THE
NORTH WEST REGION
RENAL AUDIT PROGRAMME
THE 8th ANNUAL REPORT
1999-2000
June 2000
Introduction
The North West Region Renal Audit Programme was established in 1992, to improve the
quality and effectiveness of the renal services provided to patients over the North West
Region.
Over the past year, the North West Region Renal Audit Steering Group has expanded a
series of developments initiated to further the programme of quality improvement and to
assist in the process of clinical governance. The developments include a programme of
ongoing prospective audit, a regional renal audit database, clinical effectiveness indicators
and a process of benchmarking against data from the UK Renal Registry. They were
initiated to establish a more systematic process of audit in which renal units can more
readily compare their performance with other units, year on year, regionally and nationally.
Those areas in which change is necessary can be identified and processes implemented that
will help bring about change.
In 1998 funding for the programme was secured for the period commencing 1st April 1998
and ending 31st March 2000. Audit activity for the period 1st April 1998 to 31st March 1999
was reported in the 7th Annual Report. This report summarises the progress that has been
made during the period 1st April 1999 to 31st March 2000 in the development of the regional
audit programme. It does not include results from any individual audit as time has been
given to the development of the programme at the expense of the time needed to process the
data for individual audits. A supplement to this progress report, containing the results of
audits started between 1st April 1999 and 31st March 2000 will be available later in the year.
The regional audit programme
The regional audit programme is a standards based programme of quality improvement.
Principle aim
To improve the quality and effectiveness of the renal services in the North West Region
through a continuous collaborative process of multidisciplinary evidence based clinical
audit of the care provided in the hospital and community.
Participating centres
Within the North West Region (which incorporates Greater Manchester, Lancashire and
Merseyside), all renal units and their satellites participate in the Regional Renal Audit
Programme. The units and their satellites are listed in appendix one.
Programme management
From the outset, the audit programme has been directed and managed by the
multidisciplinary Renal Audit Steering Group that includes physicians and, unit and
community based nurses from every renal unit in the region. Members of this group are
listed in appendix two.
However management of the audit programme has recently evolved to improve the process
of feedback and debate. In April 2000, a new 8 member multidisciplinary steering group
was established to direct and manage the audit programme. Time and effort previously
dedicated to arranging large quarterly steering group meetings will henceforth be dedicated
to audit presentation evenings which will take place three times a year.
Objectives for 1998/2000
In 1998 funding for the programme was secured for two years (1.4.1998 – 31.3.2000). To take
the programme forward a series of objectives were set for this funding period:
1. To systematically monitor improvement in clinical care by developing clinical effectiveness
indicators based on National and International Standards and applying them to an annual cycle of
ongoing prospective audit.
2. To prospectively evaluate outcome by developing the programme of ongoing prospective audit on a
regional renal audit database.
3. To improve cost effectiveness in the audit process by designing the programme of ongoing
prospective audit around automated data capture.
4. To benchmark clinical care in the North West Region using data published by the UK Renal
Registry.
5. To identify new audits which could lead to improvement in clinical care.
Forward plan
To meet the objectives the forward plan was to include:
A programme of prospective ongoing audit
 Annual CAPD regional peritonitis audit
 An audit of haemoglobin and Epo usage
 An audit of adequacy
 An audit of cardiovascular risk
98/99 completed
99/00 commenced
completed
commenced
commenced
A programme of new individual audit





An audit of acidosis
An audit of early deaths
An audit of patient information
An audit of ethnicity
An audit of vascular access
completed
completed
completed
commenced
postponed
Progress in meeting objectives
1. Experience from the regional peritonitis audit has shown that the most effective way of
bringing about change is through a process of year on year rolling audit, benchmarked
against national and regional data. To establish this process, time has been spent over
the past year establishing and developing the prospective ongoing audit programme.
Thus the rolling audit programme has been expanded and is now based upon six
separate audits






