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).
    2015-06-19_09-04-35

2015-06-19_09-06-46

  • 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.

 

 

References

 
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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PD Prevalence Hits 30% in the FHA Renal Program

Our most recent home dialysis statistics from September 2012 are available and they are impressive.

We know that up to 50% of patients, give appropriate education and support, would choose home dialysis in the event they required renal replacement therapy.  Given that actual uptake of home dialysis is much lower, the FHA renal program has tried to enhance support for patients in their choice to pursue independent dialysis.

We detailed a multi-pronged approach to enhance home dialysis last year and I’m excited to share the fruits of our labour.

In October 2011, 2.3% of patients on dialysis in FHA were receiving home hemodialysis (HHD) and 26.5% were on peritoneal dialysis.  By the end of October 2012, our HHD rates were similar but peritoneal dialysis rates have climbed to 30%.  This gives an overall home dialysis prevalence of 32.3%.

This is a striking improvement and has only been achieved through an exceptional effort from all areas of our program.

My sincere thanks to everyone who has made the extra effort to support our patients.

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Fraser Health Well Represented at BC Kidney Days

BC Kidney Days was a successful event that took place last week.  It proved itself as an excellent venue to meet with like minded colleagues, advance our knowledge in the practice of nephrology and learn about new initiatives that we could move forward in our program.

The FHA team had a significant presence at the meeting with Dr. Charles Constantine serving as conference co-chair and  a large contingent of FHA team members presenting at and/or chairing the sessions.

Of particular note was the contribution of the FHA home hemodialysis (HHD) team who presented an outstanding poster.  The poster was selected by both judges and conference attendees as the top poster presentation at the conference.  The poster suggests that the educational in-services provide by the HHD team have increased HHD referrals by 69%.

See the poster for yourself:  Home HD poster Treasures

 

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Update on Home Hemodialysis Referrals

This post is contributed by Terry Satchwill BHSc, Manager, Renal Services (Peritoneal Dialysis, Home Hemodialysis, Kidney Care Centre, Renal Care Coordinators)

The FHA Renal program is trying to ensure that all patients who may be candidates for Home Hemodialysis (HHD) can get timely access to the program.

One of the first steps to get onto home hemodialysis is to get referred. So here’s a quick review of the referral process, the referral form, the inclusion/exclusion criteria and some quick facts.

In addition, information pamphlets, DVD’s and posters are available. Please call the HHD office (604-777-8734) to replenish supplies if any are running low & we will arrange to have them delivered to your unit.

We are pleased to announce up-coming education sessions called Hidden Treasures of Home Hemodialysis. The goal of these sessions is to educate staff and physicians about the benefits of HHD, to clarify the processes of referral, to give you an opportunity to meet some of the current HHD patients and hear their stories and to generally dispel some of the myths that surround HHD. Our HHD educators are making arrangements with your local renal educators to come to your areas starting in February. Watch for the dates!

Some quick facts:

• Referrals can come from anyone on the interdisciplinary team or the patient.
• If your patient is somewhat hemodynamically unstable this does not necessarily mean they will not do well on HHD. As a matter of fact they may do better!
• Patients do not necessarily need a helper and do not need to own their own home to be candidates for HHD.
• The HHD team will consult with the patients’ primary nephrologist as to their suitability for HHD.
• At the moment, we have 2 training sites- TCDU & PCDU

Nephrologist order to refer to HHD
• Complete application form & fax with the order to HHD office at 604-464-1403
or
• if time is limited, just fax the referral order to the same number

Referral to Home Hemodialysis Team
• Complete application form & fax to HHD office at 604-464-1403
or
• Phone call to HHD office (604-777-8734) stating patient name (with spelling) & dialysis unit

Patient expression of interest
• Patient can call the HHD office directly & leave their name & phone number or the name of their dialysis unit
• Patient can ask their nurse, social worker, dietitian or nephrologist to refer them & follow the process above

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Diane Watson Visits FHA Renal and Shares Her Successes in Optimizing Urgent Dialysis Starts

The FHA Renal Team was pleased to host Diane Watson, NP from the University Health Network (UHN) in Toronto, Ontario.  Diane has been working for many years with patients who have started dialysis suboptimally in hospital.  Her results are nothing short of miraculous.

