Monday, 6 April 2009
Q & A: MRSA Screening and decolonisation
Q: Dear Donal, does the new guidance apply to day case access surgery, renal biopsies, day case ward iron infusions, regular haemodialysis attendances? What is the evidence that decolonisation reduces the risks of MRSA sepsis in these settings? This policy has significant operational implications and is expected to be in place by 1 April 2009. Dr Chris Winearls, Consultant Nephrologist, Oxford.
A: Dear Chris, thank you for your email of 2 March concerning MRSA screening and decolonisation. MRSA is as you know a serious and significant problem in the dialysis population and renal medicine is listed as one of the high risk areas in the MRSA screening – operational guidance. Good progress is being made in reducing MRSA blood stream infections in renal services by a combination of general measures and improvement in vascular access, much of the later based on the innovative approach you have taken in Oxford coupled with the implementation of the professional societies guidance on vascular access.
FAQs on the DH website include guidance on how to treat dialysis patients – they should be screened on admission to the dialysis programme and then at regular intervals thereafter. The FAQs acknowledged that some patients, such as renal patients will be tested more than once.
Renal is not exempt from the general screening policy for admissions. In other words, just as a surgical case is to be screened, so should all elective renal admissions. My interpretation is that out-patient procedures such as out-patient intravenous iron infusions are excluded.
The guidance note justifies the screening/decolonisation by citing the high risk of infections, but I am not aware of a detailed evident base for screening within the speciality of nephrology.
There is one study that supports this approach - Nasal carriage of MRSA; the prevalence, patients at risk and the effect of elimination on outcomes among out-clinic haemodialysis patients. European Journal of Medical Research 2007, July 26; 12/7): 284-8; Lederer SR, Riedelsdorf I, Schiffl H.
I understand that some UK groups are now studying the effect of screening and decolonisation for the dialysis population and I hope that will provide a better evidence base for the effectiveness of decolonisation within our speciality in due course.
A: Dear Chris, thank you for your email of 2 March concerning MRSA screening and decolonisation. MRSA is as you know a serious and significant problem in the dialysis population and renal medicine is listed as one of the high risk areas in the MRSA screening – operational guidance. Good progress is being made in reducing MRSA blood stream infections in renal services by a combination of general measures and improvement in vascular access, much of the later based on the innovative approach you have taken in Oxford coupled with the implementation of the professional societies guidance on vascular access.
FAQs on the DH website include guidance on how to treat dialysis patients – they should be screened on admission to the dialysis programme and then at regular intervals thereafter. The FAQs acknowledged that some patients, such as renal patients will be tested more than once.
Renal is not exempt from the general screening policy for admissions. In other words, just as a surgical case is to be screened, so should all elective renal admissions. My interpretation is that out-patient procedures such as out-patient intravenous iron infusions are excluded.
The guidance note justifies the screening/decolonisation by citing the high risk of infections, but I am not aware of a detailed evident base for screening within the speciality of nephrology.
There is one study that supports this approach - Nasal carriage of MRSA; the prevalence, patients at risk and the effect of elimination on outcomes among out-clinic haemodialysis patients. European Journal of Medical Research 2007, July 26; 12/7): 284-8; Lederer SR, Riedelsdorf I, Schiffl H.
I understand that some UK groups are now studying the effect of screening and decolonisation for the dialysis population and I hope that will provide a better evidence base for the effectiveness of decolonisation within our speciality in due course.
Centre not satellite for Tunbridge Wells
The Oxford English dictionary dates the origin of the term satellite from the mid-16th Century – in the sense “follower, obsequious underling” derived from the French and, in turn, Latin. Despite the fog in Manchester this morning, a bit like a film set depicting the middle-ages, I got to Tunbridge Wells Kidney Treatment Centre on St John’s Road, a busy High Street at the heart of Tunbridge Wells, in a shorter time then I would have got from Tunbridge Wells to the dialysis unit at Guys & St Thomas’s Hospital. A surprising feat given the distances, but distance doesn’t always equate to travel times. The soon to be published transport for haemodialysis audit will draw attention to that fact.
Debra Mundle (Satellite Unit Matron), and Nick Gadd (Deputy Divisional Director for Managed Networks) met me and, with Simon Steddon (Clinical Director for Kidney & Urology Services), showed me the main dialysis area where I was able to chat with a number of patients. They mentioned that it was quieter, less “clinical” and easier to get to and park. Alan Williams (Charge Nurse), showed me the patient resource room and David Gandy (Chief Renal Technician), tried to explain the intricacies of the water treatment plant to me. I didn’t like to admit that physics had never been one of my very strong points so I was starting from a low base but left considerably more knowledgeable about water quality. There is no waiting room as people don’t wait for dialysis now! Now that’s clearly a good thing. A couple of patients did mention the risk of a loss of camaraderie amongst the patients now they are in better facilities and don’t have to wait as a group. That’s a tricky one. Sense of community is very important for many people with advanced kidney disease. Some units do have formal service user groups and I know of several kidney teams that have regular social events such as an annual dialysis dinner, summer Balls and Christmas parties.