CAPD Regional Peritonitis Audit
Bone chemistry
Haemoglobin and Epo usage
Cardiovascular risk
Adequacy
Survival
Data collection for this ongoing audit programme has commenced.
Clinical effectiveness indicators have been established using national standards and are
being used in the annual cycle of ongoing prospective audit. The indicators will be
evaluated using the audit data.
2. A regional renal audit database has been established as a basis for the rolling audits and
to monitor survival and other outcomes. Again experience from the annual peritonitis
audit has shown that the audit process is greatly strengthened by ensuring data capture
on all patients treated in the region rather than data capture from a sample. Therefore all
patients established on dialysis in the region have been enrolled on the database and this
will be updated at 3 monthly intervals.
3. The programme of ongoing prospective audit has been designed around Formic
software (an automated data capture system) making the audit process more efficient.
4. Once data collection from the first year is complete clinical care will be benchmarked
regionally and nationally; using the data collected for the ongoing audit programme and
the data published by the UK Renal Registry.
5. New audits that could lead to improvement in clinical care were identified in the
forward plan. With the exception of the audit of vascular access, all these audits have
started.
Five of the audits included in the forward plan have been completed and were reported in
the 7th Annual Report that was circulated last September. A supplement to this progress
report, containing the results of audits started between 1st April 1999 and 31st March 2000
will be available later in the year.
Audit planning
Audit planning follows a well established protocol which is described in appendix 3. Project
plans for all of the audits in the 1998/2000 ongoing programme of clinical audit, and of the
audits in the 1998/2000 programme of new individual audits are detailed in appendix four.
The national audit programme
The renal units in the North West Region are committed to participation in the national
audit programme of the UK Renal Registry. Two units are now contributing towards the
Registry (Royal Preston Hospital and the Royal Liverpool University Hospital) and three
sites are developing systems that will allow them to contribute towards the registry (Hope
Hospital, Manchester Royal Infirmary and Withington Hospital).
The North West Region Renal Audit Programme will continue to provide a standards based
programme of quality improvement but will also be developed to address issues of quality
and outcome not measured by the UK Renal Registry.
Disseminating audit results
Throughout the year audit data have been presented at the quarterly steering group
meetings and following discussion recommendations for change have been made. Audits
and recommendations have then been presented at the participant units where local
decisions are taken about the implementation of the recommendations for change. Detailed
reports have been published and circulated to those affected by the audit. Results are
published openly at unit level.
From April 2000, audit data will be presented at audit presentation evenings to which all
renal clinicians working in the North West Region will be invited. Every year there will be
three audit meetings

A summer audit meeting; the programme will include audit presentations and
discussion, and presentations from guest speakers.

Autumn and spring audit meetings; the programmes will include audit presentations
and discussion, and discussion of topics of current interest.
Following each presentation discussion will lead to recommendations. Again, audits and
recommendations for change will be presented at the participant units where local decisions
about implementation of the recommendations for change will be made and detailed reports
will be published and circulated to those affected by the audit.
Implementation of change
The audit cycle is completed by implementing recommendations and monitoring the
resultant change. As the move towards a programme of ongoing prospective audit takes
place units will be able to compare their performance, identify those areas in which change
is necessary and implement processes that will help bring about the necessary change.
Change will then be monitored through the Regional Renal Audit Database and by bench
marking against data from the UK Renal Registry.
Further Information
For further details on the North West Region Renal Audit Programme, please contact Dr N
M K Reid, the Regional Audit Co-ordinator, or Mrs N Austerberry, the Regional Renal Audit
Facilitator at the Clinical Audit Department in Withington Hospital (telephone number 0161
291 3209).
Appendix one
Renal units participating in the North West Region Renal Audit
Programme





















