Thursday, 22 October 2009

Morris the Oracle

Morris has the ability to see into the future and was predicting the number of people likely to need renal replacement therapy in London last week. MORRIS, the model for optimising renal replacement investment and services is the capacity planning model that Daisy Wild, David Pearce, and David Halsall from the Clinical Policy Strategy and Analytical team at the Department of Health have been developing with Charlie Tomson and David Ansell at the Renal Registry and Ruth Davies at Warwick University to model demand for renal replacement therapy over the next 10 years. Specialist Commissioning Groups, Network leads, SHA renal IT champions and clinicians came together on 15 October for the launch of MORRIS which has been constructed to support policy making and commissioning of renal replacement therapy services for adults in England.

The model is populated with data at the Local Authority level for the whole of England and users can select their own SHA to run the programme. Results can be produced by Local Authority, Renal Centre and Primary Care Trust. Current levels of renal replacement therapy have been input from the Renal Registry returns and default values for acceptance rates, transplantation and mortality have been derived from recent national data but can be adjusted by the user to more accurately represent local conditions, local projections and test alternative scenarios.

MORRIS uses a combination of an Excel spreadsheet and a dynamic simulation software model built in the software package iThink. Although the Excel file provides the main interface for the model, there is also a user interface in iThink where users can make simple changes to the input, run new scenarios and view high level output. The results of these scenarios can then be exported to the Excel model file.

The model has now been through a few iterations and I am most grateful to the advice and support of Paul Roderick, David Ansell, Ruth Davies, Lawrence Goldberg, John Bradley, Kevin Harris and Paul Stevens during this phase.
The model gives people a very wide range of possibilities of changing the key variables and to begin with this can be quite daunting. MORRIS is now available for anyone who wishes to use the model. NHS Kidney Care will be supporting the roll out of MORRIS and we would be very interested in hearing comments and views of all stakeholders.

Wednesday, 21 October 2009

PD specification launched

The second home dialysis meeting in Manchester at the beginning of October was a fabulous meeting. The delegates had a lot of energy and I was pleased to hear of the progress that individual teams have made over the past 12 months in addressing some of the barriers to achieving dialysis at home by both haemodialysis and peritoneal dialysis. Over 250 people attended. Many units had representation from across the multi-professional team and I was encouraged to see patients attending, participating and challenging – that’s really healthy. The only group rather thin on the ground were renal Specialist Registrars but I am sure that teams will be encouraging their trainees to attend the next home dialysis meeting.

NHS Kidney Care took the opportunity of the conference to launch the peritoneal dialysis specification which is based on a patient centred pathway following the patient from renal failure to dialysis and covering 5 sections each with measurable quality outcomes that commissioners, providers and patients can use to benchmark and drive forward service improvements. I am grateful to Dr Lindsey Barker (Consultant Physician and Clinical Director Medicine, Royal Berkshire), Mario Varela (Director of Procurement & eCommerce, Barts) and the other clinicians, patients, commissioners and managers who helped draw up the national specification.

The specification should be used by patients and commissioners as a guide to services they should be able to access; by providers to offer patients genuine modality choice; by procurement departments to gain high quality, cost effective services and supplies. I am hopeful that it will help in the effort to increase real choice, including assisted peritoneal dialysis for people to have home therapies when they want.

Tuesday, 20 October 2009

Acute Kidney Injury - on the agenda

Acute Kidney Injury (AKI) has until now been the poor relation of kidney care. The National Service Framework identified AKI, previously known as Acute Renal Failure (ARF) as a national priority and states:

People at risk of, or suffering from Acute Renal Failure are identified promptly, with hospital services delivering high quality, clinically appropriate care in partnership with specialist renal teams”.

An AKI care initiative conference was held at the Royal College of Physicians in March 2009 supported by NHS Kidney Care and a report of those proceedings has now been published with hard copies available from

Representatives from different specialist communities from around the UK were invited to share their own perspectives of AKI and how it impacts on patients managed in their speciality. The aims of the conference were for the delegates to work collaboratively in considering the following areas:

1. How to work towards a consensus definition of AKI.
2. How to prevent and detect AKI.
3. How to improve medical training curriculae for both undergraduate and postgraduate trainees and enable best practice management of AKI.
4. How to share datasets and codes to allow identification of quality markers to drive improvements and inform tariff development.

The conference recommended that:

1. A national group is convened to work collaboratively enabling real improvement in the prevention, detection and treatment of AKI throughout the UK.
2. An acceptable working definition of AKI is developed by performing a multi-centre study using different staging systems and correlating with outcomes.
3. Enzymatic serum creatinine assays should be implemented in all biochemistry labs throughout the UK to ensure national comparability. For patients is admitted to different hospitals with different biochemisty laboratories the development of shared databases should be created to improve comparability between laboratories
4. An electronic alert by biochemistry system should be developed which is compliant with the AKA Map of Medicine.
5. The national vascular database should be reviewed and updated to ensure AKA data is collected and audited post-surgery. The instances and outcome of AKI in patients undergoing vascular surgery/interventional procedures should be captured routinely.
6. Further local AKI audits should be encouraged to assess the incidence of AKI among other speciality patient groups.
7. There must be a coordinated approach to improve both undergraduate and postgraduate education for AKI. Core competencies must be developed to improve the identification and management of patients at risk of developing AKI , including the acutely ill patient (NICE Clinical Guideline 50).
8. District General Hospitals without renal services should develop links with local renal services and develop agreed care pathways for patients who develop AKI, enabling optimisation of patient care and efficient transfer of patients to a renal unit if appropriate.
9. Identification of new and improved biomarkers allowing early detection of AKI should be developed to improve the potential for targeted therapeutic intervention.
10. Renal units should work together locally with radiology and cardiology departments to ensure shared guidelines are in place to prevent contrast induced nephropathy.

