B28(T)
AUDIT OF THE TREATMENT PATHWAY OF PATIENTS STARTING DIALYSIS AS
AN EMERGENCY
Cox, S1, Gardner, C2, Choi, C3
1
Guy’s & St Thomas NHS Foundation Trust, 2Audit, Information & Analysis Unit, West
3
London Renal & Transplant Centre
BACKGROUND: Research and national guidelines such as the Renal Association guidelines
for the planning and initiation of renal replacement therapy (RRT) and UKRA Clinical Practice
Guidelines for Patients with chronic kidney disease have highlighted that early referral to
specialised renal services can improve patient outcomes and reduce NHS costs. Many patients
are referred late into renal units (defined as starting RRT within 90 days of presenting to
specialised renal services for the first time). It is thought that presenting late and starting RRT in
an unplanned way can impact on the options given to patients both in terms of dialysis modality
and access to a range of services and support thus increasing morbidity and mortality. Late
presentation also impacts on planning, resources, costs and capacity at renal centres. No work
has previously been done at a regional level to review this patient cohort.
AIMS: To review late presenters and assess if they get the same information and treatment
options as planned starters and to investigate if any associated clinical or other factors are more
likely to occur in late presenters. To share examples of best practice across the regions.
METHODS: A six month prospective audit across the 14 centres in the Pan Thames Renal
Audit Group (PTRAG) for all late presenters and an equal number of planned starters. The audit
consists of a patient completed questionnaire on initiation of RRT and another questionnaire
after three months on dialysis along with collection of a series of simple clinical outcome
measures which are markers for RRT efficacy and patient wellbeing. Information on the patient
pathway at each centre will also be collected.
RESULTS: The audit period has just ended and results are currently available from 7 of 14
centres, the completed audit will be presented.
 2/7 centres use PD for late presenters but all centres use HD as primary dialysis modality.
5/7 centres have a specific pathway for late presenters.
 87% of planned starters received information from the low clearance or pre-dialysis nurse
whereas late presenters received information from a wider range of staff members.
 67% of the audit population was on HD. Late presenters were more likely to dialyse at the
main unit than planned starters (90% v 65%) while a higher proportion of planned starters
dialysed at a satellite unit (35% v 10%).
 61% of planned starters received RRT through fistulae and none had temporary access. 57%
of late presenters had a tunnelled catheter in the neck.
 Satisfaction with current treatment modality was similar for both cohorts although a small
number of late presenters did not feel able to make a judgement because of a lack of
information on other treatment options.
 Planned starters were more likely to have had a discussion about kidney transplant than late
presenters (57% v 43%). 6 planned starters were on the waiting list, no late presenters were.
CONCLUSIONS: The initial findings of this audit have confirmed differences in management
of patients undergoing planned or emergency dialysis including vascular access, dialysis setting
and transplant listing. Equity and Excellence: Liberating the NHS (2010) sets out a vision where
patients have more choice and control over their care. This audit has found that some patients
referred for emergency dialysis were unable to make choices about their care. The results of this
audit will help commission and plan care pathways enabling patients needing dialysis to be
referred for appropriate treatment and management earlier, thus optimising health outcomes,
patient experience, choice and costs.