Accrington & Victoria Hospital - Communicare NHS Trust
Arrowe Park Hospital - Wirral Hospital NHS Trust
Birch Hill Hospital - Rochdale Healthcare NHS Trust
Clatterbridge Hospital - Wirral Hospital NHS Trust
Devonshire Road Hospital - Blackpool, Wyre & Fylde Community Health Services NHS
Trust
Furness General Hospital – Furness Hospitals NHS Trust
Hope Hospital - Salford Royal Hospitals NHS Trust
Leighton Hospital - Mid Cheshire Hospitals NHS Trust
Macclesfield District General Hospital - East Cheshire NHS Trust
Manchester Royal Infirmary - Central Manchester Healthcare NHS Trust
Broad Green Dialysis Centre - Royal Liverpool & Broadgreen University Hospitals NHS
Trust
North Manchester General Hospital - North Manchester Healthcare NHS Trust
Prestwich Hospital - Mental Health Services of Salford NHS Trust
Royal Liverpool University Hospital NHS Trust - Royal Liverpool & Broadgreen
University Hospitals NHS Trust
Royal Manchester Children’s Hospital - Manchester Children’s Hospital NHS Trust
Royal Preston Hospital - Preston Acute Hospital NHS Trust
Warrington Hospital - Warrington Hospital NHS Trust
Waterloo Day Hospital - Aintree Hospitals NHS Trust
Westmorland General Hospital - Westmorland Hospitals NHS Trust
Whiston Hospital - St Helens and Knowsley Hospitals NHS Trust
Withington Hospital - South Manchester University Hospitals NHS Trust
Appendix two
Membership of the North West Region Renal Audit Steering Group
(Until March 2000)
Chairmen of the North West Region Renal Audit Programme
Dr R Ahmad
Dr R Coward
Dr M Venning
Consultant Renal Physician - Royal Liverpool University Hospital
Consultant Physician and Nephrologist - Royal Preston Hospital
Consultant Renal Physician - Withington Hospital
Members of the North West Region Renal Audit Steering Group
Sister C Blackshaw
Sister D Burrows
Mr P Cairns
Sister E Carville
Sister P Cooper
Sister M Davies
Sister A Elliot
Sister A Estrop
Sister L Ferguson
Dr R Gokal
Sister N Heelis
Sister P Hughes
Dr A Hutchison
Mr P Livesley
Dr R McClelland
Sister T McGloughlin
Sister C McGloughlin
Sister D McGregor
Sister D MacCauley
Sister M MacClean
Ms S Milligan
Dr D O’Donoghue
Sister S Orem
Mr N Parrott
Mr I Paterson
Sister S Perrin
Sister J Pickles
Sister M Pipes
Dr M Bradbury
Dr F Qasim
Mr K Radford
Dr L Solomon
Sister T Smith
Dr D Smithard
Sister N Tannerhill
Sister L Tronconi
Sister L Uttley
Dr S Waldek
Sister R Worsman
Senior Haemodialysis Sister - Birch Hill Hospital
Nurse Manager - Warrington Hospital
Senior Haemodialysis Charge Nurse - Devonshire Road Hospital
Senior Haemodialysis Sister - Whiston Hospital
Senior Haemodialysis Sister - Clatterbridge Hospital
Senior CAPD Sister - Hope Hospital
Nurse Manager - North Manchester General Hospital
Senior Haemodialysis Sister - Manchester Royal Infirmary
Nurse Manager - Arrowe Park Hospital
Consultant Nephrologist - Manchester Royal Infirmary
Senior CAPD Sister - Withington Hospital
Senior Haemodialysis Sister - Clatterbridge Hospital
Consultant Nephrologist - Manchester Royal Infirmary
Senior CAPD Charge Nurse - Royal Liverpool University Hospital
Consultant Nephrologist - Arrowe Park Hospital
Senior Haemodialysis Sister – Broad Green Hospital
Senior Haemodialysis Sister - Waterloo Day Hospital
Anaemia Co-ordinator - Royal Preston Hospital
Senior CAPD Sister - Furness General Hospital
Senior Haemodialysis Sister - Hope Hospital
Senior Renal Dietitian - Accrington and Victoria Hospital
Consultant Nephrologist - Hope Hospital
Senior Haemodialysis Sister - Royal Liverpool University Hospital
Senior Lecturer in Surgery - Manchester Royal Infirmary
Senior Haemodialysis Charge Nurse - Withington Hospital
Anaemia Co-ordinator - Manchester Royal Infirmary
Nurse Manager - Accrington and Victoria Hospital
Senior CAPD Sister - Royal Preston Hospital
Consultant Nephrologist - Royal Manchester Children’s Hospital
Consultant Nephrologist - North Manchester General Hospital
Senior Haemodialysis Charge Nurse - Leighton Hospital
Consultant Physician and Nephrologist
Clinical Nurse Specialist - Royal Manchester Children’s Hospital
Consultant Physician - Birch Hill Hospital
Anaemia Co-ordinator - Royal Liverpool University Hospital
Senior Haemodialysis Sister - Macclesfield District General Hospital
Senior Home Dialysis Sister - Manchester Royal Infirmary
Consultant Nephrologist - Hope Hospital
Senior Haemodialysis Sister - Westmorland General Hospital
Membership of the North West Region Renal Audit Steering Group
(From April 2000)
Chairmen of the North West Region Renal Audit Programme
Dr R Ahmad
Dr R Coward
Dr M Venning
Consultant Renal Physician - Royal Liverpool University Hospital
Consultant Physician and Nephrologist - Royal Preston Hospital
Consultant Renal Physician - Withington Hospital
Members of the North West Region Renal Audit Steering Group
Sister M MacClean
Sister N Tannerhill
Sister L Uttley
Sister R Worsman
Senior Haemodialysis Sister - Hope Hospital
Anaemia Co-ordinator - Royal Liverpool University Hospital
Senior Home Dialysis Sister - Manchester Royal Infirmary
Senior Haemodialysis Sister - Westmorland General Hospital
Appendix three
Audit planning
To improve the effectiveness of the clinical audit process a project plan is developed for
every audit topic. For all audits the plan identifies
The reasons for topic selection:




