Bedtime reading: NICE Guidance on venous thromboembolism

Did you know that venous thromboembolism (pulmonary emobolism and deep vein thrombosis) is two times more likely in people with CKD than without? This NICE Guideline on VTE is therefore highly relevant to all those who work in kidney services.

bedtime reading: "a revolutionary moment in the world's history - a time for revolutions not for patching" (William Beveridge 1942)

Do Beveridge’s words, as he laid the foundations for the UK welfare state in the dark days of WWII have any relevance today?

Our public services do face an unprecedented set of challenges: increasing demand, rising expectations, seemingly intractable social problems and reduced budgets. Reform can’t confront these challenges effectively: radical innovation in healthcare now needs to move from the margins to the mainstream. The question is what analysis and principles should inform this radical innovation?

“The challenge of co-production” by David Boyle and Michael Harris quote Beveridge in their foreword and argue that equal partnerships between professionals and the public are crucial to improving public services. Given the current diversity of uses of the term “co-production”, the paper also explains what co-production isn’t. They claim co-production looks set to create the most important revolution in public services since the Beverage report of 1942. The document doesn’t only deal with the NHS, it’s about all public services but it sounds like an important read for those interested in health and healthcare.

The chapter “getting more for less” might be particularly relevant.

Bedtime reading: NHS 2010-2015: from good to great - gives a plug to home dialysis

Andy Burnham, Secretary of State for Health, launched this 5 year plan which maps out the journey of improvement that's going to be required to make the step change from good to great. It aims to give people working in the NHS a clear direction and time to plan for the quality and productivity challenge we face. There is a strong steer on prevention, patient engagement is highlighted and the NHS staff are acknowledged as its greatest asset.

There is an emphasis on care closer to home and "the tariffs payment system must incentivise the shift for care out of hospital settings if this is what patients want". Home dialysis is cited as a good example where quality and efficiency come together. From good to great identifies the need to link payment systems to whole pathways of care so that long term conditions like kidney disease can be managed across the whole local health environment.

Bedtime reading: drug safety update Ciclosporin

Ciclosporin must be prescribed and dispensed by brand name. The medicines and healthcare products regulatory agency issued a drug safety update at the beginning of December emphasising the importance of prescribing and dispensing Ciclosporin by name. Ciclosporin has a narrow therapeutic index which means that the dose has to be very carefully adjusted to ensure the blood and tissue levels are spot on, not just close, and patients should be stabilised on a single brand of Ciclosporin because switching between different types or formulations without close monitoring may lead to clinically important changes in blood levels even if the same dose is taken. For kidney transplant recipients that risks rejections or toxicity from the Ciclosporin. All products that contain Ciclosporin are interchangeable ONLY if careful therapeutic monitoring takes place. Prescribing and dispensing of Cyclosporin should therefore be by brand name to avoid inadvertent switching. Patients as well as prescribers and pharmacists should be fully aware of the brand prescribed. It’s important for patients to challenge the prescriber of pharmacist if a different brand or formulation seems to have been provided eg if the drugs look different in colour or shape or even when the box or packing have changed. If switching of a patient stabilised to one brand of Cyclosporin is unavoidable, the patient should be closely monitored for side effects. Ciclosporin drug concentrations, serum creatinine levels, blood pressure and transplant function must be monitored if a switch is to be made.

Bedtime reading: NICE Guidance on Depression in CKD

Under-recognition of depression remains a major problem. As does the assessment of depression in the presence of chronic physical problems. NICE have issued a new guideline on depression focussing on adults with chronic physical health problems.

Kidney disease figures prominently in many sections of the report and the recommendations are highly relevant to the care of those with chronic kidney disease or recovering from acute kidney injury. I was struck on reading the guidelines of the parallels between depression in people with advanced kidney disease and acute kidney injury in acutely unwell patients. Both are common but often unrecognised, basic assessment of depression should be a core competency but often isn’t given prominence and when identified both are frequently mismanaged. The key message is to be alert to the possibility and questions to consider are:

“during the last month have you often been bothered by ‘feeling down’, depressed or hopeless?”
“during the last month have you been bothered by having little interest or pleasure in doing things?”

Depression in chronic physical conditions, including CKD is treatable. It is a major cause of avoidable morbidity, it prolongs length of stay and is independently associated with an increased risk of death. Read the full document (400 pages), quick reference guide or the excellent article in the BMJ (published on 27 Oct 09) by Stephen Pilling and colleagues on behalf of the guideline development group (Pilling et al. BMJ.2009; 339: b4108).

NICE have also produced guidance to promote mental wellbeing through productive and healthy working conditions that aims to help reduce the estimated 13.7 million working days lost each year due to work-related mental health conditions including stress, depression and anxiety. Sick leave in the NHS costs over £500,000,000 a year – staggering I know. David Nicholson, CEO of the NHS has highlighted this guidance to all his NHS Chief Executive colleagues because of its importance

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

Bedtime reading: BMJ launch CKD e-learning package with NICE

BMJ have launched a CKD e-learning package with NICE. Why don’t you have a go on the interactive cases and see how you get on?

Bedtime reading: National policy on antiviral medicines for CKD

Read the letter here

Bedtime reading: What do I need to know about proteinuria? Information for patients

The Department of Health have produced a leaflet for the public to explain proteinuria.

The leaflet aimed at patients explains the meaning of proteinuria, cases, signs and tests to determine proteinuria. It also covers how to manage diabetes and blood pressure with proteinuria. This is part of a pack of information on proteinuria testing. Information sheets for GPs and labs have been published on the Department of Health website.

