THE

NORTH WEST REGION

RENAL AUDIT / OUTCOMES

PROGRAMME

THE 7th ANNUAL REPORT

1998-1999

August 1999

Forward

Dr R Ahmad, Dr R Coward and Dr M Venning (Mersey, Lancashire and Manchester Chairs of the North West Region Renal Audit Steering Group) would like to thank the staff and patients who have participated in the audit programme for their contribution to this work.

Introduction

The remit of the North West Region Renal Audit Programme, established in 1992, is to improve the quality and effectiveness of the renal services provided to patients over the North West Region.

In 1998 funding for the programme was secured for the two year period from 1st April 1998 to 31st March 2000. This report summarises the regional renal audit activity that has taken place within the audit programme under the guidance of the North West Region Renal Audit Steering Group in the first year of the current funding period.

The audit programme

The regional audit programme is a standards based programme of quality improvement which will assist in the development of clinical governance.

Principle aim

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 involving hubs, satellites and the community.

Participating centres

All renal units in the North West Region (incorporating Greater Manchester, Lancashire and Merseyside) participate in the audit programme. The units and their abbreviations used are listed in appendix one.

The national audit programme

In addition to participation in the regional audit programme all the renal units are also committed to participation in the national audit programme of the UK Renal Registry. The status at the time of this report was as follows

  • Participating centres - Royal Preston Hospital
  • Sites in progress - Royal Liverpool University Hospital
  • Sites under discussion - Hope Hospital, Manchester Royal Infirmary and Withington Hospital

As the UK Renal Registry develops, the North West Region Renal Audit Programme will continue to provide a standards based quality improvement programme but will develop in such a way to provide a service which will address issues of quality and outcome not measured by the UK Renal Registry.

Programme management

The audit programme is directed and managed by the multidisciplinary Renal Audit Steering Group, which

includes physicians, unit based nurses and community based nurses from every renal unit in the region (appendix two).

New developments

To further the programme of quality improvement the steering group has initiated a number of new developments to generate a programme of audit integrated with clinical care. The new developments include

  • A programme of ongoing prospective audit
  • A regional renal audit database
  • Clinical effectiveness indicators
  • A process of benchmarking against data from the UK Renal Registry

All these developments reflect a more systematic process of audit in which units can more readily compare their performance and identify those areas in which change is necessary.

Objectives

To take the new developments forward a series of objectives have been set for the current funding period:

  1. 1.To systematically monitor improvement in clinical care by developing clinical effectiveness indicators based on National and International Standards and applying them to an annual cycle of ongoing prospective audit.
  1. 2.To prospectively evaluate outcome by developing the programme of ongoing prospective audit on a regional renal audit database.
  1. 3.To improve cost effectiveness in the audit process by designing the programme of ongoing prospective audit around automated data capture.
  1. 4.To benchmark clinical care in the North West Region using data published by the UK Renal Registry.
  1. 5.To identify new audits which could lead to improvement in clinical care.

Forward plan

To meet the objectives for the current funding period the forward plan is to include:

Prospective ongoing audits (developed around Regional Renal Database / automated data capture)

  • CAPD Regional Peritonitis Audit(continuous since 1992)
  • An audit of haemoglobin and Epo usage(3rd audit)
  • An audit of adequacy(2nd audit)
  • An audit of cardiovascular risk(1st audit)

New Audits

  • An audit of acidosis
  • An audit of early death on renal replacement therapy
  • An audit of patient information
  • An audit of ethnicity
  • An audit of vascular access

Audit planning

To improve the effectiveness of the clinical audit process a project plan is developed at the start of each audit (appendix three). The plan identifies

The reasons for topic selection: the purpose of the audit, the patient health improvement, the evidence base and whether the audit addresses national or regional renal service priorities.

The methodology: the standards available, the sample, methods, the disciplines involved and the time scale of project.

The implementation of change: how recommendations might be implemented and the persons responsible for monitoring change (this process is developed as the audit is undertaken and finalised in the audit report).