the purpose of the audit
the patient health improvement
the evidence base
whether the audit addresses national or regional renal service priorities
The methodology:



the standards available
the methods
the disciplines involved
The implementation of change:


how recommendations might be implemented
the persons responsible for monitoring change (this process is developed as the audit is
undertaken)
In addition, for individual audits the plan identifies
The methodology:


the sample
the time scale of project
Appendix four
Project plans for the ongoing programme of clinical audit
AUDIT OF ADEQUACY
PROJECT PLANNING GUIDE
AUDIT PROJECT
Audit Leads:

Specialist registrar:

Audit facilitator:

Type of audit:
REASONS FOR CHOICE
Aims & objectives:

Proposed health benefits:
Evidence base:
Priority:
METHODOLOGY
Standards:
Dr G Wood
Consultant Nephrologist
Withington Hospital
Dr Mitra
Specialist Registrar in Renal Medicine
Withington Hospital
Nicola Austerberry
Regional Renal Audit Facilitator
Ongoing
 To measure achievement of the Renal Association standard
for dialysis adequacy and albumin
 To examine the characteristics of patients not achieving the
Renal Association standard for dialysis adequacy
 To examine the efficacy of interventions given to patients not
achieving the Renal Association standard for dialysis
adequacy
 To improve survival
 To improve quality of life

 National
 Regional
 Haemodialysis patients
Renal Association Recommended MINIMUM standard1
(evidence level B)
Every patient for thrice weekly haemodialysis should show
EITHER
Stable URR > 65%
OR

Stable Kt/V > 1.2 (dialysis and residual renal
function)
PD patients
Renal Association Recommendation1 (evidence level B)
A total weekly creatinine clearance (dialysis and residual
renal function) of 50 l/week/1.73 m2 and/or a weekly
dialysis Kt/V urea off greater than 1.7, checked 6-8 weeks
after the beginning of dialysis, should be regarded as
minima. These studies should be repeated at least annually,
or if a suspicion arises that residual function has declined
more rapidly than usual.
1Standards
Guidelines:
Patients:
Methods:
Health disciplines involved:
Timescale:
ACTION
Proposed date for audit
presentation:
Persons responsible for
monitoring change:
subcommittee of the Renal Association. Treatment of
adult patients with renal failure: Recommended Standards and audit
measures. Renal Association 1997 (Second edition).

