hospital
   RLH         Royal Liverpool University Hospital NHS Trust
   LTH         Royal Preston Hospital
   WAH         Warrington Hospital
   WDH         Waterloo Day Hospital
   WGH         Westmorland General Hospital
   WHH         Whiston Hospital
   SMH         Withington Hospital
   WYH         Wythenshawe Hospital
Appendix six




Audit presentations




Two presentations of the work done on the programme of ongoing audit in the period 1st April
2001 to 31st March 2002 have been given to audiences in the North West Region.

   North West Region Renal Audit Programme
   North West Regional Peritonitis Audit

Two presentations of the work done on the programme of individual audit in the period 1st April
2001 to 31st March 2002 have been given to audiences in the North West Region.

   An Audit of Patient Information in the North West Region Renal Units
   Pre-Dialysis Management of Anaemia

See below for these presentations.

				
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