Disseminating audit results

All audit data are presented at the quarterly steering group meetings and following discussion recommendations are made. The audit and recommendations are then presented at the participant units where local decisions are taken about the implementation of the recommendations for change. A detailed report is published and circulated to those affected by the audit. Results are published openly at unit level although physician confidentiality is always maintained.

The dissemination of information is increased through the Annual Report and the Annual North West Region Renal Audit/Outcomes Presentation Evening (see appendix four). Individual presentations have also been made to professional groups such as the Dietetic Association, the Renal Social Workers Association and the North West Kidney Club. Work has also been presented at Regional, National and International conferences (appendix five).

Implementation of Change

The audit cycle is completed by implementing recommendations and monitoring the resultant change. To help implement the recommendations, audits are presented at the participant units and an audit folder is being distributed to every unit to enable units to benchmark their performance (ongoing audits) and to encourage the use of guidelines developed regionally (new audits). Currently the folder contains results from the ongoing CAPD peritonitis audit and the guidelines developed following the last three audits

  • Bone Chemistry in Patients on Renal Replacement Therapy
  • An Audit of Hypertension in Haemodialysis Patients
  • An Audit of Poor Response to Erythropoietin Therapy

As clinical effectiveness indicators are identified and the move towards a programme of ongoing prospective audit takes place change will be monitored through the Regional Renal Audit Database and by bench marking against data from the UK Renal Registry.

Further information

For further details on any of the audits described in this report or for further information on the North West Region Renal Audit Programme, please contact Dr N M K Reid, the Regional Audit Co-ordinator, or Mrs N Austerberry, the Regional Renal Audit Facilitator at the Clinical Audit Department in Withington Hospital (telephone number 0161 291 3209).

Audits

An audit of patient information leaflets

Audit leads

Consultant

  • Dr R C Coward

Consultant Physician and Nephrologist

Royal Preston Hospital

Nurse specialist

  • Sister L Uttley

Senior Home Dialysis Sister

Manchester Royal Infirmary

Audit facilitator

  • Nicola Reid

Reasons for choice

Aims and objectives

  • To establish a database of the information available to renal patients.
  • To determine if there is adequate material for patients who do not speak English.
  • To determine whether the information provided meets the needs of the patient.

Proposed health benefit

  • To improve health status and quality of life
  • To improve communication between staff and patients

Evidence base

  • Spiers H. Communication. Clarity begins at home. Health Serv J 1998 108 (5594) 28 - 30.
  • Charnock D et al. DISCERN: an instrument for judging the quality of written information on treatment choices. J Epidermiol Community health 1999 52 (2) 105 - 111.

Priority

  • Regional

Methodology

Standards

  • None

Methods

  • The audit was done through a survey of the information given to patients and a survey of the information received by patients.
  • Data from the surveys was collated and analysed by the regional audit co-ordinator.

Patients

  • All patients who were accepted onto a dialysis programme in any of the five main renal units between 1.8.98 and 31.10.98 were included in the patient survey.

Data

  • Data collected in survey of the information given to patients: professional groups delivering information, topics available, standard of leaflets, timing of distribution and languages covered.
  • Data collected in the survey of the information given to patients: receipt of information, clarity of information, usefulness of information, consistency with verbal information and effectiveness in preparation for dialysis.

Source

  • Health professionals
  • Patients

Health disciplines involved

  • Dietitians
  • Epo co-ordinators
  • Hospital and community nurses
  • Pharmacists
  • Physicians
  • Social workers

Results

Analysis showed

  • The survey of information given to patients showed the range of information available to renal patients:

There was a large variation in the number of information leaflets available to patients at the main renal units (mean 76, range 48 - 135, minimum (RP) , maximum (MR)).

All of the main renal units provided information on the following: anaemia, benefits, bone disease, blood tests, diet, drugs, employment, fistula care, fluids, holidays, health education, help groups, hospital information, infections, infectious diseases, NHS services, overviews of pre-dialysis, dialysis, haemodialysis and peritoneal dialysis, procedures, religious needs, renal disease, sexual relationships, transplants and unit information.

