INTRODUCTION: - British Renal Society

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RAPID SUSTAINABLE IMPROVEMENT TO PRE HAEMODIALYSIS BLOOD PRESSURE
CARE BY USING QUALITY IMPROVEMENT METHOD
Smith, K, Moss, M, McGee, Y, Latimer, S, Botham, H, Baker, M, Lappin, L, Nache, A, Hegarty, J
Salford Haemodialysis Unit, Salford Royal Foundation Trust
INTRODUCTION: Cardiovascular disease is the leading cause of death in haemodialysis patients, in
which hypertension is one of the most common risk factors. The Dialysis Outcomes and Practice Patterns
Study (DOPPS), has reported 73% prevalence of hypertension in European dialysis patients. There have
been numerous studies looking at ways of controlling blood pressure in haemodialysis patient. Despite
this, controlling blood pressure in the haemodialysis patient has proven difficult, reflected in yearly Renal
Registry reports with wide variation in attainment of the RA standards across the UK.
PURPOSE: We sought to rapidly improve our patient’s pre dialysis blood pressure results by
implementing multifaceted changes using quality improvement methods.
DESIGN: Our unit participated in a quality improvement collaborative using a modified Institute of
Healthcare Improvement’s Breakthrough Series methodology. This method allows frontline
multidisciplinary staff working in teams to learn from each other and share their experience of
improvement. Our unit was given an aim to have 60% of our HD patients achieving pre dialysis blood
pressure of 140/90 within one year. We identified best practice by reviewing the literature and by
communicating with good performing units. Changes were tested using by multiple PDSA cycles to help
us learn the best way to design and apply ideas into practice. Successful changes were compiled into a
change package which can be copied elsewhere in our renal network.
DISCUSSION & FINDINGS: Our unit has implemented 9 changes throughout the year: York blood
pressure protocol, nurse rounding, dialysis observation sheet, daily goals, BP multidisciplinary review,
working in same team, use of blood volume sensor, staff education on salt & fluid and patient education
on salt & fluid.
Implementation of these changes has rapidly improved pre-dialysis blood pressure control amongst our
patients. At the beginning of the project, 33.1% of our patients met the pre-dialysis BP standard, whereas
a year later, 61.2% of our patients had a pre-dialysis BP below 140/90. The improvement remains
sustainable at 8 months post project with 59.3% of our patients were within the standard.
Mean systolic
Mean systolic P value Mean diastolic Mean diastolic P
BP before
BP post
BP before
BP post
value
intervention
intervention
intervention
intervention
Salford Renal
152 (SD 26.4) 130 (SD
0.001
82 (SD 17.4)
73.4 (SD 15.4) 0.003
Unit
23.5)
Non-intervention 149 (SD 25.2) 146 (SD
0.434
78 (SD 17.5)
77 (SD 13.5)
0.918
unit
23.6)
The improvement in blood pressure was not associated with an increase in symptomatic hypotensive
events (5.1 pre v 5.3 post events per week, p=0.5). It is also associated with a 25% reduction in total BP
medications (from 137 pre to 102 post).
CONCLUSION: Rapid sustainable improvement to blood pressure is achievable using quality
improvement methods. Quality improvement makes the frontline staff own the problem and use their
know-how to find the best way to implement changes. The reduction of BP was not associated with more
hypotensive episodes as frontline staff addressed the patient holistically by improving education,
discontinuing medications and using appropriate technology.
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