Optimal access in dialysis – a novel metric in FHA renal

Optimal access in dialysis – a novel metric in FHA renal

The Fraser Health renal program has been working tirelessly the last several years to optimize dialysis for our patients.

While we encourage patients to pursue independent dialysis if it works with their wishes, beliefs and values, we recognize that many patients will elect to start dialysis on hemodialysis as their preferred modality.

Some of the best observational data suggests that HD with a permanent access is just as good as PD, in terms of mortality.

 
Perl J, 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.

 

 

Perl Vascular Access

At FHA, we believe that our AV access rate among our HD patients isn’t a primary metric of success.   Rather, it’s the percentage of all dialysis patients who start and continue dialysis without a central venous catheter that matter.  Essentially, a program’s success in supporting patients to do peritoneal dialysis shouldn’t negatively impact the program’s overall performance metrics.

So, the novel metric we’ve been tracking, the “optimal access rate” has been:

[AVF + AVG + PD]/all dialysis patients

Since we’ve launched 2 simultaneously strategies to improve permanent access rates and independent dialysis, we’re seeing consistent increases in our “optimal access” rates.

Choice of modality on dialysis

 

We’ll continue to track permanent access rates in our hemodialysis units, but we strongly believe the ‘optimal access’ rate is the most meaningful benchmark to assess performance at a program level.

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Wait times to create a vascular access drop 35-50%

Improving our incidence and prevalence rates for permanent vascular access on hemodialysis has been an FHA wide goal.

As part of our strategy to improve our rates, we looked at the wait times to get an access created.  We figured that if we could get an AV access created faster for patients on hemodialysis, our prevalence rates would improve.  And if we could ensure that wait times for patients with advanced chronic kidney disease were better, we’d see less people starting hemodialysis before their AVF was ready to be used, thereby improving our incidence rates.

As a result of a collection of strategies including a) more dedicated vascular access nurses, b) greater collaboration with our surgical colleagues and c) the implementation of a novel process of expedited vascular access creation under regional block or local aneasthesia with recovery outside the post-anesthetic care unit, we’ve noticing striking improvements in wait times from referral to vascular access creation.  Between January and September 2013, we’ve seen surgical creation wait times decrease from 138 days to 91 days for patients referred to the Surrey program and 111 to 95 days in the Abbotsford program.

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Mobile applications to support behaviour change, clinical decision making and health service delivery

I’ve been invited to present at the BCATPR event held on June 18, 2013.  I’ll be discussing some of our technological innovations at Fraser Health including the introduction of RenalConnect to support our peritonitis management in PD and our newly launched “transition nurse” program.

Program blurb:

BCATPR is pleased to announce its 6th annual workshop, taking place at St. Paul’s Hospital in Vancouver on Tuesday, June 18, 2013. Join us for British Columbia’s premier multidisciplinary workshop on telemedicine, telehealth, mobile health technologies, remote monitoring and web-based programs for chronic disease management. This year’s workshop theme underlines the importance of mobile and web-based telehealth applications that can be used by patients, clinicians, and health policy decision makers.

Learn more: http://www.bcatpr.ca/workshops

Register: http://www.bcatpr.ca/2013workshop-registration

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Understanding health care funding in BC

Understanding health care funding in BC

Ever wonder where our funding for health care comes from and how budgets are determine? The presentation provided by the Auditor General’s office is a fantastic overview.

http://www.bcauditor.com/files/publications/2013/special/report/Health%20Funding%20Explained%20information%20piece.pdf

Teaser slide:

2013-02-14_14-10-13

 

Of note, Fraser Health has the lowest per capita spending compared to all the other health authorities.  Per Capita Spending at FHA

 

For reference, the total population served in each health authority:

. VIHA 760,000 people

Š . FHA 1.77 million people

Š . VCHA 1 million people

Š . IHA 740,000 people

Š . NHA 280,000 people

 

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Medication Reconciliation: Innovative Presentation at Western PD Days

At the recent Western PD days, there was an excellent turn out from the Fraser Health team.

Clifford Lo and Bob Dutta presented “Medication Reconciliation: We All Share the Responsibility”.  While tackling the following objectives exceptionally well, they also used a really novel slide deck:

• Understand why a medication reconciliation program can improve quality of care for your PD patient

• Understand how medication reconciliation can be implemented or improved in your peritoneal dialysis program

Instead of the standard/tired power point slides, they created a presentation that was incredibly visually engaging by creating a Prezi.  Have a look:

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Thinking on your feet in PD

Thinking on your feet in PD

We recently had a bedside PD catheter insertion that was limited by severe infusion pain when trying to do the initial fill with a temporary peritoneal catheter.    We hypothesized that the pain was due to the pH of the dialysate, as the pain did not abate by repositioning the temporary catheter.

Katie Cave, our patient care co-ordinator from the Abbotsford Regional Hospital PD unit exhibited MacGyver-like ingenuity.  Instead of being forced to abandon the procedure and rebook it under general anaesthetic, Katie left the procedure room and in about 5 minutes, came up with a setup to allow us to use physioneal during the insertion procedure.  She has kindly created a cartoon of the setup so others can replicate it should this problem be encountered in the future.