There was a large variation in the number of information leaflets available to patients at the satellite units (mean 8, range 0 - 61, minimum (CL, DR and LE), maximum (WE)).

The content and aesthetic appearance of the leaflets varied greatly.

Nurses, dietitians, EPO co-ordinators and social workers hand out most of the information to patients.

  • None of the leaflets were available in languages other than English.
  • The survey of information received by patients showed that the information provided met the needs of the PD patient better than that of the HD patient:

100% of the PD patients surveyed had received some written information. Only 75% of the HD patients surveyed had received written information.

PD patients received insufficient information on drugs. HD patients received insufficient information on fluids, care of the fistula, infections, hypertension, drugs, transport and emergency contacts.

94% of the PD patients surveyed felt that the information had helped prepare them for their dialysis. This was only true for 42% of the HD patients.

33% of the PD patients wanted more information. 92% of the HD patients wanted more information.

The information actually received by both groups of patients was generally thought to be useful, clear and the same as that given verbally.

The survey was too small to identify problems specific to any individual unit.

Date of presentation

  • 11th January 1999

Action

Recommendations

  • The nurse managers on the five main renal units are to review the information available to HD patients.
  • The patient survey is to be repeated after one year. To identify problems specific to individual units the sample will be increased in size and extended to include all satellite units.

Planned change

  • A working party is to be set up to:

update the central database of information to allow information to be exchanged between the renal units.

introduce regional information leaflets in key areas (i.e. the diet sheets published by the Lancashire dietitians).

develop multi-lingual information leaflets in key areas.

Re-audit planned

  • Yes

An audit of early death on renal replacement therapy

Audit leads

Consultant

  • Dr D O’Donoghue

Consultant Nephrologist

Hope Hospital

Specialist registrar

  • Dr A Duggal

Specialist Registrar in Renal Medicine

Hope Hospital

Audit facilitator

  • Nicola Austerberry

Reasons for choice

Aims and objectives

  • To determine a definition of acceptance onto renal replacement therapy.
  • To measure the early death rate of patients starting dialysis.
  • To investigate the relationship between demographic and clinical factors, and early death.
  • To determine the proportion of patients who were associated with a classification of increased risk as defined by the EDTA classification of risk.

Proposed health benefit

  • To reduce early morbidity and mortality
  • To improve quality of life

Evidence base

  • Ratcliffe PJ. Late referral for maintenance dialysis. Br Med J 1984 288 (6415) 441 - 443.
  • Eadington DW. Delayed referral for dialysis. Nephrol Dial Trans 1996 11 2124 - 2126.

Priority

  • Regional

Methodology

Standards

  • Treatment of adult patients with renal failure - recommended standards and audit measures (second edition). Prepared by the Standards Subcommittee of the Renal Association 1997.

Recommended standard: Analysis of data on ESRF treatment

should be undertaken both from the point of initiation of

uninterrupted dialysis and at the 90 day time point.

Methods

  • Administrative staff helped to collect data retrospectively.
  • Data was collated and analysed by the regional audit facilitator.

Patients

  • All patients who started dialysis between 1.4.97 and 31.3.98 were included in the audit.

Data

  • Survival status at six and twelve months after the start of dialysis
  • Patient demographics
  • Co-morbidity factors
  • Whether the patient was known to the Nephrologist prior to starting dialysis (e.g. attendance at pre dialysis clinic)
  • Mode of dialysis at start of dialysis and at time of death
  • Albumin
  • Record of correspondence to GP
  • Risk classification (using European Renal Association classification of standard, medium and high risk according to age and diabetic status)

Source

  • Patient notes
  • Nursing documentation

Health disciplines involved

  • Physicians

Results

Analysis showed

  • Definitions of acceptance onto dialysis varied across the region which led to difficulties in comparing the results between the units. As a result some data may not be directly comparable.
  • 21% (n=105) of the patients identified as starting dialysis in the stated period (n=491) died within 12 months of commencing treatment and 13% (n=65) died within 6 months of commencing treatment:

The range for 12 month data was 10 - 27%, minimum WI (n=5/51), maximum HO (n=19/71) and RL (n=46/168).

