Quality Initiative to Grow Home Therapies is On Track

A quick post to acknowledge and thank our outstanding FHA renal team for their contribution to a recent quality initiative to support & grow home dialysis.  The initiative was launched this summer.

Since July 2015,

– Home Hemodialysis (HHD) has grown from 3% to 3.4% prevalence
– Peritoneal Dialysis (PD) has grown from 26.4% to 27.9% prevalence
– Overall, independent dialysis has grown from 29.4% to 31.3% prevalence

This is a phenomenal amount of growth in a very short period of time.

Remember, this isn’t about just moving a number.

We know that

– independent dialysis is associated with better outcomes than facility HD
– up to 50% of patients want independent dialysis so this accommodates patient choice & values
– patient we divert to urgent start PD instead of HD with a CVC avoid a therapy associated with increased morbidity/mortality
– independent therapy is less costly and lets us invest in better care throughout the rest of the program/health authority

Looking forward to us hitting our 33% target for independent modalities over the next year!


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A New BP Target in Chronic Kidney Disease?

In this brief piece which summarizes the recent rounds I presented on Nov 13, 2015 at Royal Columbian Hospital internal medicine rounds, I indicate why the results of SPRINT will change the targeted blood pressure for many of my patients with chronic kidney disease.

View Slides & Summary


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Fraser Health wins people’s choice award at 2015 BC Kidney Days

BC Kidney Days 2015 was a successful event that attracted a significant amount of local research, including several submissions from Fraser Health.  This year’s research award recipients are listed here.

Fraser Health’s Robin Cho et al were the recipient of the People’s Choice award for the poster entitled “Evaluation of Vancomycin Dosing Practices and Attainment of Target Pre-Dialysis Trough Levels in Hemodialysis Patients.”

Have a look at the poster here: Vancomycin in HD Poster



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Preventative Foot Care Project May Reduce Amputations, Hospitalization and Length of Stay in ESRD

At the 2015 BC Kidney Days, Dr. Shaoyee Yao and Sarah Lacroix present the preliminary results from a quality improvement project designed to reduce preventable complications from lower extremity wounds in patients on dialysis.

It has been know for some time that foot wounds are very common in patients on hemodialysis and peritoneal dialysis, affecting up to 30-40% patients.

In addition, lower limb disease is associated with an increase risk of death, with 5 year survival decreasing from 46% in those without lower limb disease, to 23% in those with disease.

The Fraser Health Renal program designed a CQI project to establish a multidisciplinary approach to early detection and treatment of lower limb lesions in patients with ESRD.

This project was funded via our discretionary fund for just these type of projects, in addition to funding from Amgen Canada.

We elected to roll out the pilot at the Abbotsford Regional Hospital (ARH) and compare outcomes in 2 ways.  We performed an observational analysis of patients outcomes, comparing outcomes at the same site the year prior to the intervention vs the year during the intervention.  Given some concerns over a possible Hawthorne effect or that foot care might have just improved due to general medical progress, we also elected to compared outcomes at control sites that were only offering routine foot care (Surrey Memorial Hospital and Royal Columbian Hospital).

Have a look at the slide deck included on this page (below).

Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients from Daniel Schwartz

In addition, Sarah Lacroix presents an excellent overview of the program and more details on our outcomes.

BC Kidney Days 2015 – Foot Care Nursing Breakout Session from Daniel Schwartz


In brief, our raw data comparing pre/post outcomes at ARH suggests that:

a) Amputations were reduced from 2.6% to 1.6% (RRR 38%)
b) Days in hospital were reduced from 9.0 to 5.6 per patient (RRR 38%)
c) Hospitalization for infection was reduced from 8.9% to 4.4% (RRR 51%), overall hospitalization rate was reduced from 18.9% to 17.5% (RRR 7.4%) and total length of stay was reduced

Raw data comparing outcomes at ARH (active intervention) vs SMH/RCH (control sites) suggest that:

a) Amputations were reduced from 3% to 1.6% (RRR 47%)
b) Days in hospital were reduced from 9.9 to 5.6 per patient (RRR 43%)
c) Hospitalization for infection was reduced from 8.5% to 4.4% (RRR 48%), overall hospitalization rate was reduced from 24.2% to 17.5% (RRR 28%) and total length of stay was reduced

It’s interesting to note that we saw an increase in hospitalization for peripheral vascular disease but less amputations and lower admissions for lower limb infections, suggesting that we were intervening earlier in the disease process.  This is also supported by a much lower length of stay in hospital overall.  This suggests that intervening earlier results in earlier revascularization and overall better outcomes.

