Bedtime reading: proteinuria business rules

The business rules for the new CKD domain of the Quality and Outcomes Framework have now been published. They provide the definition and codes that map to individual components of the CKD QOF. Beware, it's a very technical document but a FAQs sheet to support the business rules is in development and will be available soon.

Developing costs to develop an equitable high quality service

The final report of the dialysis PbR group was published on 1 June to coincide with the British Renal Society Annual Meeting. I have spoken before about the importance of this project that brought finance and clinical leads from 16 Trusts together to gain a better understanding of the components and costs of dialysis. Quality is the organising principle of the NHS. Patients, clinicians, commissioners and regulators all have a role in defining quality. The quality report needs to correspond to the financial spreadsheet – the key link being the clinical codes that capture the details of care.

It seems an age ago when the project started. In October 2007, the NHS was beginning the Next Stage Review, the UK economy was still strong and the run on Northern Rock hadn’t started. Arsenal were top of the Premier League. The need for robust costs was driven by the continuing growth of dialysis and our concerns about capacity. Lean thinking was in there but the importance of productivity was not as stark as it is now that the public debt has doubled to nearly 80% of the gross domestic product.

Finance directors, clinical directors, lead nurses, commissioners and kidney patient associations should all scrutinise, not only read this report. All those involved in delivering, coding and accounting for clinical activity should take care to record accurately. Accurate recording is the basis of good clinical practice – it should not be sloppy, it should not be an afterthought.

I think we will look back and see this PbR project as the first step in bringing quality, innovation and productivity together in kidney services. The lessons learned are now being applied to kidney transplantation and to develop a best practice tariff for dialysis. Definition, accurate specification and costing of other aspects of advanced kidney disease will follow. Bev Matthews (Director, NHS Kidney Care) managed the project superbly well – it was hard but rewarding work for all concerned. To quote the authors “the project has achieved its aim and provided more transparency to the calculation of renal dialysis costs” (Chris Newton, Senior Divisional Finance Manager, University Hospital, Birmingham); “it provides more informed data for the tariff system. It also enabled clinicians and finance to learn about each others work” (John Bradley, Consultant Physician, Addenbrookes Hospital, Cambridge); “to do this type of project in other areas you need buy-in from interested clinicians and finance staff. Clinicians don’t always get involved in this type of project but it is important that they do” (Hugh Cairns, Consultant Nephrologist, Kings College Hospital, London).

Adding insult to injury

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Kidney Injury study identifies systematic failings in the management of Acute Kidney Injury (AKI). The enquiry comments that “AKI is common, overlooked, poorly assessed and, when eventually recognised, mismanaged”.

Recognition and management of AKI must be linked to the care of the acutely ill patient. It was disappointing to read that the NICE guidance on acutely ill patients is not routinely being applied. Regular checks on biochemistry, administration of IV fluids and fluid balance measurements need to be built into basic management plans.

Acute Kidney Injury in numbers

• AKI affects between 5-20% of hospitalised patients
• AKI has a mortality between 19-83%
• Only 50% of people with AKI receive a good standard of care
• Between 14-22% of cases of AKI are avoidable
• Clinical errors occur in over 30%
• 24% of cases did not have an adequate senior review
• 40% of hospitals cannot provide emergency nephrostomy

Depending on the definition, and therein lies one of the problems, AKI can affect up to 20% of all acute hospital admissions. Even a small rise in the serum creatinine of only 25 umols/l is associated with a significantly increased mortality whatever the underlying condition. AKI is reported to be associated with a mortality of between 20 and 80%! Would a systematic approach to identify and treat AKI earlier improve outcomes? We don’t yet have research studies that would unequivocally answer that question. But we do know from a range of epidemiological studies that in many cases of AKI there are errors of omission and commission early in management – particularly failure to maintain good fluid balance or withdraw potentially nephrotoxic drugs.

We now have an international classification for AKI. I am hopeful that it will allow intensivists, kidney clinicians, acute physicians, radiologists, surgeons and general practitioners to speak the same language. One of the difficulties of AKI is that it occurs in many settings from the community, to the emergency medical admissions unit, on surgical wards as well as in kidney units and intensive care units where we can offer dialysis.

In March this year NHS Kidney Care therefore brought together representatives and experts from all the clinical areas to start to develop an acute kidney injury initiative. The enthusiasm from all quarters was palpable. The Renal Association Clinical Practice Guidelines and Audit Measures published in June 2008 and GIFTASUP, the British consensus guidelines on intravenous fluid therapy for adult surgical patients, provide a sound basis for developing sound pathways of care for AKI. There is a need to agree definitions and a classification system; to begin to systematically collect data to provide information on incidence, associations and outcomes and a big need to demystify the condition and educate all clinicians, both trainees and practitioners, about AKI risk, fluid management and treatment.

