O44
1 YEAR RESULTS OF A PROGRAMME TO IMPROVE QUALITY OF CARE FOR RENAL
REPLACEMENT THERAPIES PATIENTS IN A RENAL NETWORK
Nache A, Lappin, L, Baker, M, Burns, K, Gregson J, Devlin, P, Scanlon, T, Whittle, H, Shurrab, A, Hegarty, J
Department of Renal Medicine, Salford Royal Foundation Trust
PROBLEM: Best practice in dialysis care has been synthesized in clear national standards and guidance. Despite
this, a large gap remains between what we know is best practice and what is actually delivered, as demonstrated by
the widely varying achievement of recommended standards published in the UK Renal Registry every year. Quality
improvement (QI) is a way to close this implementation gap – it helps to find the best way to apply the existing best
knowledge on best practice in areas of different context and culture. We can now report 1 year clinical, staff and
financial outcomes for an ambitious improvement programme in renal replacement therapies within our network
PURPOSE: We aimed to uplift local performance in clinical care to within the top 10% renal unit in the UK Renal
Registry by working within current technologies using a quality improvement programme.
DESIGN: We performed an AHRQ Teamwork and Safety Survey at baseline and at the end to determine attributes
of clinical teams and potential impact of improvement work. We used a modified Institute for Healthcare
Improvement Breakthrough Series Collaborative methodology, in which 4 teams were given a different clinical
indicator and aim to work on for one year. We evaluated the effectiveness of our work by comparing it to a control
unit and by analysing the cost savings made during the work.
FINDINGS: The 4 areas have met their aims and made remarkable rapid improvement.
Area
Aim
Bolton HD
Reduce catheter related bacteraemia
rate to 1 episode per 120 days (to 0.8
per 1000 catheter days)
Community
PD
65% of peritoneal dialysis patients
will achieve haemoglobin range of
10.5 – 12.5
60% haemodialysis patients will
achieve blood pressure below 140/90
Salford HD
Wigan HD
90% Wigan haemodialysis patients
will achieve urea reduction rate
(URR) >65%
Pre-intervention
performance
1 infection every 45
days (2.65 per catheter
1000 days)
Performance at end
of intervention
No infection for past
370 days (0.50 per
1000 catheter days)
35.4% of patients
(mean 10.6 ± 1.4)
68.7% of patients
(mean 11.2 ± 1.2)
33.1% of patients
(mean sBP 152 ± 26;
mean dBP 82 ± 17 )
77.8% of patients
(mean 70.3 ± 8.3)
61.2% of patients
(mean sBp 130 ± 24;
mean dBP 73 ± 15)
94.2% of patient
(mean 74.5 ± 5.5)
Percentage
improvement
81%
p=0.0007
94%
p=0.001
85%
sBP p=0.001
dBP p=0.03
21%
p=0.002
All clinical indicators showed statistically significant improvement in outcomes; there was no significant
improvement to any of the indicators in the control unit over the same time period.
The improvement to clinical indicators was also accompanied by significant improvement to staff satisfaction
(AHRQ Teamwork and Safety survey) when compared to baseline. Financial analysis reveal ed that the improvement
work has made an aggregate project saving of £ 155, 027 in one year with a return of investment of 177%.
CONCLUSION: The 4 participating teams have shown remarkable rapid improvement as the result of a quality
improvement collaborative that simply would not have occurred in normal clinical care. This is a testament to the
hard work and commitment demonstrated by staff challenged to ‘raise the bar’ of care in their areas. The knowledge
gained in the first year has already begun to be shared and ‘spread’ across to other areas in our renal network.
Furthermore, the confidence and knowledge gained has made teams commit to another year of improvement on their
units
RELEVANCE: This programme is beginning to deliver greatly improved patient care to within the maximum
currently achievable with existing science and technology. In the process we have demonstrated improvement in staff
satisfaction and very significant cost savings for the NHS. These outcomes will likely be of interest to patients and
their families, clinicians, clinical leaders and policy makers in the UK and beyond.