In fact, this intervention resulted in approximately 3.4-4.2 less days of hospitalization for each patient in our program.


Extrapolating to our entire program (were we able to roll this out more widely across the health authority), with a ‘back of the napkin’ calculation:

a) Approximate number of patients with ESRD at FHA: ~1100
b) Approximate cost per hospitalization day (as per CIHI report) : ~$1000 per day
c) Approximate reduction in length of hospital stay per patient (mean of pre/post & active/control results): 3.8 days

1100 patients X 3.8 hospital day reductions/patient X $1000 per day

= $4, 180, 000

The financial investment to achieve these outcomes was relatively modest, with total expenditure of $80 888.76 during the period for which we report outcomes.

So that’s a potential $4,180,000 saved per year as a result of preventative foot care in ESRD.

Next step is to perform appropriate statistical testing and an economic analysis.  We are hopeful that we will confirm this intervention is highly cost saving, while at the same time showing an improvement in patient outcomes; essentially that it is cheaper to provide better care.

If we are able to demonstrate that the results are both statistically significant and economically advantageous, we will go back to funders to seek support for a widespread implementation of this preventative care program across the region, and hopefully the province.

What can we take away from this project?

a) Pending our statistical and economic analysis, it appears that investing in preventative care may result in better patient outcomes at markedly lower cost
b) Our discretionary project funds, in addition to industry sponsorship, can provide an amazing opportunity to explore new methods of improving outcomes (we are unique within FHA in that we have access to such funds)
c) Creating high quality project proposals is an important first step in identify projects that are set up for success.  While brief and simple, the foot care proposal we reviewed addressed the following:
a) the problem you’re trying to solve ie why does this matter?
b) what you’re going to do ie what’s the intervention?
c) how you’re going to define and measure success ie how will we know if we’ve succeeded?
d) what it’s going to cost
Have a look at the original proposal – it’s a great template for those considering future submissions.
View Foot Care Project Proposal



Ndip A1, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, Boulton AJ. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010 Apr;33(4):878-80. PMID: 20067975.
Orimoto Y1, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Yamada T, Tadakoshi M, Hida N. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013 Nov;58(5):1291-9. PMID: 23810259.
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Quality/Program targets

As members of the FHA renal team will see in this week’s “Program Update”, we will be focusing renewed attention to a few of our key program priorities.

As we’ve prioritized before, we will continue to focus on increasing uptake of independent modalities and decreasing the number of central venous catheters in use in our HD units.

Our goal for independent modalities is to reach a combined Peritoneal Dialysis and Home Hemodialysis rate of 33%.  We are currently at 30%, so have a bit of work ahead of us and will be calling on the entire program to support those patients wishing to transition to home dialysis.

We have been very successful in reducing our  PD peritonitis rates and are currently seeing patients, on average, with one episode every 43 months. Our goal here is to preserve this performance and target better than 1 episode in 40 months.

Lastly, for patients who have been on hemodialysis for more than six months, we are targeting an AVF/AVG prevalence rate of 63%. We are currently at 60%. We believe this can be achieved with the ongoing support of our teams.

We want to achieve these goals by August 31, 2016.  While these are certainly achievable goals, they will require focused attention and effort.

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Proactive Innovation: Procedure for Setting up Dianeal Bags and Administration Set for PD Catheter Insertion

Proactive Innovation: Procedure for Setting up Dianeal Bags and Administration Set for PD Catheter Insertion

I wanted to share a new set of nursing procedures for PD catheter insertions that have been contributed to by Sue Bal, Kim Neitsch and Pat Klassen.

While many of you many not be that interested in sterile setup for a PD catheter insertion, I wanted to share what I love about this little innovation.  When we insert PD catheters, we have always struggled to ensure we were adhering to sterile technique.   This can be tricky as the exterior of the PD bag isn’t sterile, yet the surgical space needs to remain sterile.

Thankfully, our post-procedural infection rate has essentially been zero.  That being said, our PD RNs identified this as a potential risk.  Rather waiting for an infection and reactively addressing it, they proactively came up with a novel method to help reduce the risk of post-procedural infection.

I also love that the solution, once laid out clearly, seems quite obvious.  The answer was hiding in plain sight but it just took interested healthcare providers to make the solution real.

I’m hoping we’ll see more and more proactive solutions developed to potential quality issues.

So what did they do?