Our NSF recommends that patients at risk of suffering from AKI should be identified promptly, with hospital services delivering high quality, clinically appropriate care in partnership with specialist teams. This provides us with the challenge of how to improve the quality of care for patients who develop AKI in the modern healthcare setting. NHS Kidney Care has made AKI a key priority. We will be working with the kidney community, the acute medicine community and critical care colleagues to clarify definitions and provide education and support to all other clinical teams and organisations to transform the services for and outcomes of AKI.

Read the report, responses to it and see powerpoint presentations on the NCEPOD website
Listen to the BMJ podcast by Jim Stewart (Consultant Physician and principle author of the NCEPOD report)

Renal NSF update June 2009

The NSF update for June is available here

Dying well : what you should hear

At the GMC Consultative Conference on 3 June 2009 on the draft guidance for doctors `End of life treatment and care: Good practice in decision-making, Jonathon Hope (member of the Patient and Carer Steering Group and the CEO Sponsor Group of the Modernisation Initiative End of Life Care Programme in Lambeth and Southwark), delivered a poignant speech from his and other patient perspectives on end of life care.

Also at the conference was Professor Gurch Randhawa (Director of the Institute for Health Research at the University of Bedfordshire) speaking about diversity, culture and belief. Gurch has been working for access to transplantation for many years and was also a member of the Organ Donation Taskforce.

Changing of the guard and a new hospital for the children of the North West

The new Royal Manchester Children’s Hospital opens this week at the heart of the Central Manchester and Manchester Children’s NHS Foundation Trust site. Mark Bradbury (Consultant Paediatric Nephrologist, Manchester), gave Maurice Savage (Prof Medicine, Belfast) and myself a sneak preview last Friday when we were at Bob Postlethwaite’s Festschrift to mark his retirement from clinical practice. It’s a fabulous building – lots of light and space. As Nick Webb, another of Bob’s colleagues and who opened the meeting, commented “it’s fit for the children of the North West”.

Nick had asked me to speak about transitional care because it is one of Bob’s passionate interests. I was pleased I was able to sit through Paul Harden’s fabulous session at the British Renal Society earlier in the week. For me it was the jewel in the crown of BRS 2009. The videos and discussions were extremely educational. I am delighted that Paul is helping us lead our NHS Kidney Care project to transform the quality of transitional services for young people with kidney disease.

Researching the whole area for my talk, what struck me most was just how much work has been done, particularly over the last few years. There is no shortage of evidence, research and “how to” documents and as I have blogged about before, there is now an educational e-learning package available. The challenge is now to go from print into practice!

The challenges are organisational and generic as much as, if not more than, kidney specific. Hospitals just aren’t welcoming to people between the ages of 14 and 26. The service is much more than the hospitals but overall the service does not seem to have considered this age group in its planning and delivery of support and treatment. “You’re welcome” is a project aimed at addressing that gap. The “You’re welcome” project team have developed explicit criteria, standards and now a self assessment checklist that NHS organisations can carry out to see how they are doing at being young person friendly. I would encourage this initiative to be discussed at hospital boards and hope to see Trusts with kidney services, both children’s and adult, going through the self assessment exercise and making that available to patients and the public. Of course we can’t blame the system without acknowledging that we are part of the system. Reflecting back on the transitional service that Bob Postlethwaite and I used to run, it was more like a transfer event than a graded, supported transition from the children’s hospital environment to the adult kidney services. It’s good that’s going to change and we are going to treat young people with more autonomy.

There was a fabulous, varied mix of speakers from Dr Mary Eminson (Clinical Lead, Greater Manchester CAMHS Network Board) speaking on “fabrication & induction of illness in children by parents” to Dr Rasheed (Bayo) Gbadeges (now at Duke University but formerly an ISN Travelling Fellow in Bob’s department) updating us on the “pathogenetics of nephrotic syndrome” and Adrian Woolf (recently appointed Prof of Paediatric Kidney Medicine in Manchester) on kidney development and the tantalising future where we hopefully will be able to talk more about a cure rather than lifelong treatment.

Bob closed the day commenting that change in the health service needs clinical leadership – integrity, commitment, vision and pragmatism. To which I might add persistence. But now to paraphrase Bob “it’s not about the building, it’s about the community that has now been brought together”, it is the start not the end.

Bedtime reading: Questions in the House

In early June a discussion Baroness Gardner of Parkes asked Her Majesty’s Government what steps they are taking to encourage the uptake of self-care dialysis, including home haemodialysis, by patients with kidney disease throughout the country. Read the answer here

FOR ACTION: Patient Transport survey results launched

Two thirds of people receiving hospital or satellite based haemodialysis completed the transport audit. That in itself speaks volumes about the importance of transport to people receiving regular haemodialysis. The Information Centre have now compiled all the information and it is available by PDF or for you to interrogate using iView at the Information Centre website.

I am sure that you are aware that the next stage is for the individual kidney units, networks and commissioners, in conjunction with patients and patient groups to put together an action plan to address any issues that have been identified in your unit.

related blogs:
Patient Transport Survey - first phase
Use NHS iView to get the most out of Patient Transport survey results