Subsequently the National Confidential Enquiry into Patients Outcomes and Death (NCEPOD) AKI study was published and shows that only 50% of patients who died of AKI received satisfactory or good care. Delays were identified in the recognition of AKI particularly those who develop AKI after admission. The report has raised the importance of AKI throughout the NHS and will act as a catalyst to drive improvement in renal care.

Some of the individuals and organisations at the March Acute Kidney Injury Care Initiative Conference came back together a few days ago to help the Department of Health and NHS Kidney Care address the following questions:

1. How can you ensure that guidance/evidence relevant to AKI is implemented?
2. What do commissioners/Trusts need in order to ensure appropriate management of AKI?
3. How do you join up all relevant specialities to ensure AKI patients are treated effectively?
4. How do you ensure to and maintain awareness and capability for managing AKI.

AKI is a major issue for a range of communities in clinical medicine and has a significant impact on patient morbidity and mortality and on NHS resources. I am pleased that it is now being regarded as a systemic issue by those responsible for training, service delivery and quality. AKI is common, harmful and treatable. AKI affects up to 1 in 5 people admitted to hospital, and even modest changes in serum creatinine are associated with a 6.5 times increase in mortality.

All acute services have received a copy of the NCEPOD report and have been asked to review their approach to acutely unwell patients in the light of the findings. AKI is now be firmly on the agenda . I look forward to improvements in education, systems and care processes to support the prevention, early identification and treatment of AKI across the NHS, whatever the clinical or organisational setting.

Bedtime reading: supported staff makes for better patient experience

Veena Raleigh of the King’s Fund and colleagues have undertaken a study analysing associations between staff survey results and inpatient experience in 166 acute and specialist trusts in England. This study is unique in its scale, using 2006 data from Healthcare Commission administered surveys which received responses from about 70,000 staff and more than 80,000 patients. It employs multiple linear regression to measure associations between patient and staff responses at each trust, and only includes staff directly involved in patient care.

Full text from the Health Policy Digest Research Findings summaries issue 29

Thursday, 15 October 2009

Tackling missed opportunities in primary care

Improving quality in primary care is a document that sets out to support PCTs as commissioners of primary care working with local clinicians and other stakeholders – including patients – to promote continuous quality improvement in primary care services. The focus of the document is on the quality of care delivered by the practice rather than the individual practitioners and I was pleased to read about the work of Lisa Eve.

'The information technology (IM&T) team at Sutton and Merton PCT picked up an issue from reviewing CHART & PRIMIS data and discussed this with Lisa Eve, Clinical Services Director and audit lead at Cricket Green Medical Practice. As a result, Lisa conducted an audit, looking at patient records and found that there was a simple READ coding issue. The results from this audit were highlighted as an education and development need within the practice and at their education meeting Lisa ensured all relevant staff within the practice were trained in using the correct READ coding for the condition. As a result all patients who have chronic kidney disease (CKD) now have this long term condition correctly READ coded on the front page of their electronic records. This audit enabled tidying up of patient electronic records by providing an easy to glance record of patient’s current and past problems. The audit also enabled the CKD clinical lead to implement improved clinical care in the form of identifying patients who have not, as yet undertaken annual urine tests for microalbuminuria.

As Lisa says: “this audit enabled us to focus on CKD, improve identification and correct READ coding of CKD and review the need for recruiting specific members of practice staff in order to
deliver targeted clinical care which has the potential to improve patient disease outcomes”.

The audits undertaken were written up, sent to the IM&T team lead at the PCT to enable the review of practice changes and sharing of audit knowledge with other practices.'

One of the things emerging from the Greater Manchester Collaboration for Leadership in Applied Health Research and Care (CLAHRC) CKD project I am involved in locally is the key role that practice managers play in setting up and monitoring the systems that enable the clinicians to improve the quality of care. Practice Managers make a really significant contribution to the health and wellbeing of the nation.

Monday, 5 October 2009

Q & A: 5 yearly revaccination of Pneumococcal (PCV) vaccine for people diagnosed with CKD

Q: I have been asked by our Primary Care Subgroup if you have heard anything further from the immunisation team in relation to vaccination and 5 yearly revaccination of Pneumococcal vaccine for people diagnosed with CKD as it is unclear in the ‘green book’. I appreciate this is a difficult one and maybe there needs to be further research undertaken into this area before we can give a definite answer. Lynda Smith, Kidney Care Network Manager, Cumbria & Lancs

A: Dear Linda, The Green Book is currently being revised and will soon contain further information regarding people who have CKD and the pneumococcal vaccine. We will outline that patients with Chronic Kidney Disease stages 3 to 5 should be offered two doses of PCV (pneumoccocal conjugate vaccine) vaccination followed by a booster dose of PCV (pneumoccocal conjugate vaccine) every five years. Patients suffering from CKD stages 3 to 5 should no longer receive PPV (pneumococcal polysaccharide vaccine).