Locally dialysis units do of course reduce travel times, improve patient experience and in addition reduce the carbon footprint associated with dialysis services. But I was not going to the Tunbridge Wells Satellite Dialysis Unit. The not so old Pembury Hospital Satellite Dialysis Unit, a portacabin style structure that was opened in 1966 and had been in the grounds of a local hospital was closed earlier this year; and yes, Tunbridge Wells kidney treatment centre does contain a “satellite dialysis unit” – bigger, better, brighter and quieter than the old unit. John Scoble (Consultant Kidney Doctor), did look a few years younger and the machines in the new centre are slicker than those in the photograph that was on show of the opening of Pembury, but the big change that struck me was the move from delivering satellite dialysis at a distance to providing a locally responsive service. The kidney centre also contains a training area for home dialysis and a self care section on the first floor quite separate from the main dialysis unit on the ground floor and clinic rooms for consultation with nursing, medical and surgical staff.
Cormac Breen (Consultant Kidney Doctor) showed me the Guys renal IT system working fast and comprehensively and that enables patients across the whole kidney care pathway to be safely, effectively and efficiently managed in the High Street in Tunbridge Wells as well at Guys tower at London Bridge. Soon venous imaging and Doppler studies will be available on site – so decisions about vascular access can be made locally. The centre offers a range of services including dialysis, transplant follow-up, chronic kidney disease assessment, conservative kidney care management and dietetics.
It was therefore a great pleasure to open the centre with Mike Rusbridge (Mayor of Tunbridge Wells). The team have made a film of building the new centre, leaving the old unit and the scramble that was opening day. It’s fun, it would make you smile and I think it embarrassed Debra but what it shows is a multi-disciplinary team working together across the boundaries that can sometimes slow us down or stop us, it shows a commitment to high quality care and a clinical vision based on the needs of local people with kidney disease. The centre is building relationships with local GPs and community services. Also, as a result of the medical presence on site in the High Street most days, the link with Kent & Sussex Hospital for education, acute kidney injury management, access to local services and joint management when inter-current illnesses develop in people with chronic kidney disease is actually stronger, more responsive and more personalised to the individuals’ needs than when a nephrologist visits the hospital for their weekly clinic.
Debra Mundle (Satellite Unit Matron), and Nick Gadd (Deputy Divisional Director for Managed Networks) met me and, with Simon Steddon (Clinical Director for Kidney & Urology Services), showed me the main dialysis area where I was able to chat with a number of patients. They mentioned that it was quieter, less “clinical” and easier to get to and park. Alan Williams (Charge Nurse), showed me the patient resource room and David Gandy (Chief Renal Technician), tried to explain the intricacies of the water treatment plant to me. I didn’t like to admit that physics had never been one of my very strong points so I was starting from a low base but left considerably more knowledgeable about water quality. There is no waiting room as people don’t wait for dialysis now! Now that’s clearly a good thing. A couple of patients did mention the risk of a loss of camaraderie amongst the patients now they are in better facilities and don’t have to wait as a group. That’s a tricky one. Sense of community is very important for many people with advanced kidney disease. Some units do have formal service user groups and I know of several kidney teams that have regular social events such as an annual dialysis dinner, summer Balls and Christmas parties.
Locally dialysis units do of course reduce travel times, improve patient experience and in addition reduce the carbon footprint associated with dialysis services. But I was not going to the Tunbridge Wells Satellite Dialysis Unit. The not so old Pembury Hospital Satellite Dialysis Unit, a portacabin style structure that was opened in 1966 and had been in the grounds of a local hospital was closed earlier this year; and yes, Tunbridge Wells kidney treatment centre does contain a “satellite dialysis unit” – bigger, better, brighter and quieter than the old unit. John Scoble (Consultant Kidney Doctor), did look a few years younger and the machines in the new centre are slicker than those in the photograph that was on show of the opening of Pembury, but the big change that struck me was the move from delivering satellite dialysis at a distance to providing a locally responsive service. The kidney centre also contains a training area for home dialysis and a self care section on the first floor quite separate from the main dialysis unit on the ground floor and clinic rooms for consultation with nursing, medical and surgical staff.