 All patients enrolled in a dialysis programme in the North
West Region will be invited to take part in the study.
 Data will be collected prospectively form computer systems
and patient records.
 Data will include
 Data will be collated and analysed by the regional audit
facilitator
 Nurses
 Physicians
 Ongoing
 October 2000
 Physicians
AUDIT OF BONE CHEMISTRY
PROJECT PLANNING GUIDE
AUDIT PROJECT:
Audit leads:



Audit Facilitator:

Type of audit:
REASONS FOR CHOICE
Aims and objectives:

Proposed health benefits:
Evidence base:










To assess calcium and phosphate control.
To assess the use of phosphate binders.
To assess local guidelines for the management of bone disease.
To assess the drug records.
To assess management of bone disease in relation to ethnicity.
To assess management of bone disease in relation to the role of the
dietitian.
To reduce the incidence of hyperparathyroidism
Gerakis A et al. Biochemical markers for non invasive diagnosis of
hyperparathyroid bone disease and adynamic bone disease in patients on
haemodialysis. Neprol Dial Trans 1996 11 2430-2438.
Malluche H et al. Risk of adynamic bone disease in dialysed patients. Kid
Int 1992 42 (suppl 38) 62-67.
Sharrad D et al. The spectrum of bone disease in end stage renal failure – An
evolving disorder. Kid Int 1993 43 436-442.
National
Regional

Haemodialysis patients


Priority:
METHODOLOGY
Standards:
Dr A Hutchison
Consultant Nephrologist
Manchester Royal Infirmary
Ms S Milligan
Chief Dietitian
Blackburn Royal Infirmary
Ms K Beaven
Renal Dietitian
Royal Preston Hospital
Nicola Reid
Regional Renal Audit Co-ordinator
Ongoing
Renal Association Recommended Standard1 (evidence level B)
The following are target ranges for pre-dialysis biochemical variables:
Phosphate
Calcium
Albumin
PTH
1.2 – 1.7 mmol/l
Total calcium within the normal range
quoted by the local pathology laboratory,
corrected for serum albumin concentration
or normal ionised calcium where available.
A target serum albumin within the normal
range quoted by the local pathology
laboratory in all patients should be the
target after 6 months on regular
haemodialysis.
iPTH should be maintained at between 2
and 3 times the local normal range (130 – 210
pg/ml).

Peritoneal dialysis patients
Renal Association Recommended Standard1 (evidence level B)
The following are target ranges for pre-dialysis biochemical variables:
Phosphate
Calcium
Albumin
PTH
1.1 – 1.6 mmol/l
Total calcium within the normal range
quoted by the local pathology laboratory,
corrected for serum albumin concentration
or normal ionised calcium where available.
The serum albumin of at least 70% of
patients should be within the local normal
range.
iPTH should be maintained at between 2
and 3 times the upper limit of the local
normal range.
Standards sub committee of the Renal Association. Treatment of adult patients with renal
failure: Recommended standards and audit measures. Renal Association 1997 (Second edition).
1
Guidelines:
Patients:


Methods:







Regional guidelines developed from previous audit.
All dialysis patients in the North West Region will be invited to take
part in the study.
Data will be collected prospectively from hospital records.
Calcium, corrected calcium, phosphate, albumin, alk phos, PTH and
bicarbonate will be collected from the three most recent blood tests.
Drug treatment including vitamin D, phosphate binders and steroids,
and the systems used to record this information will be recorded.
The number of females and their menopausal state will be defined
using age and HRT treatment.
The number of patients who have received a transplant will be
recorded.
Ethnic group, first language and ability to read English will be
recorded.
Dietitian : patient ratio will be recorded for each unit.
Dietitians
Physicians
Pharmacists
Ongoing audit