Have a look:

Slide01 Slide02 Slide03 Slide04 Slide05 Slide06 Slide07 Slide08 Slide09 Slide10 Slide11 Slide12 Slide13 Slide14 Slide15 Slide16

Do you have any innovations you’ve been working on within the renal program that others within our program or at other sites might be interested in hearing about? Please let me know.




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Updating Renal Connect

Updating Renal Connect

RenalConnect is an open-source, web-based, and freely-available (via GitHub) clinical management tool we developed in the Fraser Health renal program in order to assist with management of PD peritonitis, as well as tracking and managing patients being followed by our “transition nurses”, ie those who are new starts to hemodialysis or at high risk of needing to start dialysis imminently.

We have phased-out usage of RenalConnect for PD peritonitis as the features have been rolled into PROMIS.  While we used RenalConnect for managing peritonitis as part of our quality improvement strategy, we noted a significant impact on our program and presented these findings at the American Society of Nephrology meeting in 2012.

Our transition nurses have been using RenalConnect to track and manage their caseloads.

We are strong believers that when we track data as part of our clinical care (rather than simply have clerks or analysts enter data retrospectively or prospectively), the data records and reports generated are more accurate and useful.  Simple put, our fantastic clinicians will likely enter data really accurately as it impacts the person they are caring for.

As a result of being “power users” of the software, our transition nurses were able to provide insightful feedback.  We took this feedback and brought it back to our software developer, Dr. Dimas Yusuf, now a senior resident in Internal Medicine.

We were able to add some nice upgrades (and bug fixes) to the web application.

Some highlights:

  • Often, reporting out mean results can be significantly impacted by just a couple outliers.  We added median results in our reports to give a more complete picture of our outcomes.
    • In the example in the image below, while mean interval from starting HD to meeting a transition nurse if 17.2 days (red arrow), the median is actually 7 days (blue arrow).  This is due to a handful of outliers which skew the mean.2015-06-19_08-56-17
  • When we report out mean and median results, sometimes the results just don’t look like they make sense.  This can happen if there has been an error in data entry.  We’ve added the ability to “Inspect data”.  This feature allows one to drill down on all the data points (by clicking “Inspect data”, blue arrow) that make up any given metric and see if any of the values may be erroneous.  Inaccurate data points can then be quickly fixed (by clicking “manage start”, red arrow).


  • We added 2 new reports to assist with quality improvement in PD:  Time from PD referral to PD catheter insertion and Time from PD referral to PD start.2015-06-19_09-10-39

In general, patients on hemodialysis who are waiting to start PD are on dialysis using a central line.   We know that observational data suggests the any benefit of PD over HD in the short term is likely driven by central venous catheter usage1.  In addition, hemodialysis is much more costly that peritoneal dialysis2. Of course, people wanting to switch to PD from HD likely want it to happen sooner rather than later.  So it serves the triple aim of healthcare to move people onto peritoneal dialysis as quickly as possible.  This new reporting metric will allow our program to understand how we’re performing and try to tighten up our processes of care.

  • We added support for French and Spanish so it is more useful to other members of the global nephrology community.  Over time, we’d love to see contributors add support for more languages.
  • We added support for patients who may not yet have started dialysis (but were still being followed by our transition nurses), and for those who recovered after starting dialysis.
  • We fixed a ton of bugs, many of which were quite annoying.

Of note, all members of the Fraser Health renal team who need access, can login here http://renalconnect.com.

Login to RenalConnect


Any members of the FHA Renal team who need access, can do so by requesting it directly from the medical director.


We’ve made sure that RenalConnect remains a freely accessible tool that can be downloaded, installed, and implemented by anyone who wishes to use it around the world.  Our hope is that an open-source community will develop around this software and we’ll see it improve over time. Of note, the software developer has kindly agreed to offer a hosted and supported solution that allows medical teams to use the software without having to worry about setting up and maintaining their own installation.




Perl J1, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, Jassal SV, Moist L. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol. 2011 Jun;22(6):1113-21. PMID: 21511830.
Chui BK1, Manns B, Pannu N, Dong J, Wiebe N, Jindal K, Klarenbach SW. Health care costs of peritoneal dialysis technique failure and dialysis modality switching. Am J Kidney Dis. 2013 Jan;61(1):104-11. PMID: 22901772.
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Fraser Health Renal | Success Story in an Infographic

Fraser Health renal has a lot to be proud of.  Here are a few items that I could display really simply using an infographic.   I used a low cost, easy to use service call infogr.am. A picture is worth a thousand words so I’ll stop typing now.