The range for 6 month data was 4 - 18%, minimum - WI (n=2/51), maximum - HO (n=13/71) and RL (n=31/168).

  • The relationship between demographic and clinical factors was investigated for those patients who had died within the first 6 months of treatment:

Of the 65 patients who died within the first 6 months 62% (n=40) of patient’s notes were available for audit.

The mean age of the patients (n=40) was 63 years, 57.5% (n=23) were male and 42.5% (n=17) were female.

Co-morbidity factors: 35% diabetes (n=14), 20% IHD (n=8), 13% MI (n=5), 13% HF (n=5), 13% CVD (n=5), 23% PVD (n=9), 3% smoking (n=1), 8% myeloma (n=3), 5% malignancy (n=2), 40% hypertension (n=16).

70% (n=28) were known to the Nephrologist prior to commencement of dialysis.

80% (n=32) were HD and 20% (n=8) PD patients at the start of dialysis and at the time of death.

55% (n=22) had an albumin <35g/dl.

60% (n=24) had a record of correspondence to the GP.

  • For the patients whose notes were available for audit (n=40) 67.5% (n=27) were classified as high risk using the EDTA classification of risk (non-diabetics 65 years and over and diabetics 55 years and over).

Date of presentation

  • 13th April 1999

Action

Recommendations

  • To adopt the Renal Association standard for data analysis from the start of dialysis in all units.
  • To further define other risk factors by re-auditing prospectively with a closer evaluation of those patients identified as being high risk.
  • To evaluate strategies that would improve the selection process and reduce early mortality on renal replacement.

Planned change

  • A start of dialysis co-morbidity data collection form and a record of death summary are to be drafted and circulated to all the units and its use implemented when design has been agreed.

Re-audit planned

  • Yes

Control of acidosis in chronic haemodialysis patients

Audit leads

Consultant

  • Dr M C Venning

Consultant Renal Physician

Withington Hospital

Specialist registrar

  • Dr M Howse

Specialist Registrar in Renal Medicine

Royal Liverpool University Hospital

Audit facilitator

  • Nicola Reid

Reasons for choice

Aims and objectives

  • To measure the achievement of the Renal Association (RA) standard for the correction of acidosis in haemodialysis patients throughout the region.
  • To measure the proportion of patients with severe acidosis (where severe acidosis is defined as a pre-dialysis serum bicarbonate < 17.5 mmol/l).
  • To assess the impact of acidosis on nutrition and bone status.
  • To assess the impact of bicarbonate therapy on interdialytic weight gain and blood pressure control.
  • To assess any regional variation in the treatment of acidosis.
  • To compare individual unit performance and regional performance with national performance (measured by the UK Renal Registry).

Proposed health benefit

  • To reduce mortality
  • To slow down the progression of renal bone disease
  • To reduce the risk of muscle catabolism

Evidence base

  • Graham KA et al. Correction of acidosis in haemodialysis decreases whole body protein degradation. J Am Soc Nephrol 1997 8 632 - 637.
  • Lefebvre A et al. Optimal correction of acidosis changes progression of dialysis osteodystrophy. Kidney Int 1989 36 1112 - 1118.
  • Lowrie G and Lew NL. Death Risk in haemodialysis patients: the predictive value of commonly measured variables and the evaluation of death rate differences between facilities. Am J Kidney Dis 1990 15 458 - 482.
  • Movilli E et al. Evidence for an independent role of metabolic acidosis on nutritional status in haemodialysis patients. Nephrol Dial transplant 1998 13 674 - 678.
  • Papadyannakis NJ et al. The effect of calcium carbonate administration on nitrogen metabolism in patients on haemodialysis. Proc EDTA 1985 22 83 - 87.

Priority

  • National
  • Regional

Methodology

Standards

  • Treatment of adult patients with renal failure - recommended standards and audit measures (second edition). Prepared by the Standards Subcommittee of the Renal Association 1997.

Recommendation: A target pre-dialysis serum bicarbonate within