Monday, 17 September 2007

Back to School in Oxford

The Oxford-Ghent dialysis and transplant Summer School was held at Corpus Christi College in Oxford over last week. Paul Harden, Consultant Renal Physician at the Oxford Radcliffe Hospital invited me to talk on the Sunday about “timely vascular access” and I found the conference really buzzing. The School is in its 4th year and caters for senior nephrology trainees from northern Europe with most of the learning happening through interactive case based tutorials in true Oxbridge style. The programme covered key aspects of nephrology, dialysis and transplantation with a strong UK and European tutorial team.

Preparing for my talk I was again struck by the variance in definitive access across the UK – ranging from 44% to 94%. The message I take from that is that it is possible to provide timely and high quality access in the UK – but we are not doing it yet! A lot of the tools however are in place – timely access is an NSF must do, pathways have been published from the Modernising Renal Services Project, the Joint Societies Vascular Access Working Party report makes clear organisational and resource recommendations and data on access related MRSA bacteraemias is being collected via the MESS system. We are expecting a regular audit by the Healthcare Commission and Renal Registry. Richard Fluck, Consultant Nephrologist in Derby ( has even established a web 2.0 social networking site for healthcare professionals to share experience, support colleagues and spread good practice. But looking at the HES data, the hospital episodes statistics, for vascular access I am concerned that our coding is not as good as it needs to be – it looks to me that we are missing quite a lot of day case procedures and in some units the data really doesn’t add up. I have sent the HES data to all the clinical directors but if you would like to see your local data I am happy to provide it.

Three or 4 really challenging case were presented for panel discussion – my initial prejudice was that we may fall into the trap of talking about real rarities. I shouldn’t have been worried – the panel consisted of Alison Cornall, the first dialysis access nurse specialist in the country I think, Chris Darby, a practical and common sense Vascular Surgeon and Dr Raman Uberoi, an Interventional Radiologist. Several of the cases were of central stenosis. Chris made the point that the great vein stenoses we used to see with subclavian lines have now moved proximally and that brachial and superior vena caval occlusion can occur in a very short time. Cases of steel syndrome were also presented and the importance of delineating whether the steel is occurring in the context of a high flow or a low flow fistula emphasised. Alison commented that between 2005 and 2007 the Oxford Unit have gone from 15% of patients starting dialysis via an AVF to 68% by focussing attention on the pre dialysis patients. The overall prevalence of AVF use is in the haemodialysis population looked after by our Oxford colleagues, approximately 650 patients, is now 82% - well done! We also discussed approaches to crash landers, whether repeated in out femoral stab offered advantages over lines and when acute Tenckhoff catheter insertion should be performed.

It was fun to meet Alison and Chris again having worked with them on the Vascular Access Modernisation Initiative. The importance of a multidisciplinary team meeting for co-ordinating and problem solving was clear for all to see – do you have such a meeting every week or fortnight in your own unit? There is quite a lot of work in the cancer field that demonstrates the positive benefit of structured and mandated MDT meetings. So the cases gave us an opportunity to consider service design issues as well as pure clinical questions. In the same way, a regular MDT provides an opportunity to run and test quality improvement initiatives as well as co-ordinate individual care.

It is always enjoyable to go to Oxford and this trip was no exception (a view of Corpus Christi Quad from my room above). We don’t have that many opportunities to mix and meet with our European colleagues. If you get the opportunity I would recommend that you go to the next Oxford Ghent Summer School.

Tuesday, 11 September 2007

Q and A: Impact of eGFR on Specialist Kidney Referrals

Q: We are looking for data to back up concerns that we have regarding the effect that eGFR has had or will have on clinics in terms of inappropriate referrals and compounded by the 18 week target.

Is there any audit data available which could be shared and which we could take to our Development/Service Improvement Lead for the Trust. We would like to be able to show how the 18 week target and more specifically, the 3 week new appointment target which comes in next March will cause us some concern.
Julie Batterton, Associate Directorate Manager, Nephrology & Renal Transplant Directorates Royal Liverpool & Broadgreen University Hospital Trust, Prescot Street, Liverpool

A: Dear Julie , my consultant colleague passed on your request for audit info re the impact of eGFR on specialist kidney referrals.

In general terms, the introduction of eGFR reporting and of CKD in QOF has lead to a substantial increase in new referrals to renal services - some appropriate (ie in line with the well publisied RCP RCGP guideline), but many inappropriate. Also we need to bear in mind that this last year has been the first year - so a lot of prevalent cases have been uncovered . You would know how many by looking at your local PCT and practice CKD observed as expected prevalence in the QMAS data - well worth doing - it essentially shows where there is educational need in primary care.

Systems that have been operating eGFR for some time and have good referal pathways in place have seen a fallback in referrals to manageable numbers - the key is excluding (by education - look at the Derby website) as well as encouraging proforma referrals that don't all need a traditional OPD - ie establishing (commissioning) virtual clinics - they do need real time!!

Richard Fluck in Derby (who has an excellent system) and Kevin Harris in Leicester/East Midlands Renal Network each have good local audit data - Kevin over a diverse range of providers.

The main issue arising nationally is the need to have robust, coordinated advance CKD care (predialysis , supportive and palliative) that ensures adequate preparation and choice for people with CKD Stages 4 and 5 - small numbers (in comparison to Stage 3 the overwhelming majority of whom should get the greatest amount of care in the primary/community setting) . You would know how good comparatively your pre-dialysis care is by looking at the proxies of pre-emtive transplant listing/transplanting and percentage who start haemodialysis via an AVF - data in the Renal Registry.

Let me know if I can be of more help.