FHA Renal Success Stories | Create infographics
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Secure sharing of patient information

Secure sharing of patient information

We live in an era of ubiquitous computing using mobile devices, where we can get instant updates on social events from our family and friends on Facebook, instantly share  photographs that capture important moments in our lives on Instagram and even do our day-to-day banking whenever and wherever we have a free moment.

Yet in healthcare, we have struggled to advance past handwritten notes, desktop-based medical record applications and faxed messages.

Healthcare professionals are now at a crossroads.

We know what can be achieved using the latest in mobile and secure communications, yet struggle to adapt our professional lives given the security and privacy requirements when sharing patient information.

As a result, our patients may be impacted by missed opportunities for their care team to communicate through digital channels, or have the security of their personal health information potentially threatened by well-meaning health care providers who use insecure means such as email and text messages.

I’m going to share a few examples of what I’ve been exploring in my own practice, and compare/contrast what’s happening vs how we could do things differently with concrete, real-world examples.

Inter-provider messaging/communication

Status quo

In Fraser Health, when a member of the health care team needs to contact a physician, we generally send a page, or perhaps call a cellphone.

While a reliable means of communication, there is no mechanism to identify the priority of a message and it can interfere with existing workflow and patient care.  Most physicians can remember examples of  being paged to get a laxative order for a patient with mild constipation while in the middle of managing a critically ill patient.  While the incoming message may be important, it may not be urgent enough to interrupt the current activity.

There’s likely a reason while the millennial generation has larger abandoned voice and moved to text.  It’s far more efficient, adapts to a fast paced lifestyle and allows one to prioritize easily.  Seems to be an excellent match for healthcare.

Reports from US institutions suggest that HCPs are frequently using insecure technologies to send digital messages.  There is every reason to believe this is also happening in Canada.


In the Fraser Health renal program, we been trialling a secure messaging platform provided by Medinet (the same folks who get lab results securely/digitally into physicians medical records).


How does it work?

It’s basically like email, but more secure.

For those who are unaware, we can’t send email that contains personal health information, as email gets transmitted around the world through the open internet.  If you wouldn’t write something on the back of a postcard, it shouldn’t go in email.  So email is not safe for the personal health information of our patients as it’s too easy for someone to intercept and isn’t compliant with privacy legislation.

Secure messaging ensure that the content of a message cannot be accessed by anyone but the intended recipient while in transit or stored on a server.

If anyone did see the content of a message, it would look something like this (as it has been encrypted):


Our partners in IT and privacy spent more than 1 year vetting the Medinet secure messaging solution and we’ve now been piloting it in our Royal City Kidney Care Centre.

By using this technology, the Kidney Care team can easily communicate with the physician as needed to address important but non-urgent issues, despite challenges of distance and competing priorities (such as on call emergencies).

With the pilot successful thus far, I’m really looking forward to this technology rolling out to more members of our renal program.

Physician submissions to Medical Services Plan (MSP)

Status quo

Physician are frequently paid via a fee for service model rather than being salaried or employed by the health authority.  This requires that the physician record the following information for patient encounters: patient name, personal health number, date of birth, date/time of contact, service provided and diagnosis.  This information must then be submitted electronically to the Medical Services Plan (MSP) and physicians often using billing agents to achieve this.  How the patient health information gets from the bedside to MSP is essentially up to each individual physician, but given the sensitive nature of the information, it should be protected in keeping with privacy requirements.

The challenge is that there are no existing secure methods to extract, record and transmit this information from the hospital to a physician’s office or billing agent, and existing physician practices are not well described.

Anectodally, it would seem that many are recording this information on paper and physically transporting it, with the risk of documents being lost or misplaced along the way.  One might also speculate that some may use insecure digital solutions such as email, excel, or dropbox to transmit this information.  Again, these solutions wouldn’t meet the security and privacy requirements needed when storing and transmitting personal health information (PHI).


Ideally, I’d like a solution that allows physicians to capture the information required for billing using a digital device that cannot be accessed by others, and then securely transmits this information to their billing agent.

As it turns out, I’ve discovered a solution which offers this exact service.

Dr-Bill.ca offers a mobile app for iPhone that allows physicians to easily capture required demographic data on patients they see in hospital or clinic.  The information is protected behind a secondary login (known only to the physician) as well as layers of digital security, both on the device and in the servers where the information is housed.


While the information is moved from the iPhone to Dr Bill’s server, it is encrypted.  This means that even if someone could intercept the data being shared, it is impossible to understand what it says.  This is the same technology that allows one to safely move ones banking information between the bank’s computers and ones laptop or smartphone.

