Implementing NICE guidance in nursing practice – Dr Nicola Thomas
(Renal Nurse Consulting)
The ENABLE project: Reducing the variability of management of kidney
disease in primary care using a care bundle approach
(based on NICE guidance Chronic Kidney Disease, CG073)
Implementing the guidance in practice
Chronic kidney disease (CKD) is common affecting about 6-8% of the population (de
Lusignan 2009). It is an important risk factor for both end-stage renal disease and
for cardiovascular disease (CVD). CKD is frequently unrecognised since it causes no
symptoms in the early stages. However, it often exists together with other
conditions, for example, hypertension, CVD and diabetes. Data from the Quality and
Outcomes Framework indicate the presence of widespread variation, within and
between PCTs, in the identification and treatment of kidney disease in primary care
(NHS Information Centre).
The overall aim of the project is to improve the management of people with kidney
disease in primary care, using a Quality Improvement (QI) intervention called a care
bundle. A care bundle is a group of simple, well-defined, evidence-based quality
improvement interventions that have yielded excellent results both in terms of the
improved reliability of delivered care and better clinical outcomes. Our care bundle
for kidney disease is based on NICE guidance CG73 (2008).
The Project is funded by The Health Foundation and the Project team is managed by
Kidney Research UK. The Project team comprises two renal nurses, two
nephrologists and a patient, who also chairs the Patient and Carer Advisory Group
(six patients and carers with experience of CKD, diabetes and heart disease).
Objectives
Our main objectives are to:
1. Implement and evaluate a care bundle for CKD to 25-30 GP practices.
2. To achieve >95% compliance with the care bundle in each practice (all
components of the bundle carried out at each consultation) through the
application of recognised methodologies to achieve systematic reliability.
3. To utilise and further validate patient self-management tools.
4. To deliver an organic project communications plan and final dissemination
programme that will effect change in managing CKD in other GP Practices by
promoting the effectiveness of the care bundle approach.
Methods
A CKD-specific care bundle was developed by the study investigators and patients in
collaboration with an expert group and piloted in a single practice in 2008-2009. The
Care Bundle has four components:
A. Ask the patient if they wish to participate in the self-management programme
B. Measure and document proteinuria and prescribe medication if significant
proteinuria present
C. Document Blood Pressure and treat if hypertension present
D. Document cardio-vascular risk.
GP Practices were recruited either via a renal network, through personal connection
or via a local Primary Care Research Network (PCRN). The study team (comprising
patients and renal practitioners) provided training for each Practice, helped with
implementation of the study, collated results and organised monthly teleconferences
to review progress.
Results and evaluation
The study finishes in September 2012. Progress in each participating Practice has
been monitored monthly by:
A. Practice-level outcome measures submitted to the study team - This includes
recorded prevalence of CKD (i.e. percentage of practice population on CKD
register) and proportion of patients on the CKD Register treated according to
NICE guidance on blood pressure control. At baseline results show Practices
were recording wide variation in prevalence as 4.8% +/- 2.2%. This shows that
prevalence recording is variable although greater than mean recorded prevalence
in Strategic Health Authorities (SHAs) (2.6-5.2%) in 2010-2011. The Study Team
have worked with Practices to improve their reported CKD prevalence, especially
if <3% at baseline.
B. Monitoring individual process measures - Each aspect of the care bundle is being
studied separately as individual process measures. Results show that the number
of patients with CKD per month (up to December 2011) who had the QI
intervention applied has ranged from 1 to 33 (mean 5.96 SD 7.88). The number
of patients seen depends on the size of the Practice and in what context the
Care Bundle is being applied: in a nurse-led long-term conditions clinic for
example, higher numbers of patients are seen compared with the number seen
that might be seen during ad hoc appointments. By May 2012, over 500 patients
have taken up the offer of self-management (70% of those asked) and patient
feedback so far has been very positive.
Key learning points: what has helped or hindered nurses to implement the
guidance
The intervention is on the surface extremely simple, a care bundle for the
management of people with CKD based on NICE guidance to be applied in a primary
care setting in the UK. However we have learnt the following:
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It is worth investing in good training in CKD management and this is valued by
Practices and patients
Self-management training delivered by patients is crucial
There are competing interests in primary care when implementing a QI
programme so flu-jab season/end-of-QOF year etc are best to be avoided
QI works best when there is a QI champion in each Practice who has support of
colleagues
Outside facilitation for QI projects is beneficial
Help is sometimes needed to search IT systems to identify people with CKD
Careful consideration is needed when explaining CKD to patients
Resources for staff and patients will be freely available from Kidney Research UK
at the end of the project in Autumn 2012.
Role of the RCN
Although the RCN did not have direct influence on this project, following publication
of the CKD guideline, the RCN does offer guidance to nurses who are undertaking
similar implementation projects. There are numerous publications on Quality
Improvement on the RCN website to help you but sometimes help and support on an
individual basis can be more beneficial and productive.
See: Clinical Governance: Quality improvement – other support, guidance and tools.
http://www.rcn.org.uk/development/practice/clinical_governance/quality_improveme
nt/other_support/guidance__and__tools#techniques
In the RCN Learning and Development Institute, colleagues in the Quality Standards
and Innovation Unit can provide support, information and advice to individuals
wishing to implement quality improvement projects. The RCN has links with many
nurses who have quality improvement experience who are willing to share their
expertise, especially if the improvement projects are to do with implementation of
NICE guidance.
Dr Nicki Thomas contributed to the development of the NICE CKD through the RCN.
Contact Details
Name:
Dr Nicola Thomas
Job Title:
Project Co-ordinator ENABLE study
Email:
nicola.thomas@renalnurse.co.uk
Website:
www.kidneyresearchuk.org/enable