Bedtime reading: National Diabetes Audit 2007/08

This Audit makes interesting reading. All complications of diabetes apart from eye disease are more common with increasing social deprivation with a two fold increase between the least and most deprived. Even more striking are the large differences in the rates of complications between regions with up to two fold difference for kidney failure. This variance suggests that significant improvements could be made and I think that also follows from a knowledge of the pathophysiology. It depends whether you are a glass half full or a glass half empty person on how you respond to the albuminuria testing data. This has improved from only 20% of registered patients having an ACR in 2003/04 to 62% in 2007/08. That's still nearly 40% of the people who are known to have diabetes who are not getting satisfactory kidney care, let along those who have not yet been identified with diabetes. There are clear opportunities to work locally, regionally and nationally with primary care and diabetes colleague to improve the kidney care of those with diabetes.

Bedtime reading: NHS clinical knowledge summaries

A new resource intended to support the management of chronic kidney disease is now available

NOTE
The NHS Clinical Knowledge Summaries (formerly PRODIGY) are a reliable source of evidence-based information and practical 'know how' about the common conditions managed in primary care. They are aimed at healthcare professionals working in primary and first-contact care.

Bedtime reading: MRSA : your help needed - who is your contact person?

Meticillin resistant Staphylococcus aureus (MRSA) is an important cause of infection associated with healthcare. All episodes of MRSA bacteraemia in England are reported to the Department of Health via a web-based data capture system managed by the Health Protection Agency. The numbers of MRSA bacteraemia reported by each NHS Trust are published every quarter and since this system was established good progress has been made in reducing the rates of infection.
Since many of these infections occur in patients established renal failure (ERF) additional data on the type of vascular access of these patients has been collected by this system since 2007 and published in the UKRR annual report. The system for capturing this enhanced data relies on sending this email alert to the renal unit whenever a patient in ERF who develops MRSA bacteraemia is recorded in the system. The alert asks the renal unit to access the system to complete the relevant data for that patient. Each renal dialysis unit in England should identify 2 contacts to receive these email alerts and be responsible for completing the data on MRSA bacteraemia.

I have written to all renal unit CDs outlining the system that the Health Protection Agency and Trusts have in place.

Bedtime reading: Programme budgeting for kidney care

The 2007-2008 programme budgeting data was released this on 16 July. It allows organisations to gain a better understanding of where NHS resources are being used. The programme maps all PCT and SHA expenditure, including on primary care services, to 23 programmes of care based upon medical conditions. Renal care is now split from 17 problems of genito-urinary system into 17b. The overwhelming majority of the renal spend is in secondary care. It covers both dialysis and kidney transplantation; it makes interesting reading.

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.

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

Bedtime reading: annual evidence on proteinuria and eGFR (NHS evidence - kidney disease)

The 2009 Annual Evidence Update on Proteinuria and estimated Glomerular Filtration Rate provides an update on the evidence presented during last year's Knowledge Week. The most useful papers on the following topics have been selected by Dr David Goldsmith and Dr Edward Sharples:

1. Basic science
2. Clinical aspects
3. Management

Provided by NICE, NHS Evidence is a new service which will develop, enhance and expand the services that were previously provided by the National Library for Health (NLH). The NLH and its Specialist Libraries became part of NHS Evidence on 1 April 2009. Release 1 of the NHS Evidence portal and search engine went live on 30 April 2009.

The specialist collections have been developed to identify and meet the information needs of particular communities of practice. They are web-based collections containing clinical and non-clinical information on the major health priority areas. Each specialist collection identifies and provides access to quality assessed information of relevance to the community that it serves. An aspect of this involves the production of Annual Evidence Updates, which aim to highlight the best current evidence for selected healthcare topics. Annual Evidence Updates consist of the good quality evidence from a search of research evidence on a particular topic over a 12 month period, plus user-friendly summaries written by relevant experts, and links to guidelines, secondary research and primary research, if applicable. All information included in Annual Evidence Updates has been subject to rigorous selection criteria.

Bedtime reading: Specialised Services National Definition Set (3rd edition 2009)

The Specialised Renal Services (Adults) Definition has now been published. The Specialised Definition Set for childrens kidney services has recently been consulted on and is expected to be published later this year.



http://www.nscg.nhs.uk/ssnds.htm

Bedtime reading: Tackling health inequalities: 10 years on

This is a lengthy report but one that is filled with lots of information about indicators and trends relevant to the social determinance of health. Between 1995-1997 and 2005-2007 average life expectancy for all groups in England has increased significantly - for males by an extra 3.1 years and for females by an extra 2.1 years. The report highlights some developments that have worked well but also the challenges that need to be addressed to get further improvements in the health of disadvantages groups and areas, and a long term narrowing of the gap. This will be particularly important in the wake of the more difficult economic conditions, especially through its impact on unemployment, together with environmental challenges like climate change.

Bedtime reading: Quality improvement story - healthcare associated infection

Thanks to Chris Lacey (Renal Unit Matron), Tracey Harrison and the St Lukes Hospital team from Bradford for this improvement story about reducing MRSA and other healthcare associated infections - keep up the good work Bradford!

Bedtime reading: you're welcome

The You're Welcome quality criteria have now been published and the first tranche of services to successfully complete the You're Welcome exercise and become entitled to display the national You're Welcome quality mark were announced on 31 March 2009. The You're Welcome self assessment toolkit has been designed to enable service providers and commissioners to see what to do to be "young people friendly" and more appropriate to the needs of young people - as detailed in the quality criteria.