Dr-Bill is already an approved billing service by MSP, and has been required to meet their privacy and security requirements.

This solution has recently been submitted to Fraser Health for evaluation and I look forward to the review, and (hopefully) approval of this solution.

Getting second opinions on visual diagnoses

Status quo

Health care providers frequently find themselves needing second opinions when making a diagnosis.  While some requests for assistance can easily be described in words (eg. How do you generally treat relapsing ANCA vasculitis?), in some cases, there is a distinct advantage to sharing an image. For example, when one is looking at an unusual rash or a difficult to interpret ECG, sharing an image can literally be worth a thousand words.

In the past, HCPs may have often been tempted to grab a photograph using their smartphone and share it insecurely with colleagues using email, SMS or other systems.


A recently launched app called Figure1 allows one to capture images in a secure manner and share them with like-minded colleagues to get more clinical input.  The app takes into account patient permission (with a built-in tool to document patient consent) and the need to make the image private (by deleting any identifying characteristics on a lab report or obscuring any unique identifiers such as a patient tattoo).


The app also takes advantage of the crowd-sourcing concept.  Rather than just asking an opinion from a single individual you might know, Figure1 offers the advantage of getting insights and input from thousands of colleagues from all over the world.  While the advice should not be used for medical diagnosis directly, it can certainly give more suggestions and ideas than simply flipping through a medical textbook or searching through PubMed.


With the advent of increasingly seamless and convenient digital communication tools, and a growing number of healthcare providers who have adopted these tools as part of their lifestyle, we shouldn’t be surprised to learn that patient information may increasingly be exchanged through inadequately secure mechanisms.

I’m hoping that healthcare organizations will get ahead of this trend and assess, then implement, secure digital services to protect patient privacy while simultaneously enhancing patient care.











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GFR at dialysis initiation

GFR at dialysis initiation

With the release of the latest Management Indicator Report from the BC Provincial Renal Agency, the Fraser Health renal program was able to learn a tremendous amount about our performance.

In a future post, I’ll spend more time discussing other performance indicators.  One indicator that is fascinating to examine today is mean eGFR at dialysis initiation.


On Feb 4, 2014, the CSN published the guideline “Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis.”

Primary recommendation of this guideline:

For adults (aged > 18 yr) with an estimated glomerular filtration rate (eGFR) of less than 15 mL/min per 1.73 m2, we recommend an “intent-to-defer” over an “intent-to-start-early” approach for the initiation of chronic dialysis. (Strong recommendation; moderate-quality evidence.)

With the intent-to-defer strategy, patients with an eGFR of less than 15 mL/min per 1.73 m2 are monitored closely by a nephrologist, and dialysis is initiated with the first onset of a clinical indication or a decline in the eGFR to 6 mL/min per 1.73 m2or less, whichever of these should occur first.

This guideline was based primarily on the results of the IDEAL study (A randomized, controlled trial of early versus late initiation of dialysis. NEJM 2010 12; 363 (7) :609-19) which showed no advantage to an earlier dialysis start.

Of note, the IDEAL study was published in 2010, while the CSN guideline was published in 2014.

While it generally takes a long time for clinical practice to adjust to new evidence/guidelines, it appears that eGFR at initiation of dialysis didn’t change after publication of IDEAL, but starting in the 2nd quarter of 2014 at around the time the CSN guideline was published, we saw a sustained drop in eGFR at dialysis start.

Previously, mean eGFR at initiation was 11-13 ml/min.  For the last 3 quarters, mean eGFR has ranged from 10-11 ml/min.

It will be interesting to see if this trend continues or is sustained.

An analysis of IDEAL also showed that patients randomized to a lower eGFR at dialysis initiation who intended to start peritoneal dialysis were less likely to actually start on PD that those with a higher eGFR at dialysis initiation (70% vs 80%, p = 0.01).

Given the slight decline in PD incidence/prevalence in FHA during this time period, one must consider whether the trend towards lower GFR at dialysis initiation is contributing.


Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, Quinn RR, Hiremath S, Ravani P, Sood MM, Moist LM; Canadian Society of Nephrology. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
Cooper BA1, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA; IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
Johnson DW1, Wong MG, Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA. Effect of timing of dialysis commencement on clinical outcomes of patients with planned initiation of peritoneal dialysis in the IDEAL trial. Perit Dial Int. 2012 Nov-Dec;32(6):595-604. PMID: 23212859.
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