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Contents
Executive Summary
Acknowledgements
1.0 Program Statistics
2.0 Vascular Access
3.0 Medication Usage
4.0 Renal Clinic Statistics
5.0 PD Catheter Surgeries
6.0 Home and Satellite Dialysis Unit Statistics
7.0 Capacity Trends
8.0 Acute Off-Unit Hemodialysis Treatment Support
9.0 Bacteremia Rates for RDU Dickson (2015 Calendar year)
Research
Accreditation
Patient and Family Engagement
Initiatives
Quality Care Teams
Directions/Priorities for Future Planning
Executive Summary
The Central Zone Renal Program’s vision of ‘Innovative Quality Renal Care’ is achieved through its mission statement of ‘working with the health care system, its partners, patients and families to achieve optimal integrated care through advocacy, education, research, and leadership’. The Renal Program offers many services at many locations. Included are the Renal Clinic, Home Unit, Satellite Units, and in Halifax at the Dickson Building Hemodialysis Unit, Halifax Infirmary(HI) Hemodialysis Unitand at the Dartmouth General Hospital (DGH) Hemodialysis Unit. The program is multidisciplinary and includes Nephrologists, Nurse Practitioners, Pharmacists, Clinical Nurse Educators, Registered Nurses, Licensed Practical Nurses, Dietitians, Social Workers, Information Technology (IT) Systems Analysts, Clerical Support, Renal Assistants, Biomedical Technicians, a Vascular Access Nurse, and a Peritoneal Dialysis (PD) Access Nurse. The Renal Program maintains strong relationships with Inpatient Nephrology, Multi Organ Transplant Program, Victorian Order of Nurses and Continuing Care, Interventional Radiology, Vascular Surgery, General Surgery, the Nova Scotia Renal Program (NSRP), and the Cape Breton, Yarmouth, IWK, and Prince Edward Island (PEI) Renal Programs. The program also clinically supports the Guysborough, Antigonish, Strait Health Authority (GASHA), Truro,Berwick, Liverpool, Pictou, Port Hawkesbury, Springhill and the Colchester East Hants Health Centre Satellite HD Units.
The multidisciplinary Renal Clinic receives Outpatient Nephrology consultations, offers appointments with Nephrologists and Nurse Practitioners, and offers pre-dialysis education sessions and small group education sessions. Key foci in the Renal Clinic are health promotion, slowing the progression of renal disease, and supporting patients with decision-making as they near the need for dialysis or transplant.
The Home Dialysis Unit supports patients and their families to dialyze in the comfort and convenience of their own home after completing education and training. For patients performing PD or Home Hemodialysis (HHD) in their own homes, there is 24 hour on-call support. Also, the unit supports the operation of small community dialysis units in Berwick, Liverpool, Pictou, Port Hawkesbury, Springhill, Guysborough, Antigonish, Strait Health Authority (GASHA), and Truro. Key foci in the Home Unit are to maximize self-management through home therapies and keep patients in their communities.
The Hemodialysis Units in the Dickson Building, HI and DGH provide a large portion of HD treatments in the Central Zone of Nova Scotia. The Dickson Building Hemodialysis Unit provides acute HD treatments off-unit in ICU, IMCU, or ERs, as well as fallback support for the rest of the Renal Program and other renal programs in Atlantic Canada including Yarmouth, Cape Breton, PEI, New Brunswick, and Newfoundland and Labrador.
The Renal Program strives for quality, and as such has many quality teams that each focus on improving the safety and quality of care that is delivered. The Renal Program is also committed to advancing renal care and is actively involved in the research community.
Finally, the Renal Program is continuously working with internal and external partners to provide high quality, sustainable patient and family focused appropriate care. This is facilitated by Kidney Patient Advocacy Committee, modality suitability assessments, conservative management support, the promotion of home therapies, and continued advocacy for access to required medications.