We know that many patients would prefer home dialysis if given the opportunity.  At the same time, patients starting dialysis urgently never get the opportunity for the independence and improved quality of life we see with independent modalities.  Prior to starting her role as “transition nurse”, 87% of UHN patients starting dialysis urgently in-hospital ended up on in-centre hemodialysis and only 13% on home dialysis.

Since the start of her work, the UHN is now seeing only 37% patients remaining on in-centre hemodialysis with 63% migrating to home or independent dialysis.

I should point out that I had the opportunity to work with and learn from Diane when I was a medical resident and Nephrology trainee.  Not only does she facilitate choice and better outcomes for her patients, but she has a marvelous way with patients and her families, providing them with reassurance and hope.

Diane spent 2 days with our renal team –  1 day of workshops with a large multi-disciplinary group and a second day of rounds with the medical staff.  Our program was energized by her presentation in a way I haven’t seen before.  I’m exceptionally optimistic we’ll have the opportunity to learn from and adopt some of her techniques in order to provide our patients who start dialysis in an unexpected fashion with the best possible outcomes.

Not only does her care result in better patient choice and outcomes, but it is also highly cost effective.  The UHN experience suggests that her work saves exceptionally large sum that can be reinvested into other areas of the renal program.

For anyone who did not have the opportunity to attend, I’ve included her presentation here:

Vancouver 2012 Increasing use of Home Dialysis

 

 

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Promoting Independent Dialysis

Over the past number of weeks, I’ve had the opportunity to meet with the peritoneal dialysis teams and the FHA Nephrologists to brainstorm on ways to support and enhance home dialysis penetration within the FHA renal program.  I haven’t forgotten the home hemodialysis team and hope to spend some time with them as well.

We know that independent dialysis provides clinical benefits beyond that offered with in-centre hemodialysis.  In addition, the independence and lifestyle opportunities possible with home dialysis are a definite advantage for many of our patients.

So if home dialysis is so great, why aren’t all our patients receiving it?  Well, this is a complex question with no simple answers.  But, in no specific order, here are some ideas that could be implemented to enhance home dialysis within FHA.

Enhancing education on home dialysis

Almost all patients receiving dialysis in FHA flow through the Kidney Care Centres or make contact with the Renal Care Co-ordinator (RCC) through the hemodialysis units.  We need to ensure that the nurses and physicians working in these environments have adequate education about the advantages and opportunities for these forms of dialysis.  Dedicated training on site in the home hemodialysis and peritoneal dialysis programs may provide a unique opportunity for our team to become more comfortable teaching about these modalities.

FHA Nephrologists will create a lecture series on key topics in Nephrology.  These lectures will be no more than 15 minutes in duration and touch on key points about areas such as transplantation, vascular access and home dialysis.  With regards to home dialysis education, we will co-ordinate to ensure that all staff working in FHA have the opportunity to be exposed to the topic reviews, and commit to repeating the educational intervention on an annual basis.  With a more robust understanding of the benefits of home dialysis, we hope front line staff with be more equipped to encourage our patients to explore and pursue home dialysis.

To ensure all team members teaching about home dialysis have accurate information to share with prospective patients, we will need to provide up to date and readily accessible information on benefits and complications of each modality of renal replacement therapy, include those statistics which are specific to our program (eg. infection rates, modality success rates, etc).

Role of the Renal Care Co-ordinator

There has been much change and discussion around the role of the “Renal Care Co-ordinator”.  It is felt that this job has the most opportunity for significant impact by taking on the role of “transition nurse”. Patients new to dialysis should work with the RCC to achieve the following goals

a) encourage early living donor transplantation
b) encourage education and rapid transition to HHD or PD
c) for those patients that choose HHD or facility-based HD, facilitate rapid AVF creation
d) facilitate end of life discussion and decision making
The RCC role could be supported through rigorous and dedicated experiences in HHD and PD and through additional training with Diane Watson in order to adopt her published and highly successful strategy to quickly move new HD patients to home dialysis.  Of note, we’re excited to share that Diane has agreed to come to FHA to teach us her techniques.
We will also need to create formal communication tools to ensure the work of the RCC is communicated to the team in the hemodialysis units and the patient’s primary nephrologist.  This will likely be achieved through the use of existing information technology including the Meditech electronic patient record and our shared drive with patient lists.
Capacity

Increasing patient interest in home dialysis is only the start.  Will we be able to handle the load once patient volume increase?

