Tuesday, 28 April 2009

Liverpool leading the way

I visited the Royal Liverpool Hospital on 17 April and found happy motivated staff, well informed people with kidney disease and an innovative and caring senior team. I had checked out the MRSA bacteraemia rates before I visited and I knew that there had been a substantial and sustained fall over the last 3 years. Pauline Connelly can take some of the credit for that. Pauline, a medical secretary by background, took over the coordination and support of vascular access in May 2007. There has been a progressive rise in the use of arterial venous fistulas for the first dialysis (the incident population) and in the overall Arterial Venous Fistula (AVF) rate in those on haemodialysis (the prevalent population) with fast track systems now in place for those who start dialysis in an unplanned way. Now, over 85% of people on haemodialysis at the Royal Liverpool Hospital and its satellites at Broadgreen, Whiston, Warrington and Halton are dialysed through an AVF. I was pleased to learn from Matthew Howse (Consultant Renal Physician) that less than 3% of people in the dialysis programme are considered technically unsuitable for a fistula. Coordination and the weekly multidisciplinary team meeting between renal unit staff, interventional radiologists and surgeons are key to achieving these ambitious targets.

Matthew also raised the thorny issue of attribution of MRSA bacteraemias between the centres and their satellites. When Richard Fluck and our Kidney Care Healthcare Associated Infection Group discussed this with the Cleaner Hospitals Team and the Health Protection Agency, they decided that attribution should be linked with clinical governance and I am sure that’s correct. Medical governance is via the responsible renal consultant through the CEO of the Trusts. However, in commercially run satellites, the governance arrangements are shared – it’s a partnership. Contracts can’t specify the safety and clinical protocols that must be in place, even if they could, the risk would be fossilising of practice. Matthew’s point was that a Chlorhexadine concentration of 0.5% as skin preparation may not be sufficiently concentrated. We discussed the route cause analysis of the MRSA bacteraemias and agreed they should include and address the issue of variance in protocols between different settings. Patient safety being the overriding concern.

In my short visit I wasn’t able to see everything but 3 further initiatives stood out for me. Two that will directly and considerably improve patient experience and one change in practice that is already saving money that is being used to improve other aspects of quality of care for people with kidney disease at the Royal Liverpool Hospital. Eileen Newall (Holiday Dialysis Coordinator) has established a database of kidney units across the world that are suitable and willing to take UK patients. Eileen spends a considerable amount of time ensuring the database is up to date and her efforts have promoted an increase in uptake of dialysis away from the base unit, usually for holidays but sometimes for other reasons, in the patients on haemodialysis in Cheshire & Merseyside. In the region of 35-40% of dialysis patients in Liverpool now holiday abroad each year – a British Renal Society survey a few years ago showed that in most units less than 10% of people were actually getting away from base for up to or more than 2 weeks a year. This is a really valuable service and Eileen’s system is among one of the best that I have seen or heard about. Jonathan Davies (Lead Nurse) introduced me to one of the recent ABO incompatible transplant recipients who was doing really well and told me that his creatinine was below 100 and that Liverpool Football Club would win the Premiership. I wished him well with regard to transplant function! I also commented on how tidy the kidney unit looked, some VIP visits do lead to repainting of wards and other superficial and temporary changes but I don’t warrant such an approach. The tidiness resulted from the reduction of clutter and consumables by moving to each individual patient’s dialyser and canulation kit being pre-packaged resulting in a tremendous space saving, no boxes in the corridor (!) and a financial saving of around 12.5%.

Finally, I had the pleasure of sitting on the appointments committee for 2 new consultants. One of the those appointed, Dr Muhammed Ahmed will be developing the new service in Warrington and Dr Rema Saxena has been appointed to the Royal Liverpool Hospital and has a special interest in a conservative care programme pioneered by Dr Peter Williams who is now the Medical Director of the Trust.

I suggested to Gordon Bell (Consultant Nephrologist & Clinical Director) and Talib Yaseem (Deputy CEO) that all these initiatives: reduced MRSA rates, increased fistula rates, better holiday dialysis arrangements and new and successful ABO compatible transplant programme and the cost saving approach to consumables allowing reinvestment elsewhere, should be put forward for innovation prizes, but being in Liverpool, and coming from Manchester, I had to caution about the unrealistic prospect of getting all 5 prizes in the one year – that would be the elusive quintuple.