Tabassum Ata Quraishi M.B.B.S; MHA, Nephrology Quality Leader
Acknowledgements
This report would not have been possible without the support and contributions of many dedicated and talented individuals in the Renal Program and beyond. It would not be possible to individually acknowledge all those who assisted or contributed to the development of this report, however, the following deserve special mention. Special thanks go to the Renal Program Quality and Patient Safety Team for developing the framework for this Annual Report, and also to Doctors Steven Soroka, Ken West, and David Hirsch for their on-going guidance and support. Thanks goes to the committee chairs of each quality team for submitting on behalf of their respective teams their annual reports. Data was provided by Niall Sheehy and Michael Trumbull, the Renal Program Systems Analysts, as well as Nancy MacDonald from STAR Reporting, Kathy Hart from Infection Control, Denise Harrie, Program Secretary, Jeanette Squires, Data Entry Clerk, Paula Mossop, Vascular Access Nurse, Cindy Everett, PD Access Nurse, Clinical Leader Home and Satellite Dialysis, and Dave Riggs, BioMedical Engineering. Stephen MacKay from the Pharmacy Department provided all medication usage information. Karen Webb-Anderson, Quality and Patient Safety Leader for Critical Care provided CRRT data. Research information was provided Dr. Steven Soroka, Dr. Karthik Tennankore, Dr. Jo-Anne Wilson and Dr. Michael West. Finally, we would like to acknowledge all staff and physicians who on a daily basis focus their energy and attention on the care and safety of all patients and families. Each treatment, appointment, teaching or training session, surgical or radiological intervention, or change of modality requires a coordinated approach that involves many factors, variables, and team members. Thank you for all that you do.
1.0 Program Statistics
The following analysis includes all patients undergoing dialysis at theDickson Building Hemodialysis Unit, HI, and DGH, as well as those in the Satellite Clinics. Also included in this report are HHD and PD patients. These are referred to as cases in Central Zone in this report. These analyses do not include cases on Hemodialysis in Yarmouth, Cape Breton, PEI, and any other jurisdiction.
1.1 Total Number of Cases of Dialysis
There were 482 distinct cases on Dialysis in Central Zone Nephrology Program at the end of 2015-16. This is an increase by 7.3% from the end of last year’s total cases of 449. In last year’s report the total of cases for 2014/15 were mistakenly reported as 417. This was a result of an error of not reporting the numbers from HI.
1.2 Modality of Dialysis
Table 1 exhibits the distribution of the total number of cases of dialysis in Central Zone by modality from 2008/09 to 2015-16. At the end of year 2015/16, there were 482 total cases, out of these 269 (56%) were having their dialysis In-Centre, 136 (28%) in Satellite Clinics and 77 (16%) in Patient Homes. The proportionate use of dialysis in Satellite Clinics is increasing steadily each year over the last eight years; 21% of the total cases were in Satellite Clinics in 2008/09, this has increased to 28% of the total in 2015/16.
Table 1.1Number of Dialysis Cases by Modality, Central Zone, Fiscal year 2008/09 to 2015/16
Dialysis Modality Trends / In-Centre / Satellite / PD / HHD / Total / Growth Rate2015-2016 / 269 (56%) / 136 (28%) / 59(12%) / 18(4%) / 482 / 7.3%
2014-2015 / 254 (57%) / 122 (27%) / 54(12%) / 19(4%) / 449 / -2.3%
2013-2014 / 255 (55%) / 121 (26%) / 65(14%) / 19(4%) / 460 / 5%
2012-2013 / 247 (56%) / 115 (26%) / 58(13%) / 18(4%) / 438 / -1.1%
2011-2012 / 252 (57%)( / 112(25%) / 61(14%) / 18(4%) / 443 / 6.7%
2010-2011 / 244 (59%) / 90(22%) / 67(16%) / 14(3%) / 415 / -0.5%
2009-2010 / 228 (55%) / 91(22%) / 87(21%) / 11(3%) / 417 / 0.7%
2008-2009 / 242 (58%) / 89(21%) / 78(19%) / 5(1%) / 414
The temporal trends in number of cases by Modality of Dialysis from 2008-09 to 2015-2016 in Central Zone of Nova Scotia are presented in Figure 1.1. In 2015-16, there was a rise by 7.3% in the total number of cases from what it was in 2014/15. The rise was by 16% in the last eight years from 2008/09 to 2015/16. Increases are also observed in the total number of cases for In Centre Dialysis by 15cases (6%), Satellite Clinics by14 cases (11%) and Peritoneal Dialysis by 5 cases (9%) in 2015-16 from what they were last year. The total number of cases in Home Hemodialysis Unit was 19 last year and decreased to 18 in 2015/16.
The trends in the Use of Modality of Dialysis cases over the last eight years from 2008-09 to 2015-16 are presented in Figure 1.2. The trend line for the use of Satellite Clinics is upwards whereas the line for the use of Peritoneal Dialysis is trending downwards over time. The total number of cases increased by 16% from 2008-09 to 2015-16 and the total number of cases in Satellite Clinics increased by 52% in the same time period.