For peritoneal dialysis, we will work to ensure we have the capacity to provide PD catheter insertion at RCH and ARH, and provide any needed IPD and PD training at both sites.  Surrey patients will continue to be supported through the RCH site.  We currently have 5 Nephrologists able to insert PD catheters at the bedside, with a 6th being trained.  We have excellent surgical support at RCH and while we have an interested surgeon at ARH, we are still petitioning to get OR time to facilitate this critical surgical activity.

Home hemodialysis presents a unique challenge given the long training period needed to get a patient comfortable doing hemodialysis independently.  We continue to recruit training nurses and will explore the option of training more than 1 patient per nurse (using staggered start dates).

Increasing Home Dialysis Candidacy

We will increase the number of patients who may be candidates for PD by continuing to promote such innovative programs as presternal PD catheter insertion, a unique technique to insert PD catheters that opens the door to PD for patients with ostomies and other conditions that previously were viewed as contraindications to PD.

Many patients need chronic placement and would be candidates for peritoneal dialysis.  We will work to increase the number of nursing home beds available to patients on PD, especially in the eastern region of FHA.

Patient Engagement

We know we will only be successful if we’re offering care that patients find attractive. We would like to physically move home dialysis patients and training so that other patients can directly observe their experience and hopefully seek to learn more.

We also believe that patients deserve to be exposed to educational materials in physician offices, the kidney care centres and the dialysis units so that they can learn about home dialysis, even when not formally working with a member of our clinical team.  These materials can include posters, pamphlets, educational videos and online materials.  We will make investments to ensure we have the appropriate DVD library and DVD players in the HD units.

Referral Process

In order to remove barriers to home dialysis, we will be encouraging all staff members to educate and refer, even if they are not the patient’s primary Nephrologist.  In the interests of continuity, there will be an expectation and systems in place to ensure the patient’s primary Nephrologist is aware and support the shift in dialysis modality.

We will be adding simple checkboxes on commonly used pre-printed order sheets, in order to both remind and expedite home dialysis referrals.

Cross-Promotion 

Patients who have experienced home dialysis generally don’t want to return to in-centre hemodialysis, even when medical conditions or social factors dictate that the modality is no longer possible.   We will work with the home hemodialysis and home peritoneal dialysis programs to ensure they cross-promote one another’s program.

Role of the Nephrologist

Many of our patients start dialysis in a suboptimal fashion with an inpatient dialysis start on a central venous catheter.  While the RCCs can certainly play a role in optimizing care, we will work to create a model whereby the patient’s primary nephrologist reviews all such patients within 4 weeks of starting dialysis – this will provide an opportunity to facilitate home dialysis transitions.

Just as we will use the PROMIS database to encourage physician review of patients’ vascular access, we propose to use the PROMIS database to review patients whose profile fits someone who may be a candidate for home dialysis.  This list will be provided to each primary nephrologist on a regular basis.

Just as we have proposed for our vascular access strategy, we will work to develop consistent messaging around home dialysis that Nephrologists will communicate in their private offices.

Offer More Acute PD

Traditionally, for patients who have needed to start dialysis in a hurry, we have offered HD starts with a central venous catheter (CVC).  We need to recognize, as a program, that starting a patient on HD with a CVC commits them to an extended exposure to what we know to be the worst type of dialysis – hemodialysis with a central line.  While we support the patient’s right to choose dialysis modality, we can only recommend PD or HD with an established vascular access.  For patients who won’t have a vascular access in place given the short time frame to get dialysis started, we will encourage and facilitate rapid initiation of dialysis via PD and provide IPD until such time the patient can be trained to do PD independently.

Avoid Losses from our Home Dialysis Program

Preventing losses from our home dialysis program is as important as recruiting patients into the program.  In my next post, I’ll share ideas how we can minimize the number of patients who discontinue home dialysis and return to in-centre hemodialysis.

 

 

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