April 2001




Health disciplines involved:
Timescale:
ACTION
Proposed date for audit
presentation:
AUDIT OF CARDIOVASCULAR RISK
PROJECT PLANNING GUIDE
AUDIT PROJECT
Audit Leads:
Specialist registrar:
Audit facilitator:
Type of audit::
REASONS FOR CHOICE
Aims & objectives:
Proposed health benefits:
Evidence base:
Priority:
METHODOLOGY
Standards:
 Dr R Foley
Consultant Renal Physician
Hope Hospital
 Dr L Solomon
Consultant Renal Physician
Royal Preston Hospital
 Dr M Venning
Consultant Renal Physician
Withington Hospital
 Dr G Wood
Consultant Renal Physician
Withington Hospital
 Dr E O’Riordan
Specialist Registrar in Renal Medicine
Manchester Royal Infirmary
 Nicola Reid
Regional Renal Audit Co-ordinator
 Ongoing
 To assess cardiovascular risk in the dialysis population in the North West
Region
 To assess cardiovascular risk intervention in the dialysis population in the
North West Region
 To compare blood pressure control at unit and regional level, with
national performance (measured by the UK Renal Registry).
 To provide a basis for prospective evaluation of the relationship between
cardiovascular risk factors, interventions and patient outcome.
 To reduce mortality
 To reduce cardiovascular events
 To improve quality of life
 RN Foley, PS Parfrey and MJ Sarnak. Epidemiology of cardiovascular disease
in chronic renal disease J Am Soc Nephrol 9 S16-S23 1998
 P Jungers et al. Incidence and risk factors of atherosclerotic cardiovascular
accidents in pre-dialysis chronic renal failure patients: A prospective study.
Nephrol Dial Transplant 12 2597-2602 1997
 KB Meyer and AS Levey. Controlling the epidemic of cardiovascular disease in
chronic renal disease: Report from the National Kidney Foundation task force on
cardiovascular disease. J Am Soc Nephrol 9 S31-S42 1998
 National
 Regional
 Regional Association Recommended Standard1 (evidence level B)
Target pre-dialysis blood pressures should be:
Age <60: BP<140/90 mmHg (Korotkoff V if auscultation is used)
Age >60: BP<160/90 mmHg (Korotkoff V if auscultation is used)
1Standards
Guidelines:
Patients:
Methods:
Health disciplines involved:
Timescale:
ACTION
Proposed date for audit
presentation:
Persons responsible for
monitoring change:
subcommittee of the Renal Association. Treatment of adult patients
with renal failure: Recommended Standards and audit measures. Renal
Association 1997 (Second edition).
 British Hypertension Society Guidelines
 All patients enrolled in a dialysis programme in the North West Region
will be invited to take part in the study.
 Data will be collected prospectively from patients, patient notes and
computer systems onto a standardised data collection sheet.
 Data collected from patients will include: age, sex, socio-economic status,
obesity, smoking history, no alcohol consumption, physical inactivity,
history of hypertension, diabetes, menopause, current medication, family
history of early onset CVD, history of MI, history of stroke, history of
CABG, history of angioplasty, history of vascular surgery.
 Data collected from patient records will include: blood pressure, Hb,
Albumin, PTH, URR, total cholesterol, LDL and HDL cholesterol.
 Data will be collated and analysed by the regional audit co-ordinator.
 Physicians
 Hospital nurses
 Ongoing
 April 2001
 Physicians
AUDIT OF PERITONITIS
PROJECT PLANNING GUIDE
AUDIT PROJECT
Audit Lead:

Specialist registrar:
Audit facilitator:


Type of audit:
REASONS FOR CHOICE
Aims & objectives:

Proposed health benefits:
Evidence base:







Priority:
METHODOLOGY
Standards:



Dr R Coward
Consultant Physician and Nephrologist
Royal Preston Hospital
Nicola Austerberry
Regional Renal Audit Facilitator
Ongoing
To measure achievement of the Renal Association standard for peritonitis
To benchmark peritonitis rates within the North West Region
To increase survival
To reduce morbidity
Golper TA and Tranaeus A Vancomycin revisited Perit Dial Int 1996 16 116
– 117
Keane WF et al Peritoneal dialysis related peritonitis: treatment
recommendations Perit Dial Int 1996 16 557 - 573
Port FK et al Risk of peritonitis and technique failure by CAPD connection
technique: a national study Kidney Int 1992 42 967 - 974
National
Regional
Renal Association Recommended minimum standard using the
disconnect system1 (evidence level A)
Peritonitis rates should be < 1 episode/18 patient-months
The negative peritoneal fluid culture rate in patients with clinical
peritonitis should be less than 10%
The initial cure rate of peritonitis should be more than 80% (without the
necessity to remove the catheter).
1Standards
Guidelines:
Patients:
Methods:
Health disciplines involved:
Timescale:
ACTION
subcommittee of the Renal Association. Treatment of adult patients
with renal failure: Recommended Standards and audit measures. Renal
Association 1997 (Second edition).
 None
 All peritoneal dialysis patients in the North West Region who present
with an episode of peritonitis between 1.4.2000 and 31.3.2001 will be
invited to take part in the study.
 CAPD nurses will collect the data prospectively from nursing records and
patient notes onto a standardised data collection sheet.
 Data will include: patient months per episode, negative peritoneal fluid
culture rate and initial cure rate of peritonitis.
 Data will be collated and analysed by the regional audit facilitator.
 PD nurses
 Physicians
 Ongoing
Proposed date for audit
presentation:
Persons responsible for
monitoring change:
 October 2001
 PD nurses
AUDIT OF HAEMOGLOBIN AND ERYTHROPOIETIN
PROJECT PLANNING GUIDE
AUDIT PROJECT
Audit Leads:

Audit facilitator:

Type of audit::
REASONS FOR CHOICE
Aims & objectives:

Proposed health benefits:
Dr P Kalra
Consultant Nephrologist
Hope Hospital
Nicola Austerberry
Regional Renal Audit Facilitator
Ongoing
 To determine the extent of Epo therapy in the region
 To measure achievement of the Renal Association standard
 To benchmark haemoglobin levels regionally and nationally (using data
from the UK Renal Registry)
 To measure efficacy of treatment
 To monitor improvement in control of anaemia
 To reduce morbidity
 To reduce cardiovascular risk
 To reduce blood transfusion (hence viral transmission and transplant
recipient sensitisation)
 To reduce iron overload
Evidence base:
 Moreno et al Influence of haemotocrit on quality of life of haemodialysis
patients Nephrol Dial Transplant 1994 9 10-34
 Eschbach et al Normalising the haemotocrit in haemodialysis patients
with Epo improves quality of life and is safe 1993 J Am Soc Nephrol 4
425
Priority:
 National
 Regional
METHODOLOGY
Standards:
 Regional Association Recommendation1 (evidence level A)
A target haemoglobin concentration of not less than 10g/dl
should be achieved in the great majority (>85%) of patients
after 3 months on HD or PD. Transfusions should be
avoided wherever possible in patients likely to be
transplanted to avoid sensitisation.
1Standards
Guidelines:
Patients:
Methods:
Health disciplines involved:
subcommittee of the Renal Association. Treatment of adult patients
with renal failure: Recommended Standards and audit measures. Renal
Association 1997 (Second edition).
 Regional guidelines developed from previous audit
 All patients enrolled in a dialysis programme in the North West Region
will be invited to take part in the study.
 Data will be collected prospectively from computer systems, anaemia coordinator records and patient notes onto a standardised data collection
sheet.
 Data collected will include haemoglobin, Epo therapy, iron status and
mode of dialysis.
 Data will be collated and analysed by the regional audit facilitator
 Anaemia co-ordinators
Timescale:
ACTION
Proposed date for audit
presentation:
Persons responsible for
monitoring change:
 Nurses
 Physicians
 Ongoing
 April 2001
 Anaemia co-ordinators
AUDIT OF SURVIVAL
PROJECT PLANNING GUIDE
AUDIT PROJECT
Audit Lead:


Specialist registrar:

Audit facilitator:

Type of audit::
REASONS FOR CHOICE
Aims & objectives:

Proposed health benefits:
Evidence base:
Priority:
METHODOLOGY
Standards:
Dr R Gokal
Consultant Nephrologist
Manchester Royal Infirmary
Dr M Venning
Consultant Renal Physician
Withington Hospital
Dr A Trehan
Research Registrar
Manchester Royal Infirmary
Nicola Reid
Regional Renal Audit Co-ordinator
Ongoing
 To measure achievement of the Renal Association Recommendation
(provisional targets).
 To benchmark survival within the North West Region
 To examine the characteristics of patients who do not achieve the Renal
Association Recommendation.
 To increase survival
 Brunner FP et al Survival on renal replacement therapy: data from the EDTA
registry. Nephrol Dial Transplant 1998 2 109-122 16 116 – 117.
 Khan IH et al Survival on renal replacement therapy in Europe: is tehre a ‘centre
effect’ Nephrol Dial Transplant 1996 11 300-307.
 Valderrabano F et al Use of APACHE II classification to evaluate outcome and
response to therapy in acute renal failure patients in a surgical intensive care
unit. Ren Fail 1995 17 731-742.
 National
 Regional

Renal Association Recommendation1 (provisional targets)
The following provisional targets may be set for mean survival:
For all patients with ‘standard’ primary disease aged 18-55 years
1 year > 90%
5 years > 80%
10 years > 70%
For all patients except those with diabets mellitus aged 18-55 years
1 year > 90%
5 years > 75%
10 years > 65%
1Standards
Guidelines:
subcommittee of the Renal Association. Treatment of adult patients
with renal failure: Recommended Standards and audit measures. Renal
Association 1997 (Second edition).
 None
Patients:
Methods:
Health disciplines involved:
Timescale:
ACTION
Proposed date for audit
presentation:
Persons responsible for
monitoring change:
 All patients enrolled in a dialysis programme in the North West Region
will be invited to take part in the study.
 Data will be collected prospectively from computer systems onto a
standardised data collection sheet.
 Data will include: date started dialysis and comorbidity.
 Data will be collated and analysed by the regional audit co-ordinator.
 Nurses
 Physicians
 Ongoing
 April 2001
 Physicians
Appendix five
Project plans for the programme of new individual audit
AUDIT OF ETHNICITY
PROJECT PLANNING GUIDE
AUDIT PROJECT:
Audit leads:


Specialist Registrar:

Audit Facilitator:

Type of audit:
REASONS FOR CHOICE
Aims and objectives:

Proposed health benefits:





Evidence base:





Priority:
METHODOLOGY
Standards:
Guidelines:
Patients:

Methods:






Dr R Ahmad
Consultant Renal Physician
Royal Liverpool University Hospital
Dr D Smithard
Consultant Physician
Birch Hill Hospital
Dr Anijeet
Specialist Registrar in Renal Medicine
Royal Liverpool University Hospital
Nicola Reid
Regional Renal Audit Co-ordinator
First time audit
To assess the availability of translators.
To assess the availability of relevant patient information.
To assess equity of treatment.
To assess equity in access and waiting times for dialysis and
transplantation.
To reduce mortality
To reduce co-morbid illness
To improve quality of life
Nazroo JY. Health of Britain’s Ethnic Minoities. PSI 1997
Ayanian JZ et al. The effect of patients’ preferences on racial differences in
access to renal transplantation. N Engl J Med 1999 341 1661 – 1669.
Garg PP et al. Effect of the ownership of dialysis facilities on patients’
survival and referral for transplantation. N Engl J Med 1999 341 1653 –
1660.
Regional
None
None
All patients receiving dialysis in the North West Region on 1.11.2000
will be invited to take part in the study.
Data will be collected prospectively via patient questionnaires and
from hospital records.
Ethnic group, first language, knowledge of other languages, level of
communication (i.e. ability to speak and read English if first language is
not English), access to translators, access to patient information in first
language will be recorded via a patient questionnaire.
Hospital record of ethnic group, availability of translators, availability
of patient information, age, sex, primary renal diagnosis, diabetes, first
mode of treatment, date dialysis started, date of first access formation,
blood group, Epo treatment, if on waiting list for transplant after 6
Health disciplines involved:
Timescale:
ACTION
Proposed date for audit
presentation:



months of treatment and creatinine at first visit to nephrologist will be
collected from hospital records.
Nurses
Physicians
April 2000 – March 2001

April 2000