The proportionatedistribution of total cases of Dialysis by Modality in 2015/16 for Central Zone of Nova Scotia is presented in Figure 1.3. 16% of the cases were on Home Dialysis in 2015-16; this is 4% lower than the provincial target of 20%.
1.3 Distribution of Cases by Sex and Age
There were 597 patients who received dialysis during 2015-16 (Table 1.2). Some of them were separated from the program during the year; details of separations are presented in section 1.5. There were 353 males and 244 females, exhibiting a male: female ratio of 1.45: 1 in 2015-16.
Table 1.2Age Group and Sex Distribution of Cases of Dialysis by Modality, 2015-16
In Center / HHD / Satellite / PDAge (Years) / Male / Female / Male / Female / Male / Female / Male / Female
90-100 / 5 / 4 / 0 / 0 / 0 / 1 / 0 / 0
80-89 / 34 / 19 / 0 / 1 / 9 / 6 / 6 / 0
70-79 / 48 / 29 / 3 / 0 / 32 / 15 / 5 / 9
60-69 / 52 / 45 / 7 / 1 / 21 / 7 / 6 / 15
50-59 / 42 / 26 / 4 / 0 / 12 / 10 / 6 / 13
40-49 / 21 / 19 / 1 / 1 / 7 / 2 / 4 / 5
30-39 / 10 / 10 / 2 / 0 / 5 / 1 / 1 / 1
20+ / 6 / 4 / 0 / 0 / 3 / 0 / 1 / 0
Total
597 / 218 / 156 / 17 / 3 / 89 / 42 / 29 / 43
The distribution of cases during 2015/16 by age group in each modality is presented in Figure 1.4. The highest numbers of cases are between 60 to 69 years of age in In-Centre Hemodialysis(Dickson, HI and DGH), whereas the highest number of cases are between 70 to 79 years of age in Satellite Units.
The distribution of cases in each modality by sex during 2015-16 is presented in Figure 1.5. There is a male predominance in the use of dialysis in In- Centre, Satellite and In Home Hemodialysis, whereas there is female dominanace in the use of Peritoneal Dialysis as a modality.
1.4 New Cases of Dialysis by Modality (Incident)
Incident Dialysis Modality is defined as the initial Renal Replacement Therapy (RRT). Table 1.3 shows the distribution of new cases of dialysis by Modality in Central Zone from 2011/12 to 2015/16. This table does not capture changes of modality, for e.g. these numbers do not reflect any changes if the modality of dialysis is changed from Hemodialysis to Peritoneal Dialysis or from Transplant to Hemodialysis, etc.There were 103 new cases started on RRT during 2015/16, an increase by 2% from last year. Out of these 91cases were In-Centre and 12 on PD. None of the cases had HHD as their initial form of RRT during 2015/16.
Table1.3Distribution of New Cases of Dialysis byModality, Central Zone, 2011/12 to 2015/16
Incident Modality / 2011/12 / 2012/13 / 2013//14 / 2014/15 / 2015/16In-Centre / 80 / 73 / 83 / 87 / 91 (88.4%)
PD / 24 / 17 / 23 / 13 / 12 (11.6%)
Home HD / 2 / 6 / 3 / 1 / 0
Total / 106 / 96 / 109 / 101 / 103
1.5 Program Separations
Table 1.4 shows the distribution of patients by their Reasons of Separation from 2011/12 to 2015/16. During 2015/16, there were110 cases separated from the program. 75 cases were separated because of death; out of those who died, 30 cases had withdrawn the RRT before death. There were 19 transplants, 6 cases had recovered function and 10 were transferred out to another program.
Table 1.4 Program Separation Trends
Reason for Separation / 2011/12 / 2012/13 / 2013/14 / 2014/15 / 2015/16Death / 83 / 81 / 76 / 55 / 45
Transplant* / 36* / 40* / 16* / 25* / 19
Stopped Treatment / 22 / 23 / 13 / 42 / 30
Recovered Function / 8 / 3 / 6 / 6 / 6
Transferred to Another Program / 2 / 3 / 2 / 7 / 10
Other / N/A / 7 / 2 / N/A / N/A
Total Program Separations / 151 / 157 / 115 / 135 / 110
* This is the number of Central Zone Chronic Dialysis Patients who received a kidney transplant, and not the total number of kidney transplants performed at Central Zone*
1.6 Hemodialysis Treatments Performed
Table 1.5 shows the total number of hemodialysis treatments performed by the Renal Program from 2011/12 to 2015/16. This does not include home hemodialysis treatments independently performed by patients in their own homes.There were62,403 total procedures of hemodialysis performed during 2015/16. This is an increase by 6.7% from last year.