 

Physioneal During Catheter insertion

 

Thanks to her quick thinking, the procedure was completed without difficulty or complication.

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Vascular access getting better in the FHA renal program

The lastest vascular access data provided by BCPRA is out and things look promising for our program.

VA incidence
FHA Renal is  now one of the top 3 centres in the province.
Between April 2010 and Sep 2012, our incidence rate of AVF/AVG has increased from 24% to 36%.
During the same interval, the provincial mean is flat (31% to 32%).
VA Prevalence
Between April 2010 and Sep 2012, our prevalence rate of AVF/AVG has increased from 48% to 58%.  However, we’ve seen little improvement over the past year and are still far below top performing centres that are achieving 72% prevalence.  We do have much higher rates of AVF/AVG + CVC than most centres, suggesting we’re on the cusp of seeing our efforts comes to fruition as we get patients transitioned from CVC to AVF/AVG.
I think we have some momentum here but need to keep pushing.
a) In KCC
  • keep pushing our strategy of earlier modality decision making with referral at GFR 20 for patients choosing facility HD or HHD.
c) In the HD units
  • continue our VA review weeks to identify patients at risk of access failure or who could transition from CVC to AVF/AVG
  • continue to have all bedside RNs and MDs share the message of the value of an AVF over CVC
  • continue to work with IR to ensure we have rapid access to VA maintenance & salvage
  • bring in the transition nurses to ensure all new starts have optimized care pathways, including AVF referral for patients choosing facility HD or HHD
b) In PD
  • Earlier referral for AVF in patients who are showing signs of UF failure
  • Continue to support urgent start PD to ensure patients who are facing a suboptimal HD start with a CVC have a safer option
c) In Transplant
  • Earlier referral for AVF with progressive transplant failure who choose facility HD or HHD after modality education
d) In the Nephrologist offices
  • Continue to recommend permanent access creation for patients not choosing conservative care, pre-emptive transplant or PD, and communicate this messaging to the primary care providers in order to secure their support
e) In the ORs
  • Continue to explore innovative ways to get patients quicker access creation
Thanks for everyone’s hard work on this initiative.  It’s incredibly encouraging to see things move in the right direction,
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Could Falling Peritonitis Rates be Increasing PD Prevalence at Fraser Health?

Could Falling Peritonitis Rates be Increasing PD Prevalence at Fraser Health?

As we reported just last week, PD prevalence at Fraser Health hit 30%.  In attempting to determine what we’ve done right, I had a quick look at our PD peritonitis rates.  Peritonitis is a strong driver of PD technique failure – some patients never come back to PD after an episode of this type of infection.  We’ve worked really hard over the past few years to reduce infections and it seems to have worked.

Here are few snapshots I’ve pulled from Renal Connect:

Our peritonitis rate in 2009 was 1 in 22.4 months

 

Peritonitis rate in 2010 was 1 in 26.9 months

Peritonitis rate in 2011 was 1 in 29.8 months

Peritonitis rate in 2012 so far is 1 in 34.6 months

In the past 6 months, our rate is down to 1 in 40.5 months.

 

I’m hopeful that we can maintain a peritonitis rate of less than 1 in 40 months.  Many had suggested that as we increase the pool of individuals to whom we offer PD, we might see an increase in infection and a fall in technique survival.  Thus far, as our program has grown and surpassed the 30% prevalence mark we’ve seen a fall in peritonitis rates.  As we transition our data collection to PROMIS, I’m hoping I’ll be able to report our technique survival data and show encouraging results.

 

 

 

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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 seeking a new Nephrologist

As the FHA Renal program continues to grow, we are seeking another Nephrologist to join our program.

Here’s the full text of the posting.  Applications should be submitted to: physicianrecruitment@fraserhealth.ca

http://physicians.fraserhealth.ca/opportunity-search/search-for-opportunities/opportunity-details?vacancyId=121

The Fraser Health Nephrology group is looking for a Clinical Nephrologist based in Surrey, BC. Our group provides coverage across all of Fraser Health in the dialysis units, inpatient services and outpatient clinics. The successful candidate will join the Nephrology group practice and will provide coverage for the inpatient service, maintain an outpatient practice, and cover the hemodialysis units as determined by the group’s arrangement to ensure appropriate coverage. The successful applicant’s geographic area of practice will be predominantly at the Surrey Memorial Hospital, the Newton and Panorama community dialysis units and an outpatient Nephrology practice in the Surrey community. This position will also provide some coverage and call for other sites in the Fraser Health region with an overall call frequency of no more than 1 in 5.  Further clinical details can be discussed with interested applicants.

This position offers the opportunity to practice in all areas of nephrology including being part of a strong PD and home hemodialysis program, multiple HD units, Chronic Kidney Disease clinics and potentially some transplant care. The candidate will also be expected to be involved in teaching in both General Medicine and Nephrology. There will be an expectation to provide clinical leadership in at least one of the program areas. 

The position is scheduled to start Feb 11th, 2013.

Please submit your completed application prior to November 12, 2012. Interviews have tentatively been set for November 27 and 28, 2012, please be available for both of those days in the event that you are shortlisted for an interview.

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