Cormac Breen (Consultant Kidney Doctor) showed me the Guys renal IT system working fast and comprehensively and that enables patients across the whole kidney care pathway to be safely, effectively and efficiently managed in the High Street in Tunbridge Wells as well at Guys tower at London Bridge. Soon venous imaging and Doppler studies will be available on site – so decisions about vascular access can be made locally. The centre offers a range of services including dialysis, transplant follow-up, chronic kidney disease assessment, conservative kidney care management and dietetics.
It was therefore a great pleasure to open the centre with Mike Rusbridge (Mayor of Tunbridge Wells). The team have made a film of building the new centre, leaving the old unit and the scramble that was opening day. It’s fun, it would make you smile and I think it embarrassed Debra but what it shows is a multi-disciplinary team working together across the boundaries that can sometimes slow us down or stop us, it shows a commitment to high quality care and a clinical vision based on the needs of local people with kidney disease. The centre is building relationships with local GPs and community services. Also, as a result of the medical presence on site in the High Street most days, the link with Kent & Sussex Hospital for education, acute kidney injury management, access to local services and joint management when inter-current illnesses develop in people with chronic kidney disease is actually stronger, more responsive and more personalised to the individuals’ needs than when a nephrologist visits the hospital for their weekly clinic.
Wednesday, 1 April 2009
Care closer to home: IV Iron
The multi-professional CKD Forum and the Anaemia Nurse Specialist Association (ANSA) have pooled their considerable expertise and produced this clear, concise guidance to assist healthcare professionals, managers and commissioners to establish services for the administration of intravenous iron for people with the anaemia of CKD in primary care and community settings. CKD is now recognised as a public health and primary care condition as much as a secondary care hospital based disease; one of its major complications is anaemia and that is one of the aspects of the disease where we have excellent evidence based treatments.
People with advanced kidney disease should not have to travel long distances to receive IV iron as an outpatient or a day case in hospital setting. “A guide to the administration of intravenous iron for people with anaemia of chronic kidney disease (CKD) in a non acute hospital setting” sets out this intention, and highlights that, where appropriate, specialist services should be transferred to a community setting; administration of IV iron is an ideal example. The CKD Forum and ANSA are leading the way in developing partnerships with primary care so that services can be delivered safely and effectively closer to patients’ homes.
Many of the 1 in 10 people affected by kidney disease in England, are elderly and most have other associated conditions – particularly vascular disease. Historically people with kidney disease were referred to specialist services but it is increasingly clear that primary care has a major part to play in care planning with people affected by kidney disease and that services can easily be provided in alternative settings such as day hospitals, community hospitals, GP surgeries and of course patients’ own homes.
Project lead Karen Jenkins (Consultant Nurse, East Kent) with contributions from Lesley Bennett (Senior Anaemia & Renal Patient Support Nurse Manager, Oxford), Sharon Benton (Anaemia Nurse Specialist, Cornwall), Laura Corner (CKD Nurse Practitioner, Liverpool), Jane Higginson (Practice Nurse Manager, Oldham), Dr Ian Wilkinson (GP, Oldham) have produced guidance which provides us all with an opportunity to take a further step in providing fair, personalised, effective and safe care for our patients. Implementation will demonstrate that the NHS is a system of care, where primary and secondary care are partners and where quality is the organising principle.
People with advanced kidney disease should not have to travel long distances to receive IV iron as an outpatient or a day case in hospital setting. “A guide to the administration of intravenous iron for people with anaemia of chronic kidney disease (CKD) in a non acute hospital setting” sets out this intention, and highlights that, where appropriate, specialist services should be transferred to a community setting; administration of IV iron is an ideal example. The CKD Forum and ANSA are leading the way in developing partnerships with primary care so that services can be delivered safely and effectively closer to patients’ homes.
Many of the 1 in 10 people affected by kidney disease in England, are elderly and most have other associated conditions – particularly vascular disease. Historically people with kidney disease were referred to specialist services but it is increasingly clear that primary care has a major part to play in care planning with people affected by kidney disease and that services can easily be provided in alternative settings such as day hospitals, community hospitals, GP surgeries and of course patients’ own homes.
Project lead Karen Jenkins (Consultant Nurse, East Kent) with contributions from Lesley Bennett (Senior Anaemia & Renal Patient Support Nurse Manager, Oxford), Sharon Benton (Anaemia Nurse Specialist, Cornwall), Laura Corner (CKD Nurse Practitioner, Liverpool), Jane Higginson (Practice Nurse Manager, Oldham), Dr Ian Wilkinson (GP, Oldham) have produced guidance which provides us all with an opportunity to take a further step in providing fair, personalised, effective and safe care for our patients. Implementation will demonstrate that the NHS is a system of care, where primary and secondary care are partners and where quality is the organising principle.
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