Treatment Location / HD Treatments 2011/12 / HDTreatments 2012/13 / HD Treatments
2013/14 / HD Treatments
2014/15 / HD Treatments
2015/16
Dickson Building Hemodialysis Unit / 34,056 / 31,022 / 30,953 / 31,241 / 33,072
DGH Hemodialysis Unit / 7,094 / 7,957 / 8,042 / 7,766 / 8,098
Satellite Dialysis Units / 15,816 / 17,429 / 18,310 / 18,560 / 20,057
Home Dialysis Unit / 215 / 436 / 113 / 102 / 126
Acute HD off-unit (ICU/IMCU/ER) / 910 / 904 / 726 / 796 / 1,176
Total HD Treatments / 58,091 / 57,748 / 58,144 / 58,465 / 62,403
Growth Rate / -0.6% / 0.7% / 0.5% / 6.7%
Table 1.5 Yearly Treatment Trends by Location, Central Zone,2011/12 to 2015/16
2.0 Vascular Access
2.1 Prevalence of Vascular Access
It is well documented that the Arteriovenous Fistula (AVF) has the best outcomes for the indicators of infection, adequate dialysis clearance, and mortality. Despite AVF’s having better overall outcomes than Central Venous Catheters (CVC’s), a CVC may be more appropriate for individual patients based on many factors including: co-morbidities including Peripheral Vascular Disease (PVD) and diabetes; clinical frailty; multiple unsuccessful AVF creation attempts; or patient preference. The Access Prevalence Trends from 2004/05 to 20015/16 are presented in Figure 2.1. In 2015-16, CVC was the dominant type of vascular access for RRT, 69% of RRT was performed using this access type and 31% AVF. There is an increase by 130% in the use of CVC for vascular access in the last decade from 2004/05 to 2015/16.
Access Prevalence by Program Area for 2015/16 is presented in Figure 2.2. Each program area exhibited a higher proportion of the use of CVC when compared with AVF except Patient Home where only 44% were CVC and 56% AVF. The proportion of total vascular access for CVC were 69%, 70%, 68%, 74%, 64% in Central Zone, DGHHemodialysis Unit, HI Hemodialysis Unit, Dickson Building Hemodialysis Unit, and Satellite Hemodialysis Units respectively during 2015/16.
2.2 Vascular Access Related Interventions
The Renal Program through the Vascular Access Nurse has developed a strong working relationship with both vascular surgery and interventional radiology. These strong relationships have been essential in providing safe, seamless, timely and appropriate vascular access-related care and interventions. This resulted in an improvement in waittimes as well as a rise in the number of vascular access surgeries performed. Well done! Table 2.1 shows Vascular Access Surgery Trends from 2011/12 to 2015/16. There were 114 patients seen for vascular access consultations during 2015-16. This was 3.6% more than last year’s number of patients seen for vascular access consultations. Out of the 114 consulted for vascular access, 90 (79%) had vascular access surgeries performed in 2015-16, which was an 18% increase from last year’s count of 76 vascular surgeries performed.
Vascular Access Surgery / 2011/12 / 2012/13 / 2013/14 / 2014/15 / 2015/16Number of Patients Seen for Vascular Access Consultation / 150 / 135 / 89 / 110 / 114
Vascular Access Surgeries Performed* / 107 / 140 / 57 / 76 / 90
Total / 257 / 275 / 146 / 186 / 204
Table 2.1Vascular Access Surgery Trends
* Vascular Access Surgeries include AVF Creations, Revisions, and Ligations*
Figure 2.3 shows a comparison between Vascular Access Referrals and Surgeries Performed over the last five years. During 2015-16, 79% of those referred had vascular access surgeries performed. There were 90 surgeries performed in 2015/16 which is 18% more than the total surgeries performed in 2014-15.
2.3 Vascular Access Wait Times
Vascular Access Average Wait Times in Days are presented for each quarter from 2013/14 to 2015/16 in Figure 2.4. This figure shows that the average vascular access wait times from the clinic to OR have gradually decreased during 2015-16 from 128 days in Q1 to 96 days in Q4. The graph also exhibits a declining trend in the average consult to clinic time for the first three quarters ofthe fiscal year 2015-16, whereas Q4 exhibited a rise in the average consult to clinic time.
2.4 Procedures Performed in Interventional Radiology (IR)
The IR procedure numbers are presented from 2011/12 to 2015/16 in Table2.2. There were 472 procedures performed in 2015-16 by IR. Although there was a decrease in fistulograms and fistuloplasties by 12 and 7 procedures each respectively in 2015-16 from last year, there was an overall rise in the number of procedures in IR by 4.6% in 2015-16 from last year.
Table 2.2 IR Procedure Trends, 2011/12 to 2015/16
Interventional Radiology (IR) Procedures
/ 2011/12 / 2012/13 / 2013/14 / 2014/15 / 2015-16Tunneled CVC Line Insertions / 115 / 131 / 109 / 134 / 158
Tunneled CVC Line Exchanges / 131 / 154 / 162 / 156 / 179
AVF Creations (NEAT) / N/A / N/A / N/A / 5 / N/A
AVF De-clots / 5 / 3 / 2 / 2 / 0
Fistulograms / 137 / 93 / 76 / 95 / 83
Fistuloplasties / 88 / 56 / 52 / 59 / 52
Total IR Procedures / 476 / 437 / 401 / 451 / 472
The trends in the IR procedure are presented from 2011/12 to 2015/16 in Figure 2.5. There was an increasing trend in Tunneled CVC line insertions and exchanges; whereas there was a declining trend in fistulograms and fistuloplasties over the last five years.
3.0Medication Usage
Medication costs do not include Aranesp® or Eprex®, as these medications are covered by the Department of Health and Wellness High Cost Drug Program. These costs are displayed separately for the Dickson Building, HI and DGH Hemodialysis units. Total drug cost in Dickson Hemodialysis Unit, DGH and HI were $869,089, $115,819 and $146,780 respectively in 2015/16.
Table 3.1 Drug Cost Trends of Dickson, HI and DGH Units, 2007/08 to 2015/16
Location / VG / DGH / HI2007-2008 / $774,431 / $124,446 / N/A
2008-2009 / $719,033 / $179,603 / N/A
2009-2010 / $1,205,459 / $138,843 / N/A
2010-2011 / $832,377 / $118,570 / N/A
2011-2012 / $742,174 / $106,998 / N/A
2012-2013 / $766,662 / $139,340 / N/A
2013-2014 / $867,095 / $137,676 / N/A
2014-2015 / $837,925 / $132,418 / $595*
2015-2016 / $869,089 / $115,819 / $146,780
The costs of drugs in Dickson Building Hemodialysis Unit and DGH from 2006/07 to 2015/16 are exhibited in Figure 3.1. The cost of drugs in HI is exhibited for the year 2015/16.
3.1 Medication in DGH
Table 3.2 Top Drug Costs in DGH HD Unit, 2006/07 to 2015/16
Drug $ Trending in DGH Hemodialysis UnitDRUG / 2006-2007 / 2007-2008 / 2008-2009 / 2009-2010 / 2010-2011 / 2011-2012 / 2012-2013 / 2013-2014 / 2014-2015 / 2015-2016
Alteplase / $8,001 / $20,032 / $60,736 / $70,592 / $65,024 / $57,152 / $62,464 / $74,410 / $78,464 / $82,205
Iron Sucrose / $13,125 / $21,375 / $31,088 / $29,812 / $23,775 / $18,075 / $28,200 / $37,688 / $31,875 / $7,500
Heparin / $6,479 / $8,294 / $15,033 / $6,322 / $4,525 / $2,894 / $11,874 / $12,999 / $12,163 / $10,864
Sodium Citrate / $0 / $0 / $0 / $3,831 / $6,591 / $6,449 / $7,384 / $8,671 / $6,463 / $8,624
Calcitriol / $774 / $2,322 / $5,169 / $5,255 / $4,031 / $2,108 / $1,061 / $982 / $940 / $2,358
Iron Dextran / $8,704 / $8,850 / $7,460 / $8,921 / $9,740 / $14,411 / $10,604 / $0 / $0 / $0
Sodium Thiosulfate / $8,602 / $43,471 / $49,097 / $5,839 / $0 / $0 / $0 / $0 / $0 / $0
Daptomycin / $0 / $0 / $0 / $0 / $0 / $855 / $0 / $0 / $0 / $716
The trend in the cost of the five most costly drugs in DGH from 2006/07 to 2015/16 is presented in the Figure 3.2. The total cost for Altepase, Calcitriol and Sodium Citrate increased in 2015/16 from what they were in 2014/15. Whereas the total cost forIron Sucrose and Heparin decreased in 2015/16 from what they were in 2014/15.
