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PRIORITIES FOR QUALITY IMPROVEMENT IN HAEMODIALYSIS: A BRS/UKRR NATIONAL SURVEY
Shaw S1, Casula A1, Cullen R1, Fluck R2, Tomson C3
1 = Renal Registry 2 = Royal Derby Hospitals 3 = Southmead Hospital
INTRODUCTION: There is extensive evidence of variation in the quality of many aspects of the care delivered to patients receiving haemodialysis by UK dialysis centres. Most of the variation cannot be explained by differences in case-mix or funding. It seems likely that this variation is caused by centre-to-centre differences in practice – the details of how care is delivered at organisational and patient level. Therefore there is a need to develop quality improvement initiatives to identify – and then accelerate the adoption of – best practice.
METHODS: In order to identify key priorities the Renal Association UK Renal Registry and the British Renal Society designed a web-based survey to identify priorities for quality improvement. Since haemodialysis patients represent the single biggest group of Renal Replacement Treatment patients, this survey sought to identify priorities for improvement in the care of these patients.
A list of seven potential QI topics was developed by discussion between the BRS and UKRR leadership. A web-based survey (SurveyMonkey) was then developed that allowed respondents to rank each topic by priority, with this question:
“If we were able to help you improve care in one of these areas, which would make the most difference to your patients?”. Seven topics were offered:
• Difficulties in cannulation (number of failed attempts to needle an AVF or AVG) – ‘cannulation’
• Intradialytic hypotension (temporary cessation of ultrafiltration, saline administration, or both) – ‘Hypo’
• High interdialytic weight gain – ‘IDWG’
• Use of a venous catheter for dialysis access – ‘Access’
• High serum potassium (pre-dialysis K+> 6.5 mmol.) – ‘potassium”
• Control of anaemia (maintenance of Hb between 100 and 120 g/L) – ‘Anaemia’
• High pre-dialysis phosphate (PO4 > 1.8 mmol/L) – ‘Phosphate’
A link to the survey was distributed to all Renal Association members (via eNews) and to all BRS virtual members and was posted on the websites of each participating organization. The survey was open for 30 days.
RESULTS: A total of 368 respondents completed the survey: 181 doctors, 150 nurses, and 37 others (including patient, dietitian, social worker, psychologist, technician, pharmacist).
Overall, when ranking by the number of first priority response, the order was:
Access > IDWG > Hypo > Cannulation > Phosphate > Potassium > Anaemia
The same order was observed for doctors, but nurses’ ranking was:
IDWG > Access > Cannulation > Hypo > Phosphate > Anaemia > Potassium
Considering the median priority score for each of the QI topics the ranking was:
IDWG > Hypo > Access > Cannulation > Potassium > Phosphate > Anaemia
Again amongst doctors the priorities remained the same, but this time, amongst nurses the priorities were very similar:
IDWG > Hypo > Cannulation > Access > Potassium > Phosphate > Anaemia
SUMMARY: There was a degree of consistency between professional groups, with priority given to the mechanics of haemodialysis itself against management of laboratory indicators. It will be important to discover if patients share the same priorities. The intention then is to identify the top area for work, identify indicators and develop change packages to help dialysis teams improve outcomes for patients.