Wednesday, 27 August 2008

Q & A: Criteria for place of maintenance haemodialysis

Q I wonder if you could help me? I have received a query from one of the Renal Centres as to whether there are criteria on deciding if patients are suitable for dialysing in a Centre or a Satellite unit. We do not seem to have one – do you know anyone who does? Nesta Hawker, Specialised Commissioning Manager, NW SCG

A Dear Nesta, thanks for your enquiry. I think the principles are probably applicable across units and commissioning areas but the specific criteria may well depend upon local factors and to be workable I think the criteria need to be owned by the local renal communities – within that group I obviously include renal commissioners and renal patient groups.

Patient safety is paramount and convenience for the individual undergoing dialysis (and their family members/carers – in some instances) are important considerations. For the majority of patients for most of the time this should mean dialysis in the facility closest in travelling time to their home.

Over the past 15 years I have seen a change from the philosophy that only fit and healthy patients can be dialysed in a satellite unit, but those with co-morbidities need to be brought into the centre where there is easier access to medical or more intensive nursing support, to a realisation that bringing sick people long distances actually increases their dependence and can reduce their quality of life such that many units would now expect that all patients are dialysed in the unit closest to their home. To quote Donal Rumsfeld “stuff occurs” such that around 15% of patients at any one time need to be managed in the central unit – because they are admitted and need dialysis from the ward, because they are attending other departments only available at the inpatient centre or because of access problems.

One aspect of a quality service that I would like to see debated in more detail and potentially measured as a marker of quality is starting dialysis as an outpatient via an AV fistula – we used to consider that the first dialysis should occur in a central unit but am not sure why it couldn’t be planned to start in a satellite unit with appropriate staff and facilities on hand. Haemodialysis is a “much gentler” procedure now that it is bicarbonate based and the flows can be regulated to individuals’ tolerance such that even severe cardiac disease should be able to be managed in both satellite and central units.

I have heard people argue that only those with uncontrolled psychiatric illness or the rare patients with a severe personality disorder need to be routinely managed in a central unit.

Nesta, I know you will be raising this at the North West Renal Strategy Groups and the Specialised Commissioning Forum in September. I will be interested to learn the views of others and will return to this issue in the blog after these events.