3.2 Medications in Dickson Centre
The top drugs used with their costs for Dickson Centre is presented in Table 3.3. Altepase was ranked highest in the budget for 2015/16.
Alteplase / $333,312 / $326,278 / $397,254 / $374,720 / $378,240 / $442,368 / $457,326 / $464,832 / $464,246
Iron Sucrose / $54,188 / $79,238 / $75,150 / $69,525 / $56,888 / $119,850 / $195,675 / $159,000 / $202,575
Sodium Thiosulfate / $173,344 / $97,328 / $358,446 / $140,306 / $88,664 / $13,115 / $58,197 / $56,403 / $77,297
Heparin / $76,868 / $75,929 / $34,345 / $32,325 / $37,606 / $58,632 / $59,795 / $67,608 / $49,523
Sodium Citrate / $0 / $0 / $31,158 / $46,402 / $53,799 / $48,840 / $47,889 / $46,925 / $38,872
Danaparoid / $24,783 / $30,777 / $2,359 / $13,365 / $11,990 / $9,518 / $14,032 / $14,698 / $15,412
Calcitriol / $8,806 / $15,682 / $12,258 / $9,274 / $4,637 / $5,187 / $2,849 / $2,998 / $2,797
Bacitracin-Gramicidin-Polymyxin Oint / $6,275 / $7,574 / $7,256 / $8,925 / $6,709 / $4,368 / $3,904 / $3,350 / $2,588
Water for Injection / $2,469 / $2,664 / $3,475 / $3,134 / $2,977 / $3,338 / $2,671 / $2,439 / $2,214
Vancomycin / $3,236 / $3,153 / $3,759 / $3,562 / $2,783 / $3,615 / $3,824 / $2,861 / $1,984
Dimenhydrinate / $790 / $1,411 / $2,082 / $3,084 / $2,143 / $873 / $668 / $668 / $1,657
Cefazolin / $1,629 / $2,258 / $2,141 / $2,122 / $2,261 / $1,469 / $965 / $1,360 / $1,469
Sodium Ferric Gluconate Complex in Sucrose / $234 / $47 / $609 / $2,508 / $914 / $2,358 / $11,119 / $7,155 / $1,091
Iron Dextran / $60,000 / $64,144 / $54,844 / $65,520 / $73,965 / $39,778 / $0 / $0 / $0
Table 3.3 Top Drug Costs in the Dickson Building Hemodialysis Unit, 2007/08 to 2015/16
The trend in the cost of the six most costly drugs used in Dickson Building Hemodialysis Unit from 2006/07 to 2015/16 is presented in the Figure 3.3. The total cost for Altepase remained almost the same; the total cost of Iron Sucrose, Sodium Thiosulphate and Danaparoid increased in 2015/16 from what they were in 2014/15; whereas the total cost for Sodium Citrate and Heparin decreased in 2015/16 from what they were in 2014/15.
3.3 Medications in HI
The top drugs used with their costs for HI is presented in Table 3.4. Altepase was of the highest cost in the budget for 2015/16.
Table 3.4 Top Drug Costs HI Unit
Drug $ Trending in HI Hemodialysis UnitDRUG / 2014-15
(not a full year) / 2015-2016
Alteplase / $0 / $65,850
Iron Sucrose / $0 / $32,625
Heparin / $0 / $31,004
Sodium Thiosulfate / $0 / $3,692
Sodium Citrate / $190 / $3,491
Danaparoid / $0 / $951
Calcitriol / $65 / $751
Sodium Ferric Gluconate Complex in Sucrose / $84 / $749
Insulin / $0 / $599
Bacitracin-Gramicidin-Polymyxin Oint / $127 / $560
Cefazolin / $33 / $559
Vancomycin / $0 / $372
3.4ESA Therapy
The quantity and cost of Erythropoietin Stimulating Agents (ESA) usage from 2012/13 to 2015/16 is presented in Tables 3.5, 3.6 and 3.7 for Dickson Building Hemodialysis